Elytes/fluids/ABG/Surgery
Signs and Symptoms of Dehydration
sunken eyes, decreased urine output, dry mucous membranes, thirst, weakness, dizziness, weight loss elevated temperature, rapid, thready pulse, increased hematocrit
A patient with a head injury now has clear drainage coming from the nose, what should the PN do next?
Assess fluid for halo sign
Most important intervention for a patient with flaccid paralysis
Changing position q2 hrs
Describe normal appearance of a stoma
Beefy red/pink, NO edema, NEVER white or purplish-blue
Instructions for a diabetic patient on sick days
continue checking blood glucose level and taking insulin as prescribed, even if not feeling well
What should be checked prior to administering preop medications?
Informed consent is signed
A patient had a total hip replacement, which intervention is important to prevent dislocation?
Hip abductor wedge
elevated BUN but normal creatinine may indicate what problem?
dehydration
Important education point for a patient with Addison's disease
take steroids as prescribed, do not abruptly stop
Patient presents with positive Chvostek and Trousseau sign indicating which electrolyte imbalance?
hypocalcemia
Seizure precautions should include:
Padded side rails
Safe environment
suction set up at bedside
rescue equipment readily available
Education for a patient regarding application of ice to a sprain
leave ice on no more than 20 minutes out of the hour
interventions to promote bowel health
increased fiber, increased fluid intake, increased exercise
DI can lead to what serious electrolyte imbalance
Hypernatremia
pH: 7.1
HCO3: 20
PCO2: 36
Metabolic Acidosis
to prevent increased ICP, the nurse should position the client how?
head midline, 30-45 degrees elevation
Priority nursing diagnosis for a patient in traction
risk for infection
what medications should be held prior to dialysis?
anti hypertensives
which medication would be anticipated in a client with hypoparathyroidism?
calcium & vitamin D
pH: 7.55
HCO3: 24
PCO2: 20
Respiratory Alkalosis
The nurse suspects a patient with a SCI is experiencing autonomic dysreflexia, what should the nurse do next?
check for stimuli (bladder distention, need for a BM, restrictive/tight clothing, wrinkles in bed sheet)
in the immediate care of a patient with second and third degree burns of the arms and legs, nursing interventions likely focus on what?
Airway and breathing FIRST... secondary with replacement of lost fluids and electrolytes
a patient who had an abdominal surgery is now complaining of severe abdominal pain and abdomen is rigid and board like, what is the PN concerned with?
peritonitis
nursing diagnosis for a patient with diabetic neuropathy
risk for injury