DKA
Manifestations include fruity breath, ____ respirations, BG > ___, altered LOC, and (+) or (-) urine and serum ketones, N/V, pH less than ____, high or low sodium bicarb.
Kussmaul, 300, (+), 7.3, low
S/S Left Sided Heart Failure
LUNGS: crackles, dyspnea, tachypnea, dry cough
Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?
1. Elevated red blood cell count.
2. Decreased platelet count.
3. Elevated white blood cell count.
4. Elevated serum blood urea nitrogen concentration.
3. Elevated white blood cell count.
7 rights of med administration
What type of insulin do you anticipate administering for DKA?
IV Regular Insulin
After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening?
A. ADHF
B. Chronic HF
C. Left-sided HF
D. Right-sided HF
Right-sided HF
SYSTEMIC CIRCULATION: JVD, weight gain, lower swelling, hepatomegaly, splenomegaly, abdominal distention.
The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6 F. Which intervention should the nurse implement first?
1. Notify the provider
2. Document the findings in the chart
3. Administer an oral antipyretic
4. Assess the abdomen
4. Assess the abdomen
Fall Risk Screening Scale
MORSE
The patient in the emergency department is diagnosed with diabetic ketoacidosis. Which laboratory value is essential for you to monitor?
A. Magnesium (Mg)
B. Hemoglobin (Hb)
C. White blood cells (WBCs)
D. Potassium (K)
Potassium
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
1. An elevated B-type natriuretic peptide (BNP)
2. An elevated creatine kinase (CK-MB)
3. A positive D-Dimer
4. A positive ventilation/perfusion (V/Q) scan
1. An elevated B-type natriuretic peptide (BNP)
The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the provider ordering?
1. TPN
2. NPO & NG
3. Higher fiber and increased fluids
4. Obtain consent
2. NPO & NG
Seizure precautions
O2 & Suction ready, bed padding, call light within reach, bed alarm, patient education, fall risk identifiers.
The patient presents to the emergency department with a glucose level of 400 mg/dL, ketone result of 2+, and rapid respirations with a fruity odor. What finding do you anticipate?
A. pH below 7.30
B. Urine specific gravity below 1.005
C. High sodium bicarbonate levels
D. Low blood urea nitrogen (BUN) level
pH below 7.30
The nurse is preparing to administer a nitroglycerin patch to a patient. When providing instructions regarding the use of the patch, what should the nurse include in the teaching?
Avoid drugs to treat erectile dysfunction
Diverticulitis present with pain in which quadrant?
LLQ
DVT Prophylaxis types
Pharmacologic, ambulation.
A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient’s labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next?
Hold IV insulin and notify Dr. of potassium
The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is the priority action by the nurse?
Potassium: Hyperkalemia puts this patient at risk for digoxin toxicity.
A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?
1. Deficient fluid volume.
2. Intestinal obstruction.
3. Bowel ischemia.
4. Peritonitis.
4. Peritonitis.
How do you assess an IV?
Dressing, temperature, color, flush/infusing