Exam 1 content
A client who is preparing to sign an informed consent form states, “Remind me again of what exactly are they going to do to me during this abdominal surgery.” What should you do as the nurse?
Find the surgeon/doctor who can explain the procedure to the patient.
A patient with left sided heart failure is admitted with acute pulmonary edema. What clinical finding should the nurse expect?
Pink frothy sputum.
A patient comes to the ED with a suspected osteomyelitis infection. You just received the lab results, what abnormal lab values would you expect to see?
High WBC and ESR
This type of precautions should always be used when caring for a patient with HIV to prevent transmission.
Standard precautions
What would be the expected ABG results for a patient with chronic COPD?
High CO2 and low O2 resulting in respiratory acidosis.
A patient presents to the ED and is diagnosed with malignant hypertension. As the nurse, what medication (and route) would you anticipate to be ordered?
IV nitroprusside
You are a nurse in a skilled nursing facility with a patient who is diagnosed with moderate Alzheimers disease, list three assessment findings you expect the patient will present with.
Disorientation to time, place, and event
delusions, hallucinations, wandering, trouble sleeping, paranoia, can't handle finances, increased ADL dependence, speech and language deficits, easily gets lost
A hallmark symptom of systemic lupus erythematosus is this type of rash that appears across the cheeks and nose.
Butterfly rash
A patient presents to the ED with cerebral edema, what IV fluid should the nurse anticipate to be ordered?
Hypertonic - to pull fluid out of the cells.
List at least three triggers for inducing a sickle cell crisis.
High altitudes, dehydration, extreme temperatures, infection, smoking, stress, blood loss, strenuous exercise
A patient on the med surg floor has a seizure lasting longer than five minutes. As the nurse what would you expect the patient is diagnosed with- and list two possible causes of this condition.
Status epilepticus
Causes: cessation of anticonvulsants, ETOH/drug withdrawl, infection, head trauma, cerebral edema, metabolic disturbances
Patients with PUD should avoid this common medication class because it increases gastric irritation and risk of bleeding.
NSAIDs
A patient comes to the health department requesting a PPD test for school. In review of their health history you notice their parents were missionaries in Africa when they were born. What should be your next follow up question?
Did you receive the BCG vaccine?
Note: the BCG vaccine can show a positive PPD if received within the previous ten years.
Explain the pathology of the development of ketones.
In an attempt to compensate for the lack of insulin to move glucose into the cells for energy, the body will begin to breakdown fat stores for energy. As a result of this process, the liver converts fatty acids to ketones.
A code stroke has been called in the ED, following the CT scan the patient was diagnosed with an ischemic stroke. You have been assigned with reviewing the patient's criteria for administering TPA. What BP readings prior to administration would warrant concern?
Systolic ≥185 or diastolic ≥110
A patient with BPH is prescribed tamsulosin. The nurse should teach the patient to monitor for this common side effect regarding patient safety.
Orthostatic hypotension
You are educating a patient on the use of a peak flow meter. The patient asks "what will I do if I blow in the yellow?" What would be your response as the nurse?
Use your reliever inhaler and then follow up with another blow into the peak flow meter.
You walk into a patient's room, who has a known history of thyroid issues, and you notice the patient is hypotensive, bradycardic, and has a greatly reduced level of consciousness. What do expect the patient is experiencing?
Myxedema Coma
You are monitoring a patient who is 48 hours post-op THA. The patient has developed a headache, petechiae on the neck, and a spO2 reading of 88% on RA. As the nurse, what would you expect the diagnosis to be, and what would be two interventions to anticipate.
Fat embolism syndrome
Interventions: O2, fluids, hemodynamic support, rest, steroid therapy, frequent neuro assessments.
A patient’s labs show BUN 45 mg/dL and creatinine 3.2 mg/dL. The nurse recognizes this as evidence of impaired renal function. What complication is the nurse most concerned about developing?
Hyperkalemia- due to decreased excretion of potassium.
A patient with chronic kidney disease is admitted with confusion, K⁺ of 6.5 mEq/L, peaked T waves on ECG, and BUN/Cr levels of 70/6.0. The provider orders IV insulin with dextrose. Explain the pathophysiologic reason for the hyperkalemia and the pharmacologic rationale for the insulin.
Answer:
Pathophysiology: In CKD, impaired renal excretion leads to potassium retention, causing hyperkalemia and cardiac conduction abnormalities.
Pharmacology:
Insulin with dextrose drives potassium into cells temporarily, lowering serum K⁺.