Assessment
Mrs. Hill's SPO2 is 88% on room air, what immediate action should the nurse take?
Apply oxygen via nasal cannula
Which diagnosis takes highest priority?
Impaired gas exchange
For impaired gas exchange, what is a measurable goal?
Maintain SpO2 greater than 94% on 2 liters oxygen
Crackles appear after IV fluids begin. What is the nurse's priority?
Slow the infusion and notify the provider
Which finding shows oxygen therapy was effective?
SPO2 greater than 94 and clear lung sounds
Fluid volume deficit
An irregular pulse and S3 heart sound support which diagnosis?
Decreased cardiac output
For decreased cardiac output, what vital sign range is desired?
HR 60-100 bpm and no hypotension
Before giving a beta-blocker, what assessment must the nurse make?
Check the apical pulse for one full minute, hold if less than 60 and notify provider.
After 24 hours, what data would show hydration improved?
Stable weight and increased urine output to at least 30mL/hr
Crackles in both lower lobes suggest what complication?
Pulmonary edema, fluid overload, heart failure
Confusion and hypotension place Mrs. Hill at risk for what?
What is injury, risk for falls
Which outcome measures fluid balance?
UOP greater than 30mL/hr and stable daily weights
What intervention best corrects metabolic acidosis?
Continue isotonic IV fluids and monitor ABGs
Which sign confirms improved cardiac output?
No hypotension, increased urine output
Which lab finding confirms renal impairment?
Elevated creatinine, 1.8
Redness at the IV site would prompt which nursing diagnosis?
Risk for infection
What is a realistic mobility goal for the end of the shift?
Ambulate with walker in room and standby assistance
What action helps prevent falls for Mrs. Hill?
Activate bed alarm, put bed low and locked, place call bell in reach, provide adequate lighting, non-skid socks, etc.
You educated the patient on a heart healthy diet. What behavior would indicate the education was successful?
Using a salt substitute for lunch
Mrs. Hill becomes dizzy when standing up. What should the nurse do first?
Assist her to sit or lie down and reassess blood pressure, obtain orthostatic vital signs
pH 7.31, HCO3 19, PACO2 32 indicate what physiological problem?
Metabolic acidosis
What overall safety goal should appear in the plan of care?
Remain free from falls and injury during hospitalization.
Which intervention maintains mobility and prevents stiffness?
Encourage active ROM and work with PT
Which ABG results confirm acidosis correction?
Look at the pH!