Unit 1
Which positioning improves oxygenation for ARDS patients?
prone
A pt is requiring cardio version. What does the nurse anticipate administering first?
sedation
What 2 assessments should be assessed with an AV fistula?
bruit & thrill
Which assessment finding would indicate a pt has moved from the emergent to the acute phase in a burn injury?
pale dilute urine
An intubated pt w/ ARDS has decreased GI motility. Name @ least 2 interventions.
place a feeding tube
Initiate enteral feeds
consult w/ a dietician
A patient with a TBI develops weight gain, weakness, and nausea and vomiting from SIADH. What is the initial intervention?
restrict fluids
What factor differentiates hypertrophic cardiomyopathy?
genetic or familial factor
What is a Mallory Weiss tear?
a spontaneous longitudinal tear from excessive vomiting
What is a common assessment finding for a pt w/ renal trauma?
micro hematuria
What assessment should be avoided in a leukopenic pt?
performing a digital rectal exam
An intubated and sedated pt becomes more agitated. What is the priority intervention?
Assess oxygenation via ABG
Name 2 expected labs in a DIC pt.
decreased platelet & fibrinogen
increased PT, PTT, fibrin degradation products, D dimer
A pt's family is visiting a pt with internal radiation therapy. Name at least 2 safety interventions for the family.
stay at least 6 feet away from pt's bedside
limit visitation time
avoid visiting if pregnant
Name at least 2 assessment findings that would indicate the need for an escharotomy?
progressive decrease in sensation
diminished to absent distal pulses
decrease in cap refill
What is the earliest indication of increased ICP?
change in LOC
What cardiac complication can occur from too high PEEP?
decreased cardiac output
A pt getting heparin develops HIT. What is the priority intervention?
d/c all types of heparin
A pt w/ an elevated BUN/Cr requires a CT. What is an appropriate intervention?
prehydrate w/ IV fluids
Name 2 assessments that may indicate a tension PTX.
deviated trachea
absent breast sounds on affected side
hypotension
decreased CO
When is it best for CCRT?
unstable, critically ill pt requiring dialysis
A pt post surgery develops SOB, CP, and hemoptysis. What is potentially occuring and what are 2 interventions?
Pulmonary embolism, 100% O2 & start IV heparin
A pt w/ a STEMI received a thrombolytic. Name a complication that requires immediate intervention.
severe headache, bleeding
What can lose dose dopamine do?
improve urine output
What should be included in the POC for a pt w/ a CT?
Assess for continuous bubbling in the suction container
encourage the client to cough every 2 hours
obtain a cxr as ordered
What is the priority for a pt w/ alkali splash burns?
irrigate the affected area w/ water