Fluids
A nurse nurse is caring for a client with multiple draining wounds who is admitted for hypovolemia. Which assessment finding would be the priority to inform the provider when evaluating fluid balance?
What is weight loss of 6kg in 2 weeks
A nurse is caring for a postoperative client who had surgery for a perforated gastric ulcer and has been receiving nasogastric suction for 3 days. The client now has a serum sodium level of 127 mEq/L (127 mmol/L). What IV Order would the nurse the expect from the doctor
What is 3% normal Saline
The nurse is caring for a client with idiopathic thrombocytopenic purpura. Which is most important action after drawing blood?
What is hold pressure for 10 minutes following needle sticks
The nurse notes that a client who was admitted with diabetic ketoacidosis has rapid, deep respirations. Arterial blood gas reveals pH 7.22, PCO2 30, HCO3 15. Which action should the nurse take first?
Start the DKA insulin gtt protocol?
The nurse assesses a client who has been hospitalized for 3 days. The client has been receiving 0.9%NS at 125 ml/hr, A NG tube to LIS, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
Endocrine disease that the nurse should plan care knowing that which client is at risk for fluid volume deficit
What is diabetes insipidus
The nurse is caring for a client who has been receiving bumetanide (Bumex) with a serum potassium level of 3.0 mEq/L. The patient has a prescription for potassiun chloride 40 mEq PO QAM. The nurse should alert the healthcare provider immediately that the client is on which medication?
What is Digoxin?
A student nurse is learning about blood transfusion compatibilities. What information does this include?
what is Donor blood type A positive can donate to recipient blood type AB positive and Donor blood type O negative can donate to anyone.
A nurse is caring for a client on a ventilator and has the following arterial blood gas (ABG) results: pH 7.59, PaO2 99 mm/Hg, PaCO2 18 mm Hg, and HCO3 14 mEq/L. How should the nurse interpret these results?
What is Respiratory alkalosis, partially compensated
Which action can the registered nurse who is caring for a critically ill client with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?
What is Administer SubQ injections.
A nurse is caring for a client post traumatic brain injury who has a serum sodium level of 152 mEq/L and requires IV fluid therapy due to NPO status. Which solution would the nurse prepare to administer?
0.45% normal saline at 75 ml/hr
A nurse is caring for a client with acute panceatitis with a serum calcium level of 6.7 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?'
What is tetany ?
The client will require a blood transfusion with a Hct 6.7 and Hgb 22. Upon reviewing the client's chart, the nurse notes that the client has experienced previous transfusion reactions. After paging the healthcare provider, the nurse anticipates receiving orders for which medications to administer prior to the transfusion?
What is diphenhydramine and acetaminophen ?
What Neuro disorder patient would be identified as having the highest risk for respiratory acidosis?
myasthenia gravis
A nurse is caring for a client with pre-term labor who is receiving IV magnesium sulfate. Which finding should the nurse report to the healthcare provider immediately?
What is decreased deep tendon reflexes
A client is receiving 1 unit packed red blood cells which is scheduled to complete at 1600. The client is scheduled to receive vancomycin IV at 1400. Which intervention is priority?
What is Start a second IV site and adminster the IV vancomycin as scheduled
he client's serium calcium is 12.6. What medication would the nurse anticipate administering to this client?
What is Bisphosphonate
The client is Jehovah's Witness. The client has become critically volume depleted from hemorrhaging overnight when the care team approaches the client about blood transfusion and the client refuses transfusion. Which action should the nurse do next?
What is record the clients refusal of blood?
A nurse is caring for a client on the respiratory unit who has the following arterial blood gas results: pH 7.55, HCO3 22, and CO2 30. Which action should the nurse plan to take?
Encourage slow deep breaths
The nurse is caring for a client that just returned from Interventional Radiology (IR) after having a central venous catheter inserted into the subclavian vein. The client suddenly develops shortness of breath and chest pain. What should the nurse do first?
What is complete a resp assessment?
You are caring for an older client who is receiving IV fluids. During your 0800 assessment of the patient, you note that the IV solution that was ordered to infuse at 125 ml/hr, has infused 950 ml since it was hung at 0400. What is your priority nursing assessment?
What is assess the client's respiratory status
Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
Flattened or inverted T-waves
The nurse is caring for a client who is actively bleeding. The following labs were obtained: Hgb 7.3, aPTT 45, PLT 160,000, and fibrinogen 0.5. Which blood product would the nurse anticipate to transfuse?
Cryoprecipitate
The nurse is caring for a client having an anxiety attack and notes the client's arterial blood gas reveals a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results
what is nausea, confusion and lightheadness
A nurse is assessing a client who has a serum potassium level of 3.0 and nausea, vomiting, and diarrhea. Which finding should the nurse expect?
what is a weak, irregular pulse