Unit 1-5
A client on chemotherapy with pancytopenia reports a sudden severe headache, vomiting, and double vision. The nurse should first take this action.
What is perform a focused neurological assessment and notify the healthcare provider immediately?
A client with heart failure on a dopamine infusion shows increased urine output from 20 mL/hr to 40 mL/hr, indicating this clinical effect.
What is improved cardiac output?
To help maintain immune function in a critically ill ICU patient, this collaborative intervention is a top priority.
What is timely assessment and administration of nutritional support?
A patient with SCI presents with a BP of 60/40, heart rate of 35, and warm, dry skin below the level of injury. These are classic signs of this type of shock.
What is neurogenic shock?
A patient arrives with chest pain, tachycardia, hypotension, and shortness of breath. This is the triage tag color the nurse should assign.
What is red?
A post-op intubated ICU client shows elevated respiratory rate, high BP, and ventilator "high pressure" alarms. The priority nursing intervention is this.
What is administer intravenous opioids and reassess pain?
A dialysis patient with a potassium level of 6.9 mmol/L, bradycardia, peaked T waves and wide QRS complexes should receive this IV medication first to stabilize cardiac membranes.
What is intravenous calcium gluconate?
An older adult ICU patient shows edema, sloughing skin, hair loss, and low albumin. These findings most likely point to this underlying condition.
What is malnutrition?
A construction worker falls and twists his head, later showing signs of diffuse axonal injury. This mechanism is most likely responsible.
What is a rotational injury?
In a patient with 35% partial-thickness burns, this urine output signals the end of the resuscitation phase.
What is at least 30 mL/hr?
In heart failure, reduced cardiac contractility lowers this value, ultimately decreasing cardiac output.
What is stroke volume?
When correcting severe hyponatremia, the nurse must limit the sodium increase to this range in 24 hours to prevent central pontine myelinolysis.
What is 4 to 8 mEq/L?
For sedated, mechanically ventilated patients, this feeding method optimizes nutrient absorption and reduces the risk of gastric distention.
What are continuous enteral feedings?
A patient with TBI has low urine output, low sodium (125 mEq/L), and weight gain. The nurse suspects this condition is developing.
What is syndrome of inappropriate antidiuretic hormone (SIADH)?
Following a high-speed car crash, this factor most strongly correlates with increased trauma severity.
What is the speed of the vehicle at the time of impact?
In treating cor pulmonale caused by pulmonary embolism, the primary therapeutic goal is this.
What is decreasing right ventricular afterload and improving right ventricular function?
During dialysis, the nurse should monitor for these two complications, both linked to shifting fluid and electrolyte levels.
What are dysrhythmias and electrolyte imbalance?
For a critically ill patient on a ventilator, this is the nurse’s priority action to meet nutritional needs within the first 24 hours.
What is begin continuous enteral feedings via nasogastric tube?
IV hydralazine is given for hypertension after TBI. The nurse avoids rapid drops in BP to prevent this complication.
What is a sudden decrease in cardiac output, which can increase ischemic injury?
In critically burned patients, early enteral feeding helps prevent this GI complication linked to systemic infection.
What is bacterial translocation and infection?
A heart failure patient with fatigue and dyspnea with minimal exertion is experiencing this pathophysiologic problem.
What is insufficient cardiac output due to the heart’s inability to respond to metabolic demands?
When giving IV furosemide to a patient with acute kidney injury, these nursing actions are essential to avoid serious complications. (Select all that apply.)
What are:
Monitor serum potassium levels?
Assess lung sounds for fluid status?
Evaluate for signs of ototoxicity such as tinnitus?
Monitor cardiovascular status, including blood pressure and heart rate?
These nursing actions are essential to safely manage enteral nutrition and detect complications. (Select all that apply.)
What are:
Monitor weight measurements, vital signs, and intake/output?
Monitor for signs of dehydration such as thirst and tachycardia?
Perform meticulous tube and IV catheter care to prevent infection?
Key education for a spinal cord injury patient includes these important self-care measures. (Select all that apply.)
What are:
Reposition every 2 hours to prevent pressure ulcers?
Perform deep breathing exercises to improve respiratory function?
Avoid tight clothing to prevent circulation problems and skin breakdown?
Maintain a high-fiber diet to prevent constipation?
A combative adolescent suspected of a pill overdose should have these labs prioritized. (Select all that apply.)
What are:
Complete metabolic profile (CMP)?
Electrocardiogram (ECG)?
Urinalysis (UA)?
Hepatic function tests (LFTs)?
Acetaminophen (Tylenol) level?