Unit 1
Two months post-HSCT, a patient reports new diarrhea, a widespread red rash, and jaundice. These are hallmark signs of this complication.
What is acute graft versus host disease (aGVHD)?
A 32-year-old female using this common medication is at increased risk for developing a pulmonary embolism.
What are oral contraceptives?
A patient in Stage 1 ARDS may present with dyspnea, restlessness, and this expected chest x-ray finding.
What is a normal chest x-ray?
When a client’s chest pain worsens with deep breathing or coughing, it suggests this type of cause.
What is a respiratory cause?
These two findings—peripheral edema and jugular vein distension—are expected during assessment of this type of heart failure.
What is right-sided heart failure?
A kidney transplant recipient presents with edema, elevated BP, fatigue, and shortness of breath. To assess for acute rejection, this is the most important question the nurse should ask.
What is “Have you been taking your immunosuppressive medications as prescribed?”
With ABG results showing pH 7.20, PaCO₂ 65 mmHg, HCO₃ 30 mEq/L, and PaO₂ 82 mmHg, the nurse should recognize this acid-base disturbance.
What is respiratory acidosis, partially compensated?
In a patient with aspiration pneumonia receiving 100% oxygen via a non-rebreather mask, this clinical sign raises concern for developing ARDS.
What is increased respiratory effort and low oxygen levels despite high oxygen therapy?
Low-dose chewable aspirin is given during anginal chest pain because of this specific therapeutic action.
What is its antiplatelet effect that reduces clot formation?
Confusion, orthopnea, and a urine output of 15 mL over 2 hours are the findings that should prompt this nursing action.
What is initiating immediate intervention for decreased perfusion in heart failure?
Three hours into a blood transfusion, a patient develops tachycardia, hypertension, shortness of breath, crackles at the lung bases, and swelling—pointing to this complication.
What is transfusion-associated circulatory overload (TACO)?
During resuscitation, waveform capnography helps guide CPR effectiveness by assessing this value.
What is end-tidal carbon dioxide?
A client in respiratory failure has ABGs showing pH 7.28, PaCO₂ 68, PaO₂ 42, and SpO₂ 83% on a 100% non-rebreather. This is the nurse's priority action.
What is prepare for intubation?
When monitoring a client on metoprolol for hypertension, this cardiac effect is the most critical for the nurse to observe.
What is decreased cardiac output?
When treating a client with hypertensive crisis using IV vasodilators, this assessment—often done via arterial catheter—takes top priority.
What is continuous blood pressure monitoring?
For a 22-year-old with sickle cell disease experiencing severe sudden-onset pain, these two interventions—often prescribed—should be prioritized.
What are administering IV fluids and high-flow oxygen?
When administering tenecteplase (TNKase) for a large pulmonary embolism, this is the most critical nursing intervention to ensure patient safety.
What is assessing for signs of bleeding and neurological changes?
A patient on mechanical ventilation with PEEP of 10 cm H₂O has this blood pressure reading, indicating a potentially serious complication.
What is hypotension?
A nurse explains that participating in cardiac rehab after a myocardial infarction is important primarily for this reason.
What is to decrease the risk of subsequent coronary events?
A client with acute pericarditis is most likely to report this type of pain, which is worse when lying flat.
What is chest pain?
A patient receiving PRBCs reports chills, back pain, and has a fever of 39°C with a blood pressure of 70/42 mmHg—signs consistent with this life-threatening reaction.
What is a hemolytic transfusion reaction?
If a client remains in moderate distress after albuterol and IV steroids for an asthma exacerbation, this IV medication may be administered next to promote bronchodilation.
What is intravenous magnesium sulfate?
Among interventions for a patient with tachypnea, this one cannot be delegated to an LPN.
What is performing a comprehensive respiratory assessment and patient teaching?
Arterial catheters are used in the ICU for pressure monitoring and should never be used for this purpose.
What is medication administration?
This signals pulmonary edema in ADHF and should be reported immediately.
What is a productive cough with frothy, pink-tinged sputum?