Mental Health
While taking clonazepam (Klonopin) what food/drinks does the PT need to avoid?
Grapefruit juice
A client arrives after a MVA with an active arterial bleeding from the leg. What is the nurses initial intervention?
apply a tourniquet proximal to the wound
A 2 yo PT with tetralogy of falots suddenly becomes cyanotic, squats, and cries inconsolably. What is the priority nursing intervention?
Knee-chest position - increases systemic vascular resistance, reducing R-L shunting and improving O2 during hyper cyanotic spells.
What findings indicate early acute respiratory distress?
tachypnea, anxiety and restlessness for EARLY signs of hypoxia
A PT arrives at the ED after a MVA and is experiencing hypovolemic shock. What is the nurses initial priority action?
initiate 2 large bore IV lines and begin fluid resuscitation to restore circulating volume
A pt on haloperidol develops muscle rigidity and a temp of 103 with altered mental status. What action should the nurse take FIRST
Hold meds, notify provider
signs of neuroleptic malignant syndrome
A client arrives to the urgent care with slurred speech and right sided weakness that began 1 hour ago. What is the nurses priority action?
check blood glucose
hypoglycemia mimics stroke and must be ruled out
A 4 month old with congenital heart disease has tachypnea, poor feeding, and diaphoresis. How should the nurse encourage feedings?
frequent small feedings to conserve energy and reduce the risk of fatigue and hypoxemia
A client in respiratory distress has the following ABG
pH 7.30, PaCO2 55 mmHg, PaO2 60 mm Hg
How should the nurse interpret this?
Respiratory acidosis with hypoxemia
elevated CO2 with low pH indicates respiratory acidosis
low O2 indicates hypoxemia
A client with pneumonia becomes acutely confused and hypotensive. What would be early signs on of septic shock for the nurse to monitor?
warm, flushed skin
hypotension
fever
elevated lactate levels
tachycardia
What are side effects of risperidone and sertraline that require immediate follow up
Extrapyramidal symtoms (EPS) or serotonin syndrome
Muscle rigidity and tremors
A PT arrives after falling off a ladder and reports numbness in both legs. What is the nurse priority intervention?
apply a cervical collar and maintain spinal alignment
A 6 month old with heart failure is receiving digoxin. Before administering the dose, the nurse notes a heart rate of 90 bpm. What is the best action?
Hold meds and notify the provider
for infants HR <90 hold dig
What assessment finding most strongly suggests a pneumothorax following blunt chest trauma?
asymmetrical chest expansions
and decreased breath sounds on the affected side
What findings best differentiates cardiogenic shock from hypovolemic shock ?
pulmonary congestion (crackles) and JVD
PT on fluphenazine reports neck stiffness and difficulty swallowing. What RX does the nurse anticipate admitting.
Benztropine for extrapyramidal symptoms
A PT with a head injury becomes increasingly restless and confused. What is the best action for the nurse to do first?
Notify provider of change of LOC bc it indicates rising intracranial pressure
A child returns from cardiac catheterization via the femoral artery. Which assessment is most important?
distal pulses and limb temperature - ensuring adequate perfusion and early detection of arterial occlusion
A trauma client develops severe dyspnea, hypotension, tracheal deviation and absent breath sounds on the right? What does the nurse suspect and what will she prepare for?
tension pneumothorax requiring immediate needle decompression
A client with high spinal cord injury presents with: BP 80/46 and HR 48, warm and dry. Suspected Neurogenic shock, what are your priority nursing interventions?
For a pt taking olanzapine, what is important for the PT to be aware of
monitor blood glucose for metabolic syndrome
(weight gain, hyperglycemia, and dyslipidemia)
A PT with blunt abdominal trauma develops hypotension and tachycardia but has no external bleeding. What is the priority nursing action?
IV fluids and monitor VS
What assessment finding is the most consistent with coarctation of the aorta?
higher BP in the arms than the legs due to aortic narrowing
A client with severe chest trauma develops refractory hypoxemia despite oxygen therapy. What is the next line of therapy?
Prepare for mechanical ventilation with PEEP
Which medication improves cardiac contractility in cardiogenic shock?
Dobutamine increases contractility and cardiac output