Cardiac
A client in sinus Brady with a HR of 43 and BP of 82/60 reports dizziness. What intervention would the nurse anticipate will be prescribed
Prepare for transcutaneous pacing
What are the 4 main types of shock?
a. Hypovolemic
b. Cardiogenic
c. Vasogenic
d. Obstructive
You are assessing the motor and sensory function of an unconscious patient with a head injury. Which technique is used to test the patients peripheral response to pain?
Pressure on nail beds
A client arrives at the ED with complaints of low abdominal pain and hematuria, The client is afebrile. What is this a s/s of?
Recent trauma to the bladder or abdomen
A patient with myocardial infarction suddenly becomes tachy, shows signs of air hunge and begins coughing frothy, pink tinged sputum. What finding would the nurse anticipate when auscultating breath sounds?
Crackles
A client with a CVP of 2 mm Hg and mean arterial pressure of 60 mm Hg, which intervention should you do first?
Increase the rate of IV fluids
What would be a nursing care plan intervention for a patient with Reye's syndrome?
Providing a quiet atmosphere with dimmed lighting
Your patient has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that CSF is present?
Fluid separates into concentric rings and tests positive for glucose
a. Hemodialysis
b. Kidney transplant
c. Bilateral nephrectomy
A patient is having frequent PVCs. What should the nurse place priority on during the assessment?
Blood pressure and oxygen saturations
A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused with a decrease in urine output, BP is 92/68, the patient is in what stage of shock?
Stage 2
What is the priority nursing intervention for a patient with surgical repair of hydrocephalus?
Reposition the patient frequently.
You are providing eduction to your patient with Parkinson's disease and you know your patient needs further teaching based on this answer?
I don't need to use my walker to get into the bathroom.
You are performing dialysis on a patient and identify that the outflow is lower than the inflow, what actions do you take?
a. Check the level of the drainage bag
b. Reposition the client to the side
c. Place the patient in good body alignment
d. Check the machine for kinks
What factor is highest priority for patients with frequent VT?
It can develop into VF at any time.
You are caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a stage of shock. What is the priority intervention?
Administration of dopamine
What is a characteristic of decerebrate posturing?
Rigid extension and pronation of arms and legs
What makes a patient most at risk for Guillain Barre' syndrome?
Respiratory or GI infections during the previous month.
You are teaching a client with DM about PD. You tell the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?
Hyperglycemia
What is the priority when evaluating a person's response to cardioversion?
Airway latency
What clinical findings are consistent with sepsis diagnostic criteria?
a. Temp of 102
b. HR of 96
c. MAP 65 mm Hg
What is the type of isolation for a patient with bacterial meningitis?
Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.
What finding would suggest a finding of meningitis in a 3 day post op patient from a crani?
A positive Brudziniski sign
A newly diagnosed client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the client needs to be assessed for?
Headache, deteriorating level of consciousness and twitching.