Meds
Why would nitroglycerin be helpful in cardiogenic shock?
Improve ventricular emptying and optimizes tissue perfusion
Which lab is pertinent to obtain with suspicion of septic shock?
lactic acid
The client pulls out their chest tube, what is the priority action?
Cover the insertion site with occlusive dressing taped only on 3 sides
What are some early signs of hypoxemia?
Tachycardia, confusion, and restlessness
What is normal ICP?
5-15 mm/Hg
edited*** 60-80 is CPP!
What is Atropine used for?
Increased heart rate
The client has a 50% reduction of platelets over the past 5 days while being on a heparin drip. What is the priority action of the nurse?
Discontinue the heparin drip
The client is post-op CABG and has a heart rate of 150 bpm but otherwise alert and asymptomatic. What is the priority action?
Administer an IV Beta Blocker
The nurse is caring for the client with a large subdural hematoma. The nurse will monitor for which early sign of potential brain herniation?
Fixed and dilated pupils
What is the scale of GCS assessment?
3-15
less than 8 intubate!
What is norepinephrine and what is it used for?
Norepinephrine, also known as Levophed or noradrenaline, is a potent vasopressor medication used to raise blood pressure in patients with severe, acute low blood pressure (hypotension).
Which electrolyte level is a priority concern with client's diagnosed with pancreatitis?
Hypocalcemia!
Which two cranial nerves play a significant role in airway and swallowing abilities?
glossopharyngeal and vagus nerve
What are early signs of increased ICP
Alert and oriented to person only
(there are many others)
What is the desired urine output with a client post electrical burn?
75-100mL/hr
Perform neuro checks hourly
monitor sodium levels
monitor ammonia levels
The client is in acute respiratory distress, what lab would be most concerning for the nurse to see?
Critically low PaO2
The client's GCS drops from 15 to 5, what is the priority?
Notify the provider and prep for intubation
What are cues for Cushing's triad
widened pulse pressure (increasing systolic, decreasing diastolic), bradycardia, and irregular respirations.
What is ideal lactic acid level?
Less than 2
over 2 indicates infection/sepsis
What are some medications the nurse can anticipate seeing on the MAR for a client with increased ICP?
Mannitol
Phenytoin
Dexamethasone
Normal PaO2
above 80%
The client suffered an open femur fracture from an MVA. What are complications the nurse should be aware of?
Risk for infection
Fat Embolism
Hypovolemic shock
(to name a few)
What are some potential cues of fluid volume deficit?
Low CVP pressure
Tachypnea
Increased renal function labs
Hypotension
Hypernatremia
Hypokalemia
etc.
What is normal MAP?
•MAP must be maintained above 60 to keep brain, kidney, and other vital organs perfusing.
•MAP between 60-65: cause for concern, low perfusion
•MAP >65 <95 ideal range
•MAP >95 means too much pressure on the arterial bed