Nursing Intervention
To prevent skin breakdown in an immobile patient, the nurse should implement a repositioning schedule at least every_______hours.
2 hours.
To prevent post-op pneumonia, the nurse teaches the patient to use this device 10 times per hour by inhaling slowly and deeply.
Incentive Spirometer (IS)
This "clot-busting" medication is the gold standard for ischemic stroke but must be administered within a 3 to 4.5-hour window.
tPA (Alteplase)
This value measures the average blood glucose levels over the past 2–3 months.
A1C
This condition is characterized by the "Three Ps": Polyuria, Polydipsia, and Polyphagia.
Diabetes Mellitus
This oxygen delivery device must be set to at least 5 to 6 L/min to ensure the patient does not re-breathe exhaled $O2, and can deliver an FiO2 of up to 60%.
Simple mask
When teaching a patient how to use a Metered-Dose Inhaler (MDI), the nurse should instruct them to hold their breath for this many seconds after inhalation.
10 seconds
This electrolyte is never given via IV push, as it can cause immediate cardiac arrest.
Potassium Chloride
What is the normal value of K+?
3.5 - 5.0
In this neurological condition, the immune system attacks the myelin sheath, leading to "flare-ups" and remissions.
multiple sclerosis (MS)
When performing suctioning on a patient with a tracheostomy, the nurse should limit each suction pass to no more than this many seconds.
10-15 seconds
A patient being discharged on Furosemide (Lasix) should be educated to increase their intake of this mineral to prevent muscle weakness and arrhythmias.
Potassium
A patient on this medication must be taught to maintain a consistent intake of Vitamin K, as sudden increases in green leafy vegetables can decrease the drug's effectiveness.
Warfarin (Coumadin)
An elevation in this specific lab value is the most sensitive indicator of myocardial infarction (heart attack)
Troponin
This life-threatening complication of hyperthyroidism involves extreme tachycardia, fever, and altered mental status.
thyroid storm (or thyrotoxic crisis)
What infectious diseases require airborne precautions? List at least three.
tuberculosis, measles (rubeola), shingles, SARS, and varicella (chickenpox)
A patient with Heart Failure should be taught to notify their provider if they experience a weight gain of this many pounds in a single day.
Generally 2 to 3 pounds
This medication is the specific antagonist (antidote) used to reverse a Heparin overdose.
Protamine Sulfate
In a patient with Hepatic Encephalopathy, the nurse expects to see an elevation in this neurotoxic byproduct.
Ammonia
While both conditions involve extreme hyperglycemia, the presence of these acidic byproducts in the blood and urine is the definitive diagnostic marker for DKA, as they are typically absent in HHS.
Ketone
What is the total CIWA-Ar score for a patient presenting with mild nausea, moderate hand tremors, moist skin, moderate anxiety and restlessness, mild agitation, denies tactile/auditory/visual disturbances, mild headache, and is oriented ×3?
Total = 16
This is the specific instruction given to a patient with a fresh cast to check for "Compartment Syndrome" by monitoring for the "6 Ps." What are the 6 Ps?
Pain, Pressure, Paresthesia, Pallor, Paralysis, and Pulselessness
Taking this class of antibiotics can lead to "Red Man Syndrome" if the infusion rate is too rapid.
Vancomycin
pH: 7.51 / PaCO2: 33 / HCO3: 24
Respiratory Alkalosis
This autoimmune disorder causes a characteristic "butterfly rash" across the bridge of the nose and cheeks.
Lupus