Priority
Which patient will be your priority?
A. Pt s/p transplant with temp change of 98.7 to 98.2
B. Pt with BP 12 hours ago of 131/76, now 122/54
C. Pt with chronic COPD on NC with sats 89%
B: change of >20mmHg is always a sign to call physician
(transplant patient with a temp increase of 1 or more degree is sign of rejection; COPD with sats of 89% is expected)
pH 7.22; CO2 60; HCO3 27
What is the imbalance and what will your patient present with?
Respiratory Acidosis
Decreased respirations
Shallow breathing
Decreased LOC
Headache
Dizziness
TRUE or FALSE: You should suction your patient's tracheostomy tube every 2 hours
FALSE: you should only suction when patient is symptomatic
This is to reduce the risk of infection
This will be one of your nursing interventions for your patient with Pre-Eclampsia on Magnesium Sulfate
Decreased stimulation
Darkened, quiet environment
Minimize visitors
Low volume on the TV
1 inch, 23 gauge, 1 ml
IM injection in the Deltoid
Which patient is a priority?
A. Pt with chronic lung disease in orthopneic positioning
B. Pt with a K of 4.1 from 3.1
C. Pt with femur fracture with change of LOC
C: femur is a fatty long bone and fractures can cause risk of fat emboli and change in LOC is a symptom of stroke
(A is expected and B now has a normal potassium level)
pH 7.55; CO2 24; HCO3 29
What imbalance is this and how will your patient present?
Respiratory Alkalosis
Anxious
Hyperventilation
Lightheadedness
You are doing your trach care and as you are finishing up changing the trach ties you notice the patient coughing and the tube is moving in and out. You know this is what?
The tube is likely dislodged
Your patient is in labor and you note contractions every 2.5 minutes lasting 125 seconds. What should you do?
Stop Pitocin and try to stop contractions
Hyperstim - contractions lasting longer than 2 minutes with only 25 seconds in between to recover. This is not safe for mom or baby.
26-27G needle, 15 degrees, 0.1ml, Intradermal
PPD Insertion
Which patient will you see first?
A. Patient with a Na of 138
B. Patient s/p stroke with sudden onset irritability and restlessness
C. Patient with hypertension with BP of 150/88
B: this is a sign of increased intracranial pressure
(A and C are expected findings)
You expect to see Kussmaul's respirations with this acid base imbalance
Metabolic Acidosis
DKA
Malnutrition
Renal insufficiency
Your patient had an NG tube surgically placed 8 hours ago. You know the most important nursing intervention with this tube is this.
Do not manipulate tuning, turn and reposition q2h, display sign with tube length measurements and reminders to not manipulate the tubing and know the ordered suction settings
You hear the monitor alarm and find the fetal heart rate has dropped abruptly and has no correlation with contractions. What will you do first?
Reposition mom to the other side
Variable = Position Change
Cord compression and you need to get baby off of the cord
Your patient is A- and you notice the blood transfusion that started 10 minutes ago has B+ blood. What will you do first?
IMMEDIATELY STOP THE TRANSFUSION before anything else!
Which patient will you see first?
A. Patient s/p ileostomy with liquid stools
B. Patient s/p ileostomy day 2 with bright red stoma with some light bleeding
C. Patient with pancreatitis with urine output of 17ml/hr
C: urine output is too low and risk of Hepatic Encephalopathy and shock
(A and B expected findings - remember sign of decreased circulation and necrosis in a stoma is dark purple or black stoma)
Your patient is on continuous NG tube suctioning. You know they are at risk for this acid base imbalance
Metabolic Alkalosis
Your patient has an implanted radium implant for ovarian cancer. You know education for this patient will include:
Avoid direct heat and sun exposure to the area
Do not remove the markings that indicate exactly where the beam of radiation is to be focused
Use a clean, soft towel or clothing. Patting motion
No powders, ointments, lotions, or creams on the radiation site unless its prescribed by radiologist
Your patient is on Magnesium Sulfate for pre-eclampsia. You know the 2 more concerning findings are these.
Respiratory depression - RR less than 12
Decreased urine output - less than 25ml/hr
Your patient has been diagnosed with peptic ulcer disease. Her morning vitals are as follows:
HR: 108, RR 17, BP 91/49
You should do this first?
Call Doctor and get an order for blood. Patient is going into hypovolemic shock (tachycardia and hypotension)
Which patient will be your priority?
A. 27 weeks with reactive NST
B. 35 weeks with excessive itching with no visible rash
C. 37 weeks who reports she "lost her mucus plug"
B- itching with no rash is a sign of idiopathic cholestasis of pregnancy. This starts around 35 weeks and has increased risk of stillbirth. Patient needs labs drawn and to be on the monitor with likely delivery between 36-37 weeks
(A and C are normal findings)
Your patient presents with muscle cramps and elevated HR. You know this can be a sign of this acid base imbalance.
Metabolic Acidosis
DM, DKA, acetylsalicylic acid, insufficient carbs, malnutrition, renal insufficiency, severe diarrhea
s/s: Kussmaul's respirations, cold clammy, lethargy, confusion, dizziness, headache, coma, BP, dysrhythmias, cold clammy skin, n/v, diarrhea, muscle weakness insulin, monitor I's & O's, seizure precautions
You are the charge nurse and observe a nurse care for patient with sealed radiation implant. You notice as she comes out of the room she brings out the BP machine and IV pump. What will you do?
Nothing, these patients do not require dedicated equipment in their room
Your patient is in OB triage and calls out that she is bleeding. You find her in bed with a large amount of dark red blood and she is yelling in pain. You know this is likely what? What will you do first?
Placental Abruption
Call OB, plan for cesarean section STAT
You are in the ER and see a 4 month old with sunken fontanels, no tears when she cries and lethargy. What will you do first?
Monitor I&Os, diaper weights and IV hydration