Sepsis
This is usually the first vital sign abnormality in early sepsis.
What is tachycardia?
Rationale:
The body compensates for decreased perfusion by increasing heart rate early in sepsis.
This is the earliest sign of increased intracranial pressure (ICP).
What is a change in level of consciousness?
Rationale:
LOC changes occur before vital sign or pupil changes.
This lab value must be monitored for tumor lysis syndrome.
What is potassium?
Rationale:
Cell lysis releases potassium, causing dangerous hyperkalemia.
This rule estimates burn surface area quickly.
What is the Rule of Nines?
Rationale:
Used for adults to guide fluid resuscitation.
ARDS is primarily caused by damage to this part of the lung.
What are the alveoli?
Rationale:
Alveolar-capillary membrane damage → fluid leakage → impaired gas exchange.
This bundle must be started within 1 hour of recognizing sepsis.
What is the sepsis resuscitation bundle?
Rationale:
Includes lactate level, blood cultures, broad‑spectrum antibiotics, and fluid bolus.
Passive range of motion that is performed after a stroke to
Joint flexibility
Rationale: Passive range of motion increases joint flexibility and reduces joint stiffness.
Patients receiving chemotherapy must avoid this type of medication unless approved by oncology.
What are NSAIDs?
Rationale:
NSAIDs increase bleeding risk and mask fevers (a critical sign).
This type of burn is painless due to nerve destruction.
What is a full‑thickness burn?
Rationale:
Nerve endings are destroyed → no sensation.
This P/F ratio indicates ARDS.
What is <300?
Rationale:
<200 = moderate; <100 = severe ARDS.
This is the recommended initial fluid bolus amount in septic shock.
What is 30 mL/kg of crystalloids?
Rationale:
Evidence-based guideline to improve perfusion and MAP.
A nursing action that is the priority to address chronic back pain that is worsens with prolong sitting and improves with walking
Rationale: Strengthening core muscles and educating on posture helps prevent recurrence of back pain and supports spinal alignment, addressing the client's symptoms effectively.
This is the most common oncologic emergency causing spinal cord compression.
What is metastatic tumor growth?
Rationale:
Especially breast, prostate, and lung → compress spinal cord → paralysis risk.
Formula used for fluid resuscitation in the first 24 hours.
What is the Parkland formula?
Rationale:
4 mL × kg × %TBSA; give half in the first 8 hours.
his ventilator setting prevents alveoli from collapsing.
What is PEEP?
Rationale:
Positive end-expiratory pressure keeps alveoli open.
The hallmark
difference between
sepsis and septic
shock.
Persistent hypotension
despite fluid
resuscitation
Septic shock requires
vasopressors to maintain MAP
65 mmHg.
An indication the client is at risk for experiencing autonomic dysreflexia?
The client’s bladder becomes distended.
Rationale: Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury.
This is the first-line treatment for superior vena cava syndrome.
What is radiation therapy?
Rationale:
Reduces tumor mass compressing the SVC.
This complication is a priority concern for circumferential limb burns.
What is compartment syndrome?
Rationale:
Edema and tight eschar impair circulation.
This position improves oxygenation in severe ARDS.
What is prone positioning?
Rationale:
Redistributes perfusion and improves ventilation.
MODS is defined as dysfunction of this minimum number of organ systems.
2 or more
Progressive failure of
multiple organs results from
uncontrolled inflammation.
The nurse takes what action when a patient has autonomic dysreflexia.
Place the client in a sitting position.
Rationale: The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in a sitting position to decrease the manifestation of hypertension.
patients who are terminally ill. with a life expediency of 6 months or less
Hospice
Care is provided in a long-term care facility; however, hospice care is also provided in a number of other settings, including the client’s home and in an assisted living facility.
In inhalation injury, this blood value helps identify carbon monoxide poisoning.
What is carboxyhemoglobin?
Rationale:
CO binds hemoglobin more strongly than oxygen.
The earliest sign of hypoxemia
Restlessness
Rationale: Restlessness and agitation occur early; cyanosis and bradycardia occur late.