Interventions
You are caring for a patient at risk for skin breakdown. Name 3 interventions for prevention.
Turn q2h, keep HOB low
Offloading devices, special mattresses
Keep skin clean and dry, check briefs
Thorough skin assessment
A patient complains of chest pain, which medication do you plan to give them to dilate their vessels quickly? How often can you give it?
Nitroglycerin
1 SL tab q 5 min up to 3 doses.
A patient complains of some bladder leakage when she coughs or sneezes, which type of incontinence does she have?
Stress Incontinence.
What is the normal lab range for K+?
3.5-5
Name 3 symptoms of hypoglycemia.
Shakiness, dizziness, diaphoresis, confusion, chills, decrease in level of consciousness, lightheadedness.
A patient has returned from having a cataract removed, what restrictions will the patient have?
No lifting, bending over, drinking with a straw, avoid blowing nose, sneezing, coughing if possible. Use laxatives to prevent straining.
When giving a patient with COPD a bronchodilator such as albuterol sulfate, which of the following side effects should the nurse advise the patient on?
Bronchodilators such as albuterol cause tachycardia, and dizziness. Patient should also be advised to rinse after to prevent thrush (yeast) in their mouth.
A patient has a weak, thready, tachy pulse, you also note dry, pale mucus membranes, how would you describe their fluid status?
hypovolemic- low blood volume
Symptoms include: tachycardia, hypotension, dry skin and mucus membranes, polydipsia, oliguria, weakness, fatigue
A patient has a WBC count of 17,000, what does this mean for the patient?
They most likely have an infection. High WBC indicates the body is trying to fight off a pathogen.
Your patient has not had a bowel movement in 3 days, what is your first intervention?
Increase fiber, fluids and mobility. All of these can be done without an order.
Laxatives, suppositories, and enemas are a last resort as they need a Dr. order and can cause fluid and electrolytes issues.
A patient is taking ferrous sulfate (Iron), and tells you they are having black tarry stools, what is the appropriate response?
This is a common side effect of Iron, it is caused by the breakdown of heme in the Iron.
Your patient who has been given lorazepam, and is not experiencing respiratory depression, which of the following medications should the nurse plan to administer?
flumazenil (Romazicon)
Your patient has a pressure ulcer that extends down to the muscle and bone, what stage would you chart?
Stage 4
A patient has a calcium level of 7.8, what recommendations should the nurse make?
Increase calcium intake. Dairy foods are a good source of calcium. Yogurts, milk, cheeses
Name the stage of grief! A pt says "I am not really sick, I work out everyday and eat healthily, cancer only happens to people who don't take of themselves."
Denial
When passing medications, which of the following are included in a standard MAR check?
Patient, medication, dose, route and time.
A patient is having anaphylaxis and needs epinephrine administered, what type of needles must be used to draw up the medication?
A filter straw, epinephrine comes in an ampule and a filter needle or straw must be used with all ampules.
Your patient comes in with complaints of fatigue, cold, shortness of breath, brittle hair and nails, and clubbing of the fingers, what is this patient most likely suffering from?
Iron deficiency anemia
What is the normal range for magnesium?
1.2-2.1 (give or take 0.1)
Name the Acid/Base Imbalance
pH- 7.31
Co2- 53
HCO3- 25
Respiratory Acidosis
Low pH
High Co2
Normal HCO3
A patient is ordered a clear liquid diet, name some choices/foods.
apple juice, water, black coffee, tea, Gatorade, broths, popsicles and jello.
They cannot put sugar or cream in any of these.
You are advising a patient on the adverse effects of ibuprofen, which of the following should you ensure your patient knows.
Ibuprofen can cause stomach ulcers and increased bleeding.
Name the problem, redness, swelling, hyperpyrexia, inflammation, and warmth.
Infection
May also see pain, elevated WBC, and purulent drainage if coming from a wound.
What is the normal range for the oxygen-carrying cell?
Approximately 4.2-5.1 depending if you are male or female, this would be the normal value for RBC (red blood cells)
This type of immunity is acquired from getting diseases such as Covid-19. Your body sees the infectious agent (Covid-19) and then produces antibodies for next time.