Stroke
The nurse is taking a history from a daughter about her father’s onset of stroke signs and symptoms. Which statement by the daughter indicates that the patient likely had an embolic stroke?
history of atrial fibrillation
The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation.
How would the nurse help to prevent VAP?
VAP is prevented by using proper hand washing, oral care and suctioning every 2 hours, and early mobilization.
What is the biggest modifiable risk factor for COPD?
cigarette smoking
While performing hourly rounding on a client with a newly inserted chest tube, the nurse notices fluctuation (tidaling) in the water seal chamber. Which action will the nurse perform next?
Fluctuation in the water seal chamber is normal and does not require further action from the nurse.
The health care provider writes an order for nitroglycerin at 15mcg/min. The patient weighs 142 pounds. The bag is labeled nitroglycerin 50mg in 250ml of D5W. What do you start the rate of the pump at? (Round your answer to the whole number)
5 ml/hr
250ml/ 50mg x 1mg/1000mcg x 20mcg/mins x 60 mins/1 hour=5 ml/hr
What is different about a TIA vs a stroke?
TIA does not result in infarction because the obstruction is transient.
The nurse is taking care of patient with pneumonia. What symptoms would the nurse expect to see if the patient is going into hypoxic respiratory failure?
dyspnea, tachypnea, prolonged expiration, nasal flaring, intercostal muscle retraction, use of accessory muscles, low SpO2, agitation, confusion, disorientation, restless & combative behavior, tachycardia, hypertension, cool and clammy skin, diaphoretic
What should be included as treatment for a patient with exacerbation of chronic obstructive pulmonary disease?
Short acting beta agonists and oral corticosteroids
The nurse notices constant bubbling in the water seal chamber of the chest tube. What should the nurse do?
A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately.
The nurse is to infuse 300 mL of Packed Red Blood Cells over 4 hours. The drop factor on the administration set is 20 gtts/mL. What would the nurse set the rate on the pump to in mL/hour? (Round your answer to the whole number)
75 ml/hr
Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke??
During the acute period, the nurse should place objects on the patient’s unaffected side. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
The nurse understands which complication occurs during the fibrotic stage of acute respiratory distress syndrome (ARDS)
Tissue forms scarring, decreased lung compliance, increased work of breathing
Explain the pathophysiology of chronic obstructive pulmonary disease (COPD)?
Chronic exposure causes inflammation that results in hypersecretion of mucous
What causes a high pressure alarm on a ventilator?
High pressure alarms indicate increased pressure. Pulmonary edema, occlusion, and excessive secretions will cause the high pressure alarm to sound.
The physician wrote an order to administer dopamine IV at 10 mcg/kg/min. The pharmacy provides dopamine 800 mg in 250 mL of D5W. What is the IV pump rate? The patient weighs 168 pounds. ________mL/hr (round to the nearest tenth)
14.3 mL/hr
68 pounds = 76.36 kg 10mcg x 76.36kg = 763.6 mcg/min 0.7636 mg/min x 60 mins = 45.816 mg/hr 45.816 mg 250mL ---------------- ------------- = 1 hour 800 mg
A patient arrives in the emergency department with reports of new onset facial drooping and impaired speech. What interventions would the nurse do in order of priority?
The nurse must perform an initial assessment of ABCs, prepare the patient for CT within 10 minutes of arrival, determine the last known normal, and complete a stroke assessment as soon as possible. Blood pressure must be maintained for the patient to receive tPA. The patient should remain NPO until a swallow study has been completed.
The nurse is assessing a patient at risk for developing acute respiratory syndrome (ARDS). Which is the most common and early sign of (ARDS)?
fine scattered crackles.
What is the main cause of COPD acute exacerbations?
Bacterial and viral infections
What is the most common cause of a low pressure alarm on a vent?
Disconnection - check all tubing connections
The nurse receives an order to initiate an IV infusion of 3000 ml of Lactated Ringer's to infuse over 24 hours. The drop factor on the administration set is 20 gtts/mL. What would the nurse set the rate to in mL/hr?
125 mL/hr
What clinical manifestations would you see on a patient who had a left-brain stroke?
Left-brain: paralysis on right side, impaired speech/language aphasias, impaired right/left discrimination, slow performance, cautious, aware of deficits, impaired comprehension related to language and math
What are normal ABG values?
The nurse is educating a patient with chronic obstructive pulmonary disease (COPD) about purse lip breathing. The patient asks what the purpose of the purse lip breathing is. The nurse knows the primary reason for purse lip breathing is?
Promote carbon dioxide elimination
Where should the chest tube collection chamber be placed?
A patient weighs 180 kg and has an order for Heparin IV at 18 units/kg/hour and a bolus of 80 units/kg. The Heparin arrives from the pharmacy with the following concentration: 25,000 units in 250ml 0.45% sodium chloride. How many units is the bolus? (Round to the whole number)
14,400 units
180kg x 80units=14400