Shock, Trauma, & Priorities
A trauma patient with facial burns, soot around the mouth, and hoarseness arrives in the ED. This is the nurse’s first priority.
What is airway protection/intubation preparation?
A patient suddenly develops chest pain that is worse when lying flat and improves when sitting forward. On assessment, the nurse hears a scratching, grating sound at the left sternal border. This condition is most likely occurring.
What is pericarditis?
The most effective intervention to reduce ventilator-associated pneumonia is maintaining this position.
What is HOB elevated 30–45 degrees?
The VERY first intervention for DKA & HHS is this.
What is IV fluid replacement?
The best indicator of adequate burn resuscitation is this.
What is hourly urine output?
A patient can no longer make end-of-life decisions due to advanced dementia. The nurse should guide the family to make decisions based on this.
What are the patient’s previously expressed wishes?
A patient with hypotension, JVD, tracheal deviation, and absent right-sided breath sounds most likely has this condition.
What is tension pneumothorax?
Before delivering a shock for ventricular fibrillation, the nurse must do this first.
What is ensure everyone is clear of the patient and bed?
An ET tube moves from 22 cm to 25 cm and the patient becomes restless. The nurse should suspect this first.
What is ET tube displacement/dislodgement?
A patient with low UOP has a potassium of 6.1 with peaked T waves and widened QRS requires this immediate treatment.
What is insulin with dextrose
Electrical burns require close monitoring for this potentially fatal complication.
What is cardiac dysrhythmias?
A patient considering a clinical trial and asks the nurse for advice. The best way to support autonomy is to do this first.
What is provide full information about risks, benefits, and answer questions?
After receiving 2 L of NS, a septic shock patient has a CVP of 10 and BP of 82/40. This medication should be started next.
What is norepinephrine?
Hypotension, JVD, and muffled heart sounds after a stab wound indicate this life-threatening condition.
What is cardiac tamponade?
A ventilated patient with thick white secretions needs this intervention most.
What is increased hydration?
A DKA patient on an insulin drip develops frequent PVCs. The nurse should suspect deficiency of this electrolyte.
What is potassium?
A platelet count under 20,000 makes this nursing priority essential.
What is bleeding precautions?
A patient with genetic testing results has a family member requesting their results. The nurse should respond and protect this principle.
What is confidentiality/patient privacy?
Bradycardia with hypotension after spinal trauma helps confirm this type of shock.
What is neurogenic shock?
A patient with ST elevation and chest pain requires this priority intervention to restore myocardial perfusion.
What is immediate PCI/cath lab activation (reperfusion)?
A burn patient with inhalation injury becomes agitated and peak airway pressures rise. This complication should be suspected first.
What is airway edema/airway obstruction?
A client with suspected SIADH has a low sodium level and begins showing confusion and seizure risk. The nurse should recognize that this priority intervention is needed first.
What is fluid restriction (and seizure precautions)?
After mannitol is given for cerebral edema, this parameter best evaluates effectiveness.
What is intracranial pressure (ICP)? Or What is the improvement of neurological status?
During a code with family present-once resuscitation begins the nurse should assign a staff member to do this.
What is stay with the family and provide updates/support?
A post-op GI surgery patient has a fever, purulent drainage, and remains hypotensive despite fluids and is now requiring vasopressors to maintain MAP above 65.
What is septic shock/refractory septic shock?
A heart rate of 35 on telemetry requires the nurse to assess this first before calling the provider.
What is level of consciousness/perfusion status?
A patient with right sided pneumonia should be positioned in this way to improve oxygenation.
What is bad lung up OR good lung down; or What is left side lying?
pH 7.23, PaCO2 61, HCO3 25 indicates this acid-base disorder.
What is uncompensated respiratory acidosis?
A client with T4 spinal cord injury develops severe headache and hypertension. This indicates this emergency.
What is autonomic dysreflexia?
A patient with terminal pancreatic cancer demonstrates correct pain management when they do this.
What is take opioids around the clock with additional doses for breakthrough pain?