Liver and GI
These two daily assessments/measurements are completed on patients admitted for portal HTN and ascites.
What are daily weights and abdominal girth?
The nurse is assessing a patient diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find?
What is exopthalamus?
A nurse in the ICU is caring for a patient admitted with a neck injury he received while diving into a lake. His blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?
What is neurogenic shock?
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
What is the patient's TBSA?
A patient with kidney injury has decreased erythropoietin production. Upon analysis of the patient's complete blood count, the nurse will expect which of the following results?
What is a decreased H&H?
The nurse notes that the patient admitted with hepatic encephalopathy has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
What is asterixis?
The nurse is caring for a patient diagnosed with hypothyroidism secondary to Hashimoto thyroiditis. When assessing this patient, what sign or symptom would the nurse expect?
What is extreme fatigue?
This crystalloid fluid should be given to a patient who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident.
What is LR?
A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred.
What is a 4th degree, full thickness burn?
A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin. The nurse should recognize the possible need for what antidote?
What is Vitamin K?
In liver failure patients, the nurse recognizes that there is a risk related to the patient's inability to synthesize prothrombin in the liver. What physiologic factor most likely contributes to this loss of function?
What is inability of the liver to use vitamin K?
The nurse is caring for a patient with a diagnosis of Addison disease. What sign or symptom is most closely associated with this health problem?
What is emotional lability?
The nurse in the ICU is admitting a 57-year-old man with a diagnosis of septic shock. The nurse's assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The patient is in this stage of shock.
What is the compensatory stage?
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After assessing the patient's cardiopulmonary status, what would be the nurse's immediate, priority concern when planning this patient's care?
What is F&E balance?
A patient has been brought to the ED with multiple trauma after a motor vehicle accident. The nurse and trauma team should take what action first?
What is perform a RAPID assessment of the patient's injuries?
What treatment should the nurse anticipate in a patient with acute, emergent esophageal bleeding?
What is IV Octreotide and volume expanders?
A patient has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal?
What is hypocalcemia?
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. What goal of this treatment should the nurse identify?
What is maintenance of the prescribed MAP?
A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation after being trapped inside a burning building for 15 minutes waiting for rescue, and has soot staining to the nares and the inside of the mouth . What is the priority in the care of a patient?
What is airway management?
The nurse is admitting a patient who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis?
What is decreased or absent sweating?
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
What is multiple, soft bowel movements per day?
The nurse's assessment thyroidectomy patient reveals tetany, and numbness and tingling in the extremities. A review of the most recent blood work corroborates this finding. The nurse should prepare to administer what intervention?
What is administration of IV Calcium Gluconate?
What specific lab helps the medical staff determine the presence of sepsis?
What is a serum lactate?
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory value?
What is serum sodium?
A homeless person is admitted the ED during a blizzard, and is unable to feel his feet and lower legs. Core temperature is noted at 95.8 F. The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this patient?
What is address the patient's hypothermia?