Assessment
A nurse assesses a patient with suspected hypovolemia. Which finding is the earliest indicator of decreased circulating volume?
-Hypotension
-Tachycardia
-Cyanosis
-Anuria
What is Tachycardia
A patient has increased thirst, frequent urination, increased hunger, and elevated blood glucose. Name the likely diagnosis
What Is Diabetes Mellitus or What is Type 1 Diabetes
You have four patients: Who do you see first?
-Post-op patient with pain rated 7/10
-Patient with oxygen saturation of 88%
-Patient asking for discharge instructions
-Patient requesting a blanket
What is the patient with an oxygen saturation of 88%
This medication can be given to push potassium back into the cells. It is also given for Diabetic Ketoacidosis.
What is Insulin/Regular Insulin
Bed in the lowest position, wheels locked, side rails, call light in place, bed alarm on, non-slip socks, hourly rounding
What is fall risk precautions
On assessment patient has: ankle edema, weight gain of 1lb overnight, crackles, and JVD.
What is worsening heart failure (left-sided heart failure)
A patient presents with severe abdominal pain that begins around the umbilicus and later moves to the right lower quadrant. They also have nausea, vomiting, and a low-grade fever. Name the likely diagnosis
What is acute appendicitis?
Which patient requires immediate assessment?
A Patient with cirrhosis who has asterixis
A patient with sickle cell disease reporting severe pain
A patient 12 hours after a femoral catherization with sudden back pain, hypotension, and tachycardia
A patient with chronic kidney disease whose potassium is 5.4 mEq/L
What is the patient with the femoral catheterization
A patient receiving IV heparin develops severe bleeding. Which medication should the nurse anticipate administering?
Vitamin K
Protamine sulfate
acetylcysteine
Naloxone
What is Protamine Sulfate
A patient with increased intracranial pressure is being positioned by the nurse. What position is generally most appropriate?
Head elevated with a neutral alignment
Four hours after a thyroidectomy, a client reports tingling around the mouth and fingertips. The nurse should immediately assess for this potentially life-threatening complication.
What is hypocalcemia causing tetany/laryngospasm
A patient with cirrhosis develops confusion and altered mental status. Increased levels of what substance are most associated with this complication?
What is Ammonia
Which patient should the nurse assess FIRST?
A patient receiving a blood transfusion who develops chills, fever, and back pain
A patient with asthma requesting a PRN inhaler
A patient with a UTI reporting burning with urination
A patient with chronic kidney disease asking about their diet
What is a blood transfusion reaction
A patient with cirrhosis develops confusion and altered mental status. Increased levels of what substance are most associated with this complication?
What is Ammonia
What is Reverse Trendelenburg
A client with a head injury becomes increasingly restless. BP changes from 128/76 to 168/54, HR decreases from 88 to 52, and respirations become irregular. These findings represent this dangerous neurologic change.
What is increased intracranial pressure with Cushing's triad?
A patient presents to the Emergency Department with complaints of facial drooping and numbness/tingling to one side of their face. They are able to raise their eyebrows. What is the likely diagnosis?
What is a Stroke (CVA)
The nurse has 4 patients. Which finding requires immediate intervention?
A patient with asthma who has expiratory wheezing
A patient with heart failure that has crackles at the lung bases
A patient with asthma that has minimal to no wheezing with respiratory distress
A patient with COPD that has diminished breath sounds bilaterally
What is the asthma patient with minimal wheezing
A patient receiving IV insulin for DKA has glucose decreased from 550 to 180 mg/dL. The anion gap remains elevated. What should the nurse anticipate?
-Immediately discontinuing insulin
-Continuing insulin while administering dextrose as prescribed
-Giving additional IV regular insulin boluses only
-Administering glucagon
What is continuing insulin while administering dextrose as prescribed.
A client with septic shock remains hypotensive after receiving IV fluids. The nurse is preparing to administer norepinephrine. This intervention is intended to correct this underlying hemodynamic problem.
What is INCREASING SYSTEMIC VASCULAR RESISTANCE/MAINTAINING MAP?
A client receiving a heparin infusion develops a sudden severe headache and vomiting. The nurse should perform this focused assessment before assuming the symptoms are medication-related.
What is a neurologic assessment for intracranial hemorrhage
A client with SIADH has a sodium of 118 mEq/L and becomes confused. The neurologic manifestations are primarily caused by this movement of water.
What is water moving into brain cells due to decreased serum osmolality, causing cerebral edema?
Which patient requires immediate assessment?
A patient with DKA whose glucose decreased from 520 to 280 mg/dl
A patient with a head injury who suddenly becomes difficult to arouse
A patient with pneumonia producing yellow sputum
A patient with hypertension whose BP is 168/94mmHg
What is a patient with a head injury
patient taking lisinopril develops swelling of the lips and tongue. What is the nurses priority action?
Give the next dose with food
Place the patient supine
hold the medication and assess/protect the airway
Administer potassium
What is hold the medication and protect the airway
A client with a tracheostomy suddenly becomes restless, cyanotic, and has markedly decreased breath sounds. The nurse suspects an obstructed airway and should perform this intervention immediately.
What is SUCTIONING THE TRACHEOSTOMY?