Top Missed Q's
This is the most appropriate nursing intervention when a client on mechanical ventilation becomes increasingly agitated.
What is obtaining vital signs and an oxygen saturation reading?
As a client's respiratory rate increases, this change in pH would be expected.
What is an increased pH?
When a client’s heart rate drops from 63 to 50 bpm, this is the first action the nurse should take.
What is taking the client’s blood pressure?
The nurse should closely monitor this client for signs of hyperkalemia.
Who is a client admitted 6 hours ago with a 40% burn injury?
A client in shock is producing lactate as the body attempts to compensate. This acid-base imbalance is expected.
What is metabolic acidosis?
A low ventilation and low perfusion ratio on a pulmonary function test is most commonly associated with this disorder.
What is ARDS (Acute Respiratory Distress Syndrome)?
Before administering acebutolol, the nurse evaluates the client based on this most significant effect on cardiac function.
What is decreased cardiac output? (Remember CO = HR x SVR)-olol affects HR & BP.
A client with a newly placed implantable cardioverter defibrillator (ICD) is experiencing runs of ventricular tachycardia (VT) without therapy from the ICD. This is the nursing priority.
What is notifying the healthcare provider immediately?
A client in shock is not responding well to fluid replacement. This is the next step in treatment.
What is administering norepinephrine?
Clients with these cardiac conditions require defibrillation.
A client scheduled for a CT scan with oral and IV contrast has this lab result, which requires immediate notification of the provider.
What is an elevated serum creatinine? (contrast is hard on the kidneys!)
This client has the greatest risk of developing cardiogenic shock.
Who is the client with a history of diabetes mellitus and previous myocardial infarction (MI)?
A client in cardiogenic shock is receiving intravenous dobutamine hydrochloride. This assessment finding indicates improvement in the client’s condition.
What is a urine output of 30 to 40 mL/hr? (This indicates improved perfusion!)
A client with left lower extremity cellulitis develops itchiness and dysphagia 30 minutes after starting IV antibiotics. These are the priority nursing interventions.
A nurse should question this medication order for a patient in anaphylactic shock.
What is IV furosemide?
A client with a neurological disorder is experiencing breathing difficulties. These are appropriate interventions for their care plan.
A client admitted after carbon monoxide exposure requires this method to accurately assess oxygen saturation.
What is serial arterial blood gas analysis? (A pulse ox will NOT be accurate!)
A patient with multiple traumatic injuries following a motor vehicle accident is showing these signs of hypovolemic shock.
A client with acute pancreatitis has a distended abdomen, pale skin, and weak peripheral pulses (+1). This is the first intervention the nurse should implement.
What is increasing the rate of IV fluids?
A patient who had a carotid endarterectomy 16 hours ago now has a hematoma at the surgical site. This is the best nursing intervention.
What is notifying the surgeon?
A client with severe aspiration pneumonia has an SvO2 level trending downward below normal at 55%. This clinical abnormality is the most likely cause.
What is fever and shivering?
A client with this condition is at increased risk for complications during hypovolemic shock treatment.
What is renal insufficiency? (Hypovolemic shock requires copious fluid resuscitation. Kidney patients may not handle this well)
A client with a history of lung disease is at risk for respiratory acidosis. These are the characteristic signs and symptoms of this disorder.
What are bradypnea, paroxysmal nocturnal dyspnea, and orthopnea?
When a bedside arterial pressure monitor alarm sounds, these are the assessments the nurse should perform.
A patient with a spinal cord injury is at risk for autonomic dysreflexia. These nursing measures help reduce the risk of occurrence.