Unit 1
This is the complication a nurse suspects when a client exhibits tachycardia, hypertension, dyspnea, edema, and crackles 3 hours after a blood transfusion.
What is circulatory overload?
This process is defined as the ingestion and digestion of a particle by a cell.
What is phagocytosis?
The assessment technique used to identify subcutaneous emphysema.
What is palpation?
A factor that increases the risk of developing acute respiratory distress syndrome (ARDS).
What is smoking two packs a day?
The purpose of chelation therapy as explained by the nurse.
What is removing toxic levels of metals from the body?
This transfusion reaction is suspected when a client complains of chills, back pain, and headache 45 minutes into a PRBC transfusion, with a fever and hypotension.
What is an acute hemolytic reaction?
This characteristic of nonspecific (innate) immunity makes it the body's first line of defense against infection.
What is being the first line of defense?
These lung sounds are characterized as deep, low-pitched, and rumbling noises.
What are rhonchi?
The oxygen flow rate recommended to avoid carbon dioxide narcosis in a client with chronic obstructive pulmonary disease (COPD).
What is 1 to 2 L/minute via nasal cannula?
The intervention the nurse anticipates for a client who reports taking 15 amitriptyline tablets 30 minutes ago and is seeking help.
What is gastric lavage?
These lab values are monitored routinely to assess improvement in a client with disseminated intravascular coagulation (DIC).
What are PT, PTT, and CBC?
This type of immunity provides the longest duration of protection.
What is natural active immunity?
These arterial blood gas values (pH 7.2, PaCO2 65, HCO3 30) indicate this condition.
What is respiratory acidosis, partially compensated?
Symptoms associated with Stage 1 acute respiratory distress syndrome (ARDS).
What are restlessness, dyspnea, and tachypnea?
The nursing priority for a patient on mechanical ventilation after ingesting cocaine and opioids.
What is continuous cardiac monitoring?
The appropriate intervention the nurse anticipates for a 76-year-old client with emphysema and a platelet count of 86,000.
What is a repeat platelet count in the morning?
The appropriate intervention when a nurse observes a small amount of bruising at a bone marrow aspiration site 10 hours post-procedure.
What is documenting this expected finding and continuing to monitor the site?
The appropriate nursing action for a client with arterial blood gas values showing pH 7.38, PaCO2 38 mm Hg, PaO2 86 mm Hg, and HCO3 23 mEq/L.
What is continuing to monitor the client?
A distinctive clinical manifestation of acute respiratory distress syndrome (ARDS) in a client with aspiration pneumonia on a 100% non-rebreather mask.
What is a PaO2 of 45, despite oxygen therapy?
The antidote that should be prioritized for an elderly client experiencing bradycardia and hypotension due to metoprolol overdose.
What is glucagon?
The priority admission assessment for a client with drug-induced idiopathic thrombocytopenic purpura (ITP) and a platelet count of 35,000.
What is checking the patient’s medication list?
This complication is suspected when a patient 5 days post-hematopoietic stem cell transplant develops a sudden high fever, significant red rash, gastrointestinal bleeding, and hematuria.
What is engraftment syndrome?
The most important nursing action for a client with acute respiratory failure and arterial blood gases showing pH 7.33, PaCO2 65, HCO3 30, PaO2 65, and SaO2 80.
What is preparing for intubation?
A finding in a client with ARDS on mechanical ventilation with PEEP of 10 cmH2O that requires immediate intervention.
What is a blood pressure of 65/30?
The priority assessment finding in a client receiving IV sodium bicarbonate after a salicylate overdose.
What is an altered level of consciousness?