GI/Misc
This is the purpose of an NG tube in someone with a bowel obstruction
To decompress the stomach
This lab result would be expected to be increased in a pt with multiple myeloma
CALCIUM
(due to the bone destruction occurring in the disease process)
This is the order of how you should removed soiled PPE:
Gloves-goggles-gown-mask
This lab value is expected to be elevated in a pt with hypothyroidism
TSH
This is a late sign of increased ICP
nonreactive/dilated pupils, widened pulse pressure, bradycardia
When performing an assessment on a child, when should the nurse examine the child's ear?
At the END of the assessment, as this can be traumatic to the child and cause the assessment to go downhill quickly :)
You are caring for a child with sickle cell anemia. What electrolyte imbalance should you monitor for?
Hypokalemia due to treatment-related diuresis
What vaccines should be given to a 1 year old child?
MMR, Varicella
What nursing interventions should be performed for a client with new onset DI?
Check urine specific gravity-in DI, is typically less than 1.005.
What is the nurses priority when caring for a hospitalized patient with osetomyelitis?
Administering antibiotics
When administering numerous medicatons to a pt with an NG @ LIS, what precautions should the nurse take?
What is: admin the meds separately, flush the tube between each med with 15-30 ml STERILE water, pinch or clamp the NG tube after disconnecting from suction (to not allow air into the stomach)
This transfusion reaction occurs when the recipient's antibodies in his blood destroy the donor's blood cells. This can result in kidney injury, DIC and circulatory collapse in the recipient.
HEMOLYTIC transfusion reaction
Priority nursing assessment in pt experiencing anaphylaxis after a bee sting:
Auscultate for wheezing
This is the process of how to mix clear and cloudy insulin
Inspect vials-Roll cloudy b/w palms-inject air into cloudy-inject air into clear
This is a priority assessment immediately following a tibial cast placement
Checking CMS/Cap refill of toes
These actions are what a nurse should take when their pt is experiencing a seizure?
Loosen restrictive clothing if able, place a pillow under the pts head, turn the pt on his/her side if able
Expected findings in someone with DIC
Excessive thrombosis, bleeding of mucous membranes, decreased platelet count, depletion of clotting factors and fibrinogen
Do not serve raw fruits or vegetables, do not allow fresh flowers/plants in the room, protective isolation should be instated, do not use a humidifier
You are caring for a having an Addisonian crisis. What nursing action should you anticipate?
Administering insulin to treat hyperkalemia
Which nursing action is most likely to relieve headache following a lumbar puncture?
Increase the pt's fluid intake
A pt who has suffered several left lower leg fractures is experiencing increasing edema to the leg. This a manifestation of what complication?
Possible compartment syndrome
These are the manifestations of fat emboli syndrome
SOB, increased heart rate, agitation, headache, petechiae of the chest and neck
Someone with a CD4 count of less than 200 cells/mm3 would be considered to have which stage of HIV?
What is AIDS, or stage 3 HIV
A 29-year-old client with type 1 diabetes is admitted to
the ED with nausea and abdominal pain. His respiratory rate is 34/min with deep breaths and a fruity smell to his breath. He is responsive, but difficult to arouse.
1. What does the nurse suspect is happening with this client ?
2.What serum glucose level would the
nurse expect to see with this client?
1. The symptoms are consistent with diabetic
ketoacidosis (DKA).
2.The client’s glucose level is likely >300 mg/dL.
When caring for a pt with quadriplegia, the pt states he has a severe sudden headache. His BP is 200/148.
1. What do you suspect is occurring?
2. What is the priority nursing intervention?
1. Autonomic dysreflexia
2. Place the pt in an upright position