BLS
In an unresponsive person, this should be checked for 5-10 seconds
What is a pulse and breathing?
The nurse should anticipate monitoring this continuously on a patient who is being admitted with new onset AFIB?
What is cardiac monitoring?
The nurse most closely monitors for this complication in post operative patients who are immobile. Signs and symptoms include leg swelling, pain, tenderness or warm skin
What is a DVT?
Chest pain/pressure, jaw pain, left arm pain, impending doom, shortness of breath, nausea, diaphoresis
What are symptoms of an MI/heart attack?
Enlargement of the liver
What is hepatomegaly?
Ratio of compressions to ventilations performed on adults without an advanced airway
What is 30:2?
Most appropriate vital sign to be monitored continuously for ventilator dependent patients in the hospital
What is SpO2 or pulse oximetry?
The nurse will be most concerned about this complication on a post operative patient that has the following vital signs:
HR: 125 BP: 88/46 Temperature: 102 F
RR: 28 SpO2: 91% on RA
What is Sepsis?
Difficulty walking/balancing, blurred or double vision, loss of vision, facial weakness or numbness, weakness in one side of the body, slurred speech, difficulty speaking. Needs to be addressed immediately
What are signs and symptoms of a stroke?
Surgical removal of the gall bladder
What is cholecystectomy?
5 back slaps and 5 chest thrusts
What action is done to relieve choking in a responsive infant?
Numeric Scale, FLACC, CRIES, PAINAD, CPOT etc.
What are the pain scales?
This should be monitored closely, as ordered, on all patients to assess adequate blood flow to the kidneys and assess fluid balance
Hint: minimum: 0.5ml/kg/hr on adults
What is urine output?
Shortness of breath, chest pain, cyanosis, bloody cough, diaphoresis, anxiety, lightheaded/dizziness, tachypnea
What are signs and symptoms of a Pulmonary Embolism?
Before meals
What is AC?
Maximum amount of time to check for a pulse
What is 10 seconds?
Minimum of time the nurse must stay with the patient during the initiation of a blood transfusion
What is 15 minutes?
The nurse encourages the use of this respiratory tool in post operative patients to prevent pneumonia
What is an incentive spirometer?
Shortness of breath, crackles in lungs, fatigue, swelling in the legs and ankles, rapid weight gain, persistent cough, decreased SpO2, decreased EF
What is CHF?
Supp
What is suppository?
This should be done during a resuscitation attempt before providing breaths on a patient who was choking before they went unresponsive
What is check for the object?
The nurse should anticipate monitoring this frequently in a patient whose admitting diagnosis was DKA
What is blood glucose monitoring?
The nurse is concerned about this complication in a patient who is post op day two of a ventral hernia repair. The patient has been taking opioid pain medication every 3 hours and has been refusing ambulation
What is constipation?
Increased thirst, increased urination, fruity-smelling breath, nausea vomiting, stomach pain, tachypnea, elevated anion gap, elevated blood glucose
What is DKA?
Every other day
What is QOD?