exam 2 questions

What is the best way to check for patency of the arteriovenous fistula for hemodialysis

Palpate the fistula throughout its length to assess for a thrill

pain medication on patient needs to be IV for fresh burns for dressing change

...

normal ICP

0-10

The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is no pain." How will the nurse categorize this injury?

3rd degree

Patient has neurogenic shock, would the patient be tachycardic?

NO - don't have sympathetic responses anymore because that is all neurologically controlled

What are you going to do to make sure patient leaves facility and has best outcome?

??

A client developed cardiogenic shock after suffering a severe myocardial infarction and failure. The client now has developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was

A decrease in the blood flow through the kidneys

During the peritoneal dialysis, the nurse observes that the solution draining from the clients abdomen is consistently blood tinged. The client has a permanent dialysis catheter in place. The nurse should recognize that the bleeding

Indicates abnormal blood vessel damage

What color should dialysis solution be?

Clear (read through it), can be slightly yellow tinge but never cloudy. No brown flakes, should never be red.

The client with acute renal failure is recovering and asks the nurse "will my kidneys ever function normally again?" the nurse's response is based on knowledge that the client's status will most likely

Continue to improve over a period of weeks

Phase of transport

Notification and acceptance by the receiving facility AFTER ASSESSMENT AND STABILIZATION

late signs of ICP

Dilated, nonreactive pupil Unresponsiveness to verbal or painful stimuli Abnormal posturing patterns (flexion, extension, flaccidity) Changes in respiratory system

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.

Elevate the head of the bed to 90 degrees Loosen constrictive clothing Assess for bladder distention and bowel impaction Administer antihypertensive medications

early signs of ICP

Headache N/V Amnesia for events Altered LOC Restlessness, drowsiness, changes in speech, loss of judgement

When caring for a client with a head and neck trauma following a vehicular crash, the nurse's initial action is to?

Immobilize the cervical area

pancreatic enzymes

Pancreatic enzymes help break down fat, protein, carbs Also neutralizes stomach acid in small intestine

A client with chronic renal failure receives hemodialysis three times a week. In order to protect the fistula, the nurse should:

Report the loss of a thrill or bruit on the warm with the fistula

A client has been admitted with acute renal failure. What should the nurse do? Select all that apply

Take vital signs Call the admitting health care provider for prescriptions

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client?

Use the unaffected arm for BP measurements

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all that apply.

Wear a wristwatch on the right arm Assess finger on the left hand for warmth

cerebral edema causes

lesions (tumors, abscesses, clots) injury (contusions, hemorrhage, post traumatic brain swelling) surgery infection toxins (lead and arsenic) systemic metabolic conditions (liver and renal failure)

16 y/o patient was in an MVC, has abdominal trauma and whispers to you "I'm pregnant." Does that change your assessment?

Yes, BUT mom stays priority with ABCs 1st priority: 16-year-old 2nd getting fetal HR important to get oxygen on these patients right away

above T2-T8 loss of function

loss of intercostal muscle function

Do we want our patients to assess their fistulas or access them?

assess them

fistulas

at the site you expect to feel a thrill and hear a bruit

above c4 loss of function

loss of phrenic nerve function; loss of respiratory effort

penetrating injury

can predict very closely by force and how long and diameter of weapon skin disruption

The client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should:

warm the dialysis solution in the warmer

what med do you give with hepatic encephalopathy

lactulose

fistula nurse shift check

every shift check for bruit and thrill, distal circulation (color of hand), no obvious signs of bleeding

s/s of potential airway damage

facial burns singed nasal hairs progressive hoarseness stridor inability to swallow edema of oropharynx give cool humidified oxygen/ possible ET

is it an MI or from the sclerosing agent, what should you do?

get an EKG

The client has experienced an electrical injury with an entrance wound on the left hand and an exit wound site on the left foot. What is the priority assessment data that should be obtained from this client immediately on admission?

heart rate and rhythm

major complications of cirrhosis

hepatic encephalopathy ascites esophageal varices (most likely to kill)

A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patients BP because of which change that is associated with liver failure?

hypoalbuminemia

direct force

initial direct load injury resulting from a dynamic energy load

hepatic encephalopathy

major confusion

'mechanism of injury'

means what forces caused the injury

blunt injury

no breakage of skin, skin is still intact

What are you going to look for in a patient with face burns

nursing dx?

test questions on acute renal failure

pre- above the kidney intra- in the kidney post- after the kidney (lower urinary tract systems involved)

fistula pt education

pt has to check site daily when they go home check periodically to make sure they are not oozing blood teach how to check/assess for thrill and bruit, radial pulse, distal circulation, color of hand

your patient has a GI compression device and complains of SOB. what is the first thing you want to do?

pull it out keep scissors at bedside

indirect force

results from direct force injury from secondary insult ex: lack of oxygen or blood supply

what is the biggest priority with hepatic encephalopathy

safety

cerebral edema tx

steroids, diuretics, and hypertonic solutions

You are caring for a client who is undergoing peritoneal dialysis. You note the color of the returned fluid to appear cloudy and slightly pink-tinged. What is your best action?

stop the dialysis flow and notify the health care provider

Peritoneal dialysis: you're due to drain. You put in 2L of fluid and 2L is not coming out. What do you do?

turn pt

asterixis

twitching in hands

where do you palpate for an enlarged liver?

underneath ribs on the anterior right side; lower right quadrant