Final review

What CD4+T count attributes to an AIDS diagnosis?

<200

Nurse assessing a pt with a femur fx. Nurse obtains VS on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse the client could be developing a serious complication?

A RESPIRATORY RATE OF 18 TO 26

Client who sustained head injury, is intubated on SIMV node. Nurse should tell the family that SIMV means what?

THIS IS SHARED MODE, THE CLIENT WILL BREATHE SPONTANEOUSLY BETWEEN SET VENTILLATOR BREATHS

Client in ICU on vent for 2 wks with ET tube. Which intervention should be prepared next?

TRACHEOSTOMY

An infectious disease specialist is teaching a group of nurses about risk factors regarding infectious diseases of the heart. An infectious disease specialist will include which of the following in the teaching?

Talk about oral hygiene, IUD's, getting antibiotics before you go and have dental work done, prolonged catheter use, and body piercings.

After a positive PPD, what test would be expected next to rule out active disease?

chest x-ray

which of the following symptoms observed by the nurse indicates liver biopsy complications?

decreased BP and elevated heart rate due to bleeding

gastrectomy avoid which of the following?

don't drink liquid with meals

Nurse performing admission assessment on pt diagnosed with right side colon tumor? characteristics?

dull abdomen pain

EGD

gag reflex

Metabolic alkalosis

high pH and high HCO-3

Resp Alkalosis

high pH and low PaCO2

Tidal Volume

how big a breath that is delivered to the client when the breath is a vent breath.

Rate

how many breaths the ventilator is set to deliver to the client.

Bulging fontanels can mean what?

hydrocephalus, increased ICP, meningitis, echephalitis

Resp acidosis

low pH and high PaCO2

Metabolic acidosis

low pH and low HCO-3

Compensated

pH is within normal range, PaCO2 and HCO-3are both high

nurse is assessing pt with cholecystitis for development of jaundice?

pale/ clay-colored stool and itchy skin

Intestinal obstruction with acute pain even with NG tube is draining and patent

perforation/rigid abdomen

Crohn's with diarrhea, cramping, abdominal pain, wt loss monitor what?

potassium

Pyloric stenosis

projectile vomiting

bedrest for UC

reduce intestinal peristalsis

Intussusception symptoms

sausage like mass and bloody/mucus in stool

gastric bypass high in b12

Meats

What disease has a positive Brudzinski's sign?

Meningitis

Colon polyps removed via colonoscopy purpose?

Risk of colon cancer

How would a nurse identify squamous cell carcinoma?

Rough & scaly with central ulceration

Ulcerative colitis patient coming to inpatient side/ dehydration

antidiarrheal

A client has DIC, which clinical manifestations should you expect the nurse to observe?

BP decreased and HR elevated. They're bleeding.

An adolescent who has experienced blunt trauma to the abdomen, which of the following is the nurse's priority?

BP that is going down

Nurse expects which finding in a pt with low controlled asthma?

BREATH SOUNDS CLEAR BILATERALLY

Caring for a pt with a PE. Nurse would expect which assessment finding for this pt?

SUDDEN ONSET OF CHEST PAIN AND DYSPNEA

Name some signs of peritonitis.

Hard-rigid abdomen, fever

What is an ERCP used for?

Helps to visualize the biliary and pancreatic ductal system.

What does protein in the diet do?

Helps with wound healing/tissue repair

Client Dx with ARDS has RR 24, HR 114, ABG indicated Pao2 of 54% on 02 at 10L per min. which should nurse prepare for first?

THEY ACCEPTED PREPARE FOR INTUBATION AND BAG THE CLIENT

The nurse is preparing a client for a transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor what?

Hemodynamic status

gallbladder removed diet?

Low fat

When a patient exhibits weight gain in a short period of time, what is the nurse's priority assessment?

Lung sounds

Pt recently intubated and placed on mechanical ventilation. PRIORITY nursing action?

MONITORING BLOOD PRESSURE Q1 HR.

Which hormones are released from the anterior pituitary exerting an effect on the adrenal glands and the thyroid gland?

-ACTH -TSH

A nurse is aware that which of the following conditions can increase the patient's risk of hypovolemic shock?

-Burns -Diarrhea -Diuresis

Patient on the tele unit has been diagnosed with HF. The nurse is aware that which of the following factors can cause HF?

-CAD -Afib -Recreational drug use

Name two diseases that need to be on airborne isolation.

-Chicken pox -TB

What hormones are released from the adrenal glands and the thyroid to exert an effect on the hypothalamus?

-Cortisol -T3, T4 and Thyrocalcitonin

Which hormones are secreted from the hypothalamus exerting an effect on the anterior pituitary?

-Cortisol Releasing Hormone -Thyroid Releasing Hormone

Nursing student assisting with care for a pt on a vent. Which action performed helps prevent ventilator acquired pneumonia?

MOUTH CARE

A nurse is obtaining a health history for a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?

"Has your child had a sore throat recently?"

Family of client with SIADH asks nurse if water restriction is a punishment for pts uncooperative behavior. Which is best response?

"LIMITING FLUID PREVENT BLOOD FROM BECOMING MORE DILUTE AND CAUSING MORE COMPLICATIONS"

Nurse teaching dietary changes necessary with COPD. Which statement indicates an understanding?

"MILK PRODUCTS MAKE SECRETIONS THICK AND HARD TO COUGH UP"

What are the D's of diabetes insipidus? What does each D mean for the body?

-Deficient ADH - means there is nothing to stop the kidneys from diuresing. -Diuresis - peeing a lot -Dehydration - when the vascular system has a decreased amount of fluid -Drink - this is the body's compensatory mechanism because the body needs fluid -DDAVP - medication used to treat DI. Most common route intranasally

Which data collected by the nurse caring for a patient who has cardiogenic shock indicates the patient may be developing MODS?

-Extremities are cool -Bilateral crackles -Kidney function

Nurse caring for pt with cushings. Which manifestation is cushings?

-FACIAL HAIR -TREMORS -MOON FACE -PURPLE STRAIATIONS -BUFFALO HUMP

Client recovering from hypophysectomy. Which postop is priority?

-GET PREDISONE, FLORINEF, SYNTHROID REPLACEMENT -HOURLY NEURO CHECKS 24 HOURS -ASSESS POST NASASL DRIP

Presenting with acute respiratory distress. What assessment findings would you anticipate?

-HR & RESP -USE OF STERNTRAPEZIOUS MUSCLES? -SIT IN TRIPOD POSITION -HIGH ANXIETY LEVEL

What is the difference between a hypophysectomy and a bilateral adrenalectomy?

-Hypophysectomy is the removal of the anterior pituitary requiring the client to replace a multitude of hormones. The highest priority being levothyroxine, cortisol, and florinef. -Bilateral adrenalectomy is the removal of the adrenal glands and requires the replacement of only the adrenal hormones. Specifically, cortisol and florinef.

Client has ssuepcted addisons. Which diagnostics report supports?

-LOW SODIUM -CALCIUM ELEVATED -LOW GLUCOSE

What are the manifestations of SIADH the nurse needs to monitor?

-Mental changes from confusion to coma due to increased intracranial pressure secondary to the decreased sodium levels. Remember when sodium levels drop around 110 to115 fluid moves from vascular space to intracranial. -Seizures increased intracranial pressure -Cramps, tremors, nausea and vomiting due to electrolyte imbalances. -Weight gain due to the excess fluid.

What effect does SIADH (increased antidiuretichormone) and DI (deficiency in antidiuretic hormone)have on the blood volume. Think about what happens to BP, and electrolyte values.

-SIADH causes the client to retain fluid. This dilutes all the electrolytes within the blood (potassium, sodium, calcium, phosphorus, hemoglobin, etc. are all decreased) and blood pressure is increased because the vascular volume is so high. -DI causes the client to loose fluid and become dehydrated. This makes blood components increased and blood pressure decreased.

What signs and symptoms would the nurse expect to see in a client experiencing thyrotoxicosis(thyroid storm)?

-Sweaty report 1 degree increase in temperature -Tachycardia greater than 140 beats per minute -High systolic, low diastolic, but eventually hypotensive to shock -Irritable -Confusion

When prioritizing arterial blood gases, which component is the highest priority to evaluate?

-The answer is pH. Everything in a blood gas will affect the pH causing it to be more acidotic or more alkalotic. Acidotic pH's are a higher concern than alkalotic pH's. The lower the pH the higher the concern. -Once the pH is within normal range then look at the PaCO2and HCO-3. If both are normal the blood gas is normal. However, if the pH is normal but the PaCO2 and HCO-3. are out of normal range, then the blood gas is compensated.

⦁ Client has chronic hypercortisolism. Which is highest priority?

-WASH HANDS WHEN ENTERING ROOM (DECREASED IMMUNE SYSTEM)

By definition what is ARDS (adult respiratory distress syndrome)? What is the highest priority in treatment?

-hypoxemia in the presence of oxygen. -Highest priority is to get the client to oxygenate. Remember these clients have a high mortality rate

A patient has 65% TBSA and weighs 220pounds. How many ml/hr would the nurse infuse in the first 8 hours? Use the Parkland formula.

1,625 ml/hr

Contact dermatitis is caused by?

A direct exposure to an allergen, chemical, or mechanical irritation

Client has hormone deficiency. Which deficiency is highest priority?

ADH

Scheduled for adrenalectomy. Immediately preop nurse should do what?

ADMINISTER IV STEROIDS

When teaching pt with primary addisons. Nurse explains disease results from which problem?

ADRENAL GLAND DYSFUNCTION

Hypotension associated with addisons involves a disturbance in production of?

ALDOSTERONE

Hypovolemic shock is caused by?

ANY type of fluid loss. (diarrhea, vomiting, diuresis, etc)

Nurse caring for pt presenting with RR 28, accessory muscle use, and HR of 138. On 100% nonrebreather with spo2 of 86%. Crackles in breath sounds. Nurse suspect client has what?

ARDS

Nurse caring for pt who has been on bedrest for several days. Auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize this pt has which of the following conditions?

ATELACTESIS

Which nursing diagnosis will be priority for the client with myocarditis?

Activity intolerance

turners sign/ cullons sign?

Acute pancreatitis

What diets are appropriate for Addison's?

Addison's need salt and glucose

How will the nurse know that fluid resuscitation has been successful?

Adequate urine output

A nurse receives an order to administer a colloid solution for a patient experiencing hypovolemic shock. Which common solution would the nurse most likely administer?

Albumin

What do you screen patients for prior to an ERCP?

Allergy to contrast dye

74 y/o with dyspnea, persistent cough, and unable to sleep at night due to difficulty breathing. Nurse notes crackles, RR 25, and O2 90% on RA. Which lab confirms HF?

BNP

Diagnosed with HF. Which lab data would indicate that the client is in sever congested HR?

BNP

What is the most common lab diagnostic regarding heart failure?

BNP

A nurse is caring for a client who is in a Compensatory stage of shock. Which of the following findings should the nurse expect?

BP 115/68

Name a GI disease that can use an ultrasound to diagnose

Appendicitis

nurse caring for client with portal vein HTN?

Ascites and esophageal varies

What is the most common risk factor for a AAA?

Atherosclerosis

Nurse assist with chest tube insertion for pt with a spontaneous pneumothorax. Which data indicates tx has been effective?

BILATERAL BREATH SOUNDS

In order to diagnose GI disorders that cause weight loss, what must be done for a definitive diagnosis?

Biopsy

A patient with DIC should be placed on which safety precautions?

Bleeding

Name the main difference between Crohn's disease and UC.

Blood in the stool

A nurse is caring for a client who has valvar heart disease and is at risk for developing left sided HF. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness

Patathyroid gland responsible for regulation of which of the following

CALCIUM AND PHOSPHORUS

Client was intubated, now extubated, and placed on venturi mask. Prior to extubating, ph was 7.38, co2 38, and pao2 90. 1 hr after being placed on venturi mask another ph was drawn. Ph 7.3, co2 58, pao2 54. Which action is most appropriate?

CALL PHYSICIAN AND PREPARE FOR INTUBATION

Nurse assessing for hypoxemia. Which should nurse expect?

CONFUSION

Client admitted with asthma. Blood gas: pH- 7.38, Co2-38, bicarb-24, and PaO2-92. Nurses best action?

CONTINUE TO MONITOR

What diets are appropriate for COPD?

COPD clients are carb restricted because when carbs breakdown the break into CO2 and water. These clients already have too much CO2

Assessing pt with exacerbation of COPD secondary to a URI. The nurse should expect what?

COURSE CRACKLES AND RHONCI

A resection of an AAA yesterday, the client has an IV infusion at a rate of 150 mL/hr unchanged for the last 10 hours. The client's urine output for the 3 hours has been 90, 50, and 28. BUN is 35 and Creatinine is 1.8 measured this morning. What nursing action is your priority?

Call the doctor

An electrical burn can cause?

Cardiac dysrhythmias

The nurse on a Med-Surg floor is providing diet discharge teaching of a patient with a history of HF. Which of the following statements made by the patient represents that they understood the diet teaching?

Consumption of frozen meals because frozen meals have a lot of salt in them.

What types of isolation precautions are there?

Contact isolation, droplet isolation

Name some symptoms of TB.

Cough 3 weeks or longer, low grade fever, weight loss, poor appetite, night sweats

Name some signs of acute pancreatitis.

Cullen's and Turner's sign

What diets are appropriate for Cushings?

Cushing's need to limit salt, and carbs because they have an elevated sodium and glucose level.

Nurse caring for a client being tx for asthma attack. Nurse determines respiratory status is worsening if which of the following is assessed?

DECREASED BREATH SOUNDS

Nurse would expect to see increased RR if pt has which of the following?

DECREASED PH LEVEL

What is the highest priority with having too much PEEP on the ventilator?

Decrease in blood pressure. Increased PEEP places pressure on the superior vena cava decreasing the amount of blood returned back to the heart. This decreases cardiac output, which causes a decrease in the blood pressure.

A client with infective endocarditis is admitting to the medical department, which health care provider's order should be implemented first?

Do blood cultures

Nurse understands increase in TSH will produce effect on which organ/gland?

EFFECTS THYROID GLANDS

The cardiac lab has faxed a stress test report to the floor nurse. The nurse is aware that the patient is in HF when the ejection fraction is noted at which of the following?

Ejection fraction below 40 indicates HF.

cirrhosis?

Elevated urine output

What happens in the rehabilitative phase of burn care?

Emotional support, promoting wound healing, nutrition, and physical function.

Inhalation injuries tend to happen in which areas?

Enclosed

What is the effects of portal vein hypertension?

Esophageal varices, ascites, splenomegaly, hemorrhoids, encephalopathy

True or false. DIC is a genetic disorder involving a vitamin K deficiency.

False. DIC is abnormal coagulation involving fibrinogen

Risk factors for dilated cardiomyopathy (DCM)include:

Family history, substance abuse, hypertension

Which lab result would the nurse expect for a client diagnosed with DIC?

Fibrinogen

Pericarditis. The nurse can expect to hear what type of sound?

Friction rub

Client is 6 hr post op. Reports fatigue and SOB when getting up to walk to the bathroom. Pulse ox is 91%. What is the nurses best action?

GET A CBC

Nurse knows which intervention is priority with hypothyroidism?

GIVE 6 SMALL WELL BALANCED MEALS A DAY

Herpes simplex virus type 2 is found on which part of the body?

Genitalia

upper GI test following xray?

Give stool softener/ increase fluids

Nurse on surgical unit caring for pt who had a Whipple for pancreatic cancer which of the following is the highest priority?

Glucose

celiac disease

Gluten free diet

When doffing PPE, based on the CDC recommendations, what does the nurse remove third?

Gown

Which statement explains why pt with Cushing's may experience manifestations of diabetes mellitus?

HAS TO DO WITH GLUCOCORTICOIDS EXCELETRATE PROCESS OF GLUCOGENESIS

Nurse assessing pt with emphysema. Which finding requires further follow up with the physician?

HEMOPTYSIS (BLOODY COUGH)

Which of the following reoccurring conditions most commonly occurs in the client with cardiomyopathy?

HF

A nurse is assessing a client who has left sided heart failure. Which of the following findings should the nurse expect?

Hacking cough

The hallmark finding of impetigo is?

Honey-crusted lesions

Clinical signs & symptoms of hypovolemic shock include?

Hypotension & tachycardia

What diets are appropriate for hypothyroidism?

Hypothyroidism require an increase in fiber secondary to the constipation associated with hypothyroidism.

Nurse understands which statement about peep is true?

IMPROVES GAS EXCHANGE

Nurse caring for a client coughing up thick secretions. Which action would promote thinning of respiratory secretions?

INCREASE FLUID INTAKE

Clients serum sodium 128 and potassium 2.8. which problem is likely to cause this?

INCREASED ADH

Caring for pt with serum sodium 112. Highest priority?

INCREASED ICP

Which condition priority for nurse to monitor after a hypophysectomy?

INCREASED ICP

Experiencing DI. Expects what?

INCREASED PLASMA OSMOLARITY POOR SKIN TURGOR HYPERTHERMIA ATAXIA

42 y/o female with suspected graves (hyperthyroidism). Which findings is expected?

INCREASED PROTEIN AND FAT SYNTHESIS INCREASD STROKE VOLUME INCREASED TEMPERATURE HYPERGLYCEMIA

Planning care for pt admitted bleeding esophageal varies interventions?

IV fluid bolus, RBCs, tube, TIPS

What would you do for a client with peritonitis?

IV fluids, antibiotics, high-fowler's position, NPO, prepare for surgery

A nurse on the ICU is taking a patient diagnosed with DIC. The nurse should question which of the following physicians orders?

Ibuprofen

What is the purpose of PEEP?

Improve oxygenation by increasing surface area of the alveoli tissue to the blood supply

pt with cirrhosis?

Ineffective breathing R/T pressing on the diaphragm

What is reverse isolation?

Isolating a patient because they are severely immunocompromised. Mask, gown, gloves. Private room.

What is the leading cause of acquired heart disease in children?

Kawasaki disease

What is kernig's sign?

Knee flexed 90 degrees, hip flexed 90 degrees, and when trying to extend the knee, it is painful

Nurse caring for pt on vent. Which action most important to prevent a pneumothorax?

LIMIT PRESSURE

Which dietary alteration should make with cushings?

LOW SODIUM AND LOW CARB DIET

Acute pulmonary edema because of HF is usually the result of damage to which of the following areas of the heart?

LV

The nurse in the ER is caring for a patient experiencing shock. Which lab result demonstrates that the patient's cells are using anaerobic metabolism?

Lactic Acid

A nurse is caring for a client who has heart failure and a potassium level of 2.4. The nurse should identify which of the following medications as the cause of the clients low BP?

Lasix (furosemide)

pt with cirrhosis and hepatic encephalopathy?

Mental status change

Pt in ER with acute pancreatitis what kind of diet?

NPO

risk for PUD?

NSAIDS, stress, smoking

diverticulosis to prevent itis?

Need daily BM

What is the purpose of an arterial line insertion("A-line")?

Needed for continuous BP monitoring and blood specimens for ABGs & other blood tests

Would you place a patient who had a hemorrhoidectomy in high-fowler's?

No

What is the hallmark sign of meningitis?

Nuchal rigidity

Client dx with hyperparathyroidism. Which following should nurse expect to find?

OSTEOPEROSIS WEIGHT LOSS INCREASED SERUM GASTRUM LEVEL MENTAL STATUS CHANGES

When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome. The nurse is aware that it is what type of shock?

Obstruction

A toddler with heart failure would exhibit?

Orthopnea

nurse caring for pt experience ADH inbalance. Nurse says ADH is secreted from which gland?

POSTERIOR PITUITARY

Nurse caring for pt with hyperparathyroidism should assign priority to which intervention?

PREVENTING FALLS

Which is priority in Addisonian crisis?

PREVENTING IRREVERSIBLE SHOCK

during episode of chest pain nurse notices which ECG would be an indicator of first-degree heart block?

PROLONGES QT INTERVAL

Charge nurse assigning pts on a new shift. Which pt should go to the new grad?

PT ON THE VENTILATOR ON PRESSURE SUPPORT FIO2 35 AND 7 PEEP

Nurse caring for several pt on respiratory unit. Which should be seen first?

PT WITH A SP02 91% ON 2 L ON A YOUNGER ADULT

What are signs of bowel perforation?

Pain, bleeding, hypovolemic shock symptoms

What is the next step regarding irreversible shock?

Palliative care.

Shiny, bright red, blistered, and extreme pain is considered which type of burn?

Partial-thickness

A client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative treatment intervention should the nurse anticipate?

Pericardiocentesis

A common manifestation of right-sided heart failure includes?

Peripheral edema of the stomach, arms, & legs

Acute appendicitis/ rigid abdomen?

Peritonitis

How can a nurse determine multiple organ dysfunction syndrome (MODS)?

Poor kidney function

abdominal girth increased with cirrhosis related to which complication?

Portal vein HTN

PEEP

Positive end expiratory pressure splints the alveoli open to improve gas exchange

Nurse assessing pt with small bowel obstruction?

Projectile vomiting, inability to pass stool and gas for more than 8hrs, onset dehydration, increased bowel sounds above obstruction

A patient comes to the ER with acute shortness of breath, a cough that produces pink frothy sputum. Admission assessment reveals crackles and wheezes, BP 85/46, HR 122, RR 38. The client's medical history includes diabetes, HTN, HR. Which of the following does the nurse suspect?

Pulmonary embolism or edema, not sure which one she said

The nurse is aware that which type of cardiomyopathy is not caused by genetics?

RCM

Which hormone regulated or secreted by the hypothalamus?

RELEASING HORMONES

Receiving mechanical ventilation for 5 hours and has the following ABG: pH:7.32, co2: 87, bicarb 25. Based on this, nurse would anticipate a change in which vent setting?

RESPIRATORY RATE

Providing diet teaching with cushings. What recommendation?

RESTRICT SODIUM INTAKE

When a patient is immunocompromised, what is one way you can protect them?

Restrict visitors that are ill

Rheumatic endocarditis is caused by?

Rheumatic fever, untreated strep throat and scarlet fever

Which of the following conditions is most commonly associated with weight gain, nausea, and an inflamed spleen?

Right sided

A 70 year old patient that is malnourished and has type 2 diabetes and is admitted to the nursing home with pneumonia and a fast HR. For which kind of shock should the nurse closely monitor this patient?

Sepsis

A client with which condition is of greatest risk of developing DIC?

Septic Shock and Sepsis

A common manifestation of left-sided heart failure includes?

Shortness of breath

What are two of the symptoms of small bowel obstruction?

Sporadic, colicky pain, vomiting

The treatment option of choice for AAA that is 6 cm?

Surgery, because it has to be greater than 5.5.

Nurse review lab values in client with primary hypothyroidism. Nurse anticipates elevation in which value?

T3 T4 THYROID CALCITONIN?

If the ventilated client is displaying a low PaO2on the ABG, which change to the ventilator would the nurse expect?

The first change would be to increase the FiO2. Once the FiO2 reaches 100%, then an order to start increasing PEEP would be received.

Tinea pedis is found where on the body?

The foot, between the toes.

It is important to inform the provider before any invasive procedures with a history of infective endocarditis. True or false?

True. Antibiotic prophylaxis will need to be initiated

Client on vent on assist control. Tital volume 550, FiO2 45% and peep 7. Respiratory rate is 22 breaths a minute. How many ventilator breaths is a client receiving?

They accepted the 10 and the 22

What is the highest priority for a client experiencing respiratory distress?

This depends on the client. If they have no oxygen on, the apply oxygen and sit them up. If they are receiving high flow oxygen and the distress is not resolving, then ambu until intubation can occur.

Which patients have the highest priority when assigning private rooms?

Those in need of airborne isolation

The client is on A/C of 12, Vt of 750 mL FiO2 of 50% and 7.5 of PEEP. The total respiratory rate on the ventilator is 16. What is the total ventilator delivered rate? What is the client's independent rate? (Not ventilator delivered)

Total ventilator rate is 16. Because the mode is A/C all the breaths are delivered by the ventilator. Even the ones that are client initiated. Client's independent rate is 0 If the client was on SIMV then the set rate would be subtracted from the total rate to determine the client's independent rate. If the client is on PSV, then all the breaths are client breaths and there are not ventilator breaths.

Dx with hypothyroidism. Which of the following symptoms expected?

WEIGHT GAIN FINE THIN HAIR WITH HAIR LOSS DECREASED ENERGY, FATIGUE, & CONSTIPATION

Nurse auscultating chest of a pt with asthma. Nurse expects which breath sound?

WHEEZING

Nurse assisting pt with hypothyroidism with meal planning. What should nurse recommend adding to the diet?

WHOLE GRAINS

A client is in respiratory acidosis according to the arterial blood gas. Which changes to the vent would the nurse expect?

When the client is in respiratory acidosis on the ABG, the pHis low and the PaCO2 is high. Therefore, to get rid of some of the CO2 the client needs to breath faster. Increasing the rate on the ventilator will decrease PaCO2.

Client with chronic obstructive pulmonary disease asks why he is having increased difficulty with fine motor skills such as buttoning his shirt. Which response is most therapeutic?

YOUR BODY ISNT RECEIVING ENOUGH OXYGEN TO SEND DOWN TO THE FINGERS. THIS CAUSES THEM TO CLUB AND MAKES DEXTERITY DIFFICUT

Diverticulitis labs

amylase

evaluating pt with IBD which labs not helpful

amylase/lipase

care for pt late-stage cirrhosis precautions highest priority?

bleeding

SIMV

shared mode. The client receives a set number of vent breaths and breathes on their own in between vent breaths.

dietary for prevention of reflux?

small frequent meals

risk factors colorectal cancer

smoking, alcohol, history of IBD, increased fat/protein diet

Pilonidal Cyst?

stool softeners

PSV

the client is totally breathing on their own. The vent is not doing any of the breathing

Assist Control

the vent is doing all the work. The client can trigger a breath, but the vent is the one who delivers the breath

FiO2

this is how much oxygen that is being added to the air the client is breathing.

pain for appendicitis?

where did the pain start?