Health and Illness 5
The nurse provides discharge teaching to a patient with sickle cell disease (SCD). Which statements made by the patient indicate understanding of the teaching? (Select all that apply). "I shouldn't receive the pneumococcal injection." "I should drink 2-4 liters of fluid every day." "I should avoid high altitudes." "I should wear socks and gloves when going outside on cold days." "I can safely consume uncooked seafood."
"I should drink 2-4 liters of fluid every day.", "I should avoid high altitudes.", "I should wear socks and gloves when going outside on cold days." Rationale: Patients with SCD should avoid crises by avoiding activities that cause hypoxia. High altitudes can increase the risk for the development of hypoxia. The patient should drink 2-4 liters of fluid every day to avoid dehydration. Eating uncooked seafood increases the risk of infection; this type of product is rich in iron and should be avoided. The pneumococcal injection is recommended to prevent infection. Dress warmly in cold weather to prevent sickling of RBC's in the exposed area. Rationale: Patients with SCD should avoid crises by avoiding activities that cause hypoxia. High altitudes can increase the risk for the development of hypoxia. The patient should drink 2-4 liters of fluid every day to avoid dehydration. Eating uncooked seafood increases the risk of infection; this type of product is rich in iron and should be avoided. The pneumococcal injection is recommended to prevent infection. Dress warmly in cold weather to prevent sickling of RBC's in the exposed area. Rationale: Patients with SCD should avoid crises by avoiding activities that cause hypoxia. High altitudes can increase the risk for the development of hypoxia. The patient should drink 2-4 liters of fluid every day to avoid dehydration. Eating uncooked seafood increases the risk of infection; this type of product is rich in iron and should be avoided. The pneumococcal injection is recommended to prevent infection. Dress warmly in cold weather to prevent sickling of RBC's in the exposed area.
normal ST segment
0.08 to 0.12, not elevated
normal QRS interval
0.08-0.10
normal PR interval is
0.12-0.20
Normal INR
0.8-1.1
Bleeding time
1-9 minutes
what is the sepsis bundle
1. measure lactate level. remeasure if lactate >2 mmol/L 2. Obtain blood culture (before giving antibiotics) 3. Start on broad spectrum antibiotics 4. Begin rapid administer 30mL/kg crystalloid fluids for hypotensive or lactate level >4 5. Vasopressors is hypotension persists after fluid resuscitation to maintain MAP >65.
ARDS criteria
1. respiratory symptoms begins within 1 week 2. Bilateral opacities not explained by atelectasis/effusions 3. PaO2/FiO2: <300 with PEEP of >5 OR <200 regardless
BUN
10-20
normal PT
11-12.5 seconds
Platelets
150,000-400,000
normal MAP
70-100
normal ion gap levels
8-12 mmol/L
Calcium level
9-10.5
GFR
90-120
normal lactate level
<1.0 mmol/L
labs of hyperglycemia in diabetic ketoacidosis
>250 mg/dL
respiratory acidosis is a
decrease in respiratory drive
cause of pre-renal AKI
decreased blood flow to kidney (hypotension, septic/anaphylactic shock, burns, dehydration, hemorrhage, excessive diuretic use, dysrhythmias, cardiogenic shock, heart failure, MI)
Metabolic acidosis can be due to
diabetic ketoacidosis, lactic acid accumulation, starvation, inadequate O2 delivery, intense exercise, cardiac arrest, shock, alcoholism
metabolic acidosis is what
excess acid production
Symptoms of rejection of kidney within 48 hours
fever, HTN, pain at transplant site
Symptoms of acute HIV infection stage 1
flu like symptoms: fever (>100.4), fatigue, muscle/joint aches, pain, skin rash, HA, sore throat, swelling of lymph nodes, night sweats, diarrhea
sepsis: 3rd spacing
fluid moves out of vessels;edema
Treatment for ketoacidosis
fluid resuscitation (0.9% NaCl) 1-2L for first 2 hours, then 250-500 cc/hr. monitor patient for fluid overload and cerebral edema. Regular insulin
If procalcitonin (normal <0.15) is elevated what does that mean
has bacterial infection, distinguish between bacterial and nonbacterial infection, high levels=probability of sepsis
what can acute kidney injury lead to
heart failure, pulmonary edema
medication for sickle cell disease
hydroxurea
virchow's triad
hypercoagulability, endothelial damage, stasis of blood
diabetic ketoacidosis is characterized by
hyperglycemia, metabolic acidosis (increased anion gap), ketosis, ketonuria, dehydration
electrolyte disturbances with resp. acidosis
hyperkalemia
Electrolyte disturbances with metabolic acidosis
hyperkalemia, calcium release, Mg may decrease
electrolyte disturbances with respiratory alkalosis
hypokalemia, hypocalcemia, hypochloremia
electrolyte disturbances with metabolic acidosis
hypokalemia, hypochloremia, decreased ionized calcium from loss
criteria for qSOFA
hypotension (SBP >100) 1 point altered mental status or GCS <15 1 point tachypnea >22 1 point
qSOFA score think "HAT"
hypotension (SBP: <100), altered mental status, tachypnea (>22)
septic shock involves persistent
hypotension requiring vasopressors to maintain a MAP greater than 65 & serum lactate level greater than 2 despite volume resuscitation
Labs for sepsis
increase in WBC, neutrophils, monocytes, immature WBCs
3 phases of peritoneal dialysis
inflow (over 10 minutes), dwell (30 min-8 hours), drain (15-30 min)
How to treat hyperkalemia
kayexalate or glucose + insulin
a byproduct of cell metabolism that accumulates when cells lack sufficient O2
lactic acid
causes of prolonged PT time
liver disease, missing clotting factors, DIC, warfarin therapy
Metabolic alkalosis is what
loss of hydrogen ions (excess bicarbonate)
what kind of acid base imbalance does hypoxemic respiratory failure lead to
metabolic acidosis
45-year-old tachypneic patient in the ER with blood glucose 1100.ABG's: pH 7.25 PaC02 26 HC03 11 Pa02 99
metabolic acidosis partially compensated
lab findings for acute kidney disease
metabolic acidosis, hyperkalemia, hyperphosphoremia, hypermagnesemia, hypocalcemia, increased creatinine/BUN
Ketoacidosis starts as resulting in _____________, as an attempt to correct increases _______________, to blow off excess CO2, can lead to ____________ ___________
metabolic acidosis, respirations, respiratory alkalosis
An emergency room patient complaining of chest pain and stomach distension. ABG's: pH 7.50 PaC02 45 HC03 34 Pa02 99
metabolic alkalosis no compensation
A febrile patient admitted to ICU diagnosed with Community Acquire Pneumonia (CAP), WBC 28, BP 90/72, poor air exchange and low urine output.ABG's: pH 7.10 PaC02 60 HC03 18 Pa02 49
mixed acidosis
signs of hypokalemia (look for in metabolic alkalosis)
muscle weakness, decreased peristalsis, dysrhythmias, dizziness
symptoms of rejection of kidney within weeks
oliguria, anuria, HTN, low grade fever, tenderness over kidney, lethargy, increased BUN/creatinine/K, azotemia, fluid retention-> increase immunosuppression
Hypoxemic
oxygenation: ARDS, Pneumonia, pulmonary emboli, pulmonary edema
indicates atrial depolarization
p wave
A client who overdosed on heroin is unresponsive and has a respiratory rate of 8. Which ABG result does the nurse anticipate
pH 7.28, PaCO2: 60, HCO3: 26
collection of fluid around the lungs
pleural effusion
Most common infections that lead to sepsis
pneumonia, UTI
Non-cardiogenic pulmonary edema
pneumonia, acute respiratory distress syndrome, sepsis, DIC, inhaling harmful fumes/smoke, chemicals, high altitude pulmonary edema
what can a shunt be caused by
pneumonia, atelectasis, ARDS
fluid in the lung due to left sided heart failure
pulmonary edema
Examples of Increased V/Q
pulmonary emboli
Decrease V/Q
receive blood flow, but no or compromised O2 exchange
S/S of acute kidney injury
reduced urine output, fluid overload (edema, HTN, distended neck veins, bounding pulse, weight gain)
what acid base imbalance does hypercapnic respiratory failure cause
respiratory acidosis
84-year-old patient admitted with exacerbation of CHF.ABG's: pH 7.25PaC02 60 HC03 25 Pa02 55
respiratory acidosis no compensation with hypoxemia
The nurse cares for a client with severe pain and a respiratory rate of 32 breaths per minute. Which acid-base imbalance does the nurse expect to find?
respiratory alkalosis
40-year-old post-op ACL repair. Tachypneic with a normal Sp02.ABG's: pH 7.50 PaC02 30 HC03 23 Pa02 90
respiratory alkalosis no compensation (post op pain, anxiety resulting in hyperventilation
Pulmonary emboli symptoms
severe dyspnea, tachypnea, cough, chest pain, hemoptysis
blood flow good but no gas exchange
shunt
extreme form of V/Q mismatch
shunt
prerenal AKI management
stent, angioplasty, vasopressors/fluid for BP, fluid challenge
Early phase symptoms of sepsis
tachypnea, tachycardia, normal-hypotensive, narrow pulse pressure, hyperthermia, skin warm/flushed, urine output normal
Hypercapnic
ventilation: COPD, sedative/opioid overdose, severe head injury, spinal cord injury
Normal fibrinogen level
200-400 mg/dL
HCO3 normal range
22-26 mEq/L
normal aPTT
30-40 seconds
PaCO2 normal range
35-45 mm Hg
WBC
5,000-10,000
normal CD4 count
500-1500 cells/mm3
normal PTT
60-70 seconds
treatment for a shunt
O2 therapy alone=ineffective, may need mechanical ventilation
Which clinical manifestations of respiratory failure are associated with hypoxemia? (Select all that apply). A.Agitation B.Confusion C.Restlessness D.Vomiting E.Morning headache
A.Agitation B.Confusion C.Restlessness
ROME (Respiratory opposite, metabolic equal)
Resp: increase in pH (alkalotic)-> decrease in PaCO2, decrease in pH (acidosis)-> increase in PaCO2 Metabolic: increase in pH-> increase in HCO3, decrease in pH-> decrease in HCO3
Practice QuestionThere are 4 patients in the ED with signs and symptoms of the flu. Which patient would you see first? A.A toddler with a temperature of 37.5°C PO B.An adolescent who is coughing and RR-22/min C.An elderly male with confusion and tachypnea. D.A newborn with a RR 50 and HR of 150
C.An elderly male with confusion and tachypnea.
Practice Question The nurse would evaluate which response to determine the effectiveness of the use of vasopressor in a patient with sepsis? A.SpO2 greater than 94% B.Lactic acid less than 2.0 mmol/L C.Mean arterial pressure greater than 65 mm Hg D.Systolic BP greater than 80 mm Hg
C.Mean arterial pressure greater than 65 mm Hg
Increased V/Q
Areas of the lung receive O2, but decreased or no blood flow
Which condition predispose a patient to acute respiratory distress syndrome (ARDS) by causing a direct lung injury? Pancreatitis Sepsis Multiple blood transfusions Aspiration of gastric contents
Aspiration of gastric contents (Rationale: In direct lung injury, pathogens come into direct contact with the lungs. Aspiration of gastric contents come into contact with lung tissues. Other direct lung injury causes are pneumonia, near-drowning, chest trauma, and inhalation of toxic fumes. Sepsis, pancreatitis, & multiple blood transfusions are indirect causes of ARDS. The problem is outside the lung (indirect) that leads to widespread inflammation, that affects the lung as well as other organs.)
lab values associated with DKA
BG: >250 pH: <7.30 anion gap: >10 serum bicarbonate: <18
Dialysis Disequilibrium Syndrome
BUN reduced more rapidly in BODY then in BRAIN-> brain edema/electrolyte shifts
When giving insulin with ketoacidosis what are the parameters and what should you check
Bolus (0.1 unit/kg) then continuous insulin drip 0.1 unit/kg/hr. Check K level is below 3.3 supplement first!!!
Which assessment finding in a patient who reports dyspnea requires the most rapid action by the nurse? A.Patient can only speak three words between breaths. B.Patient requests that the head of bed be at a 45-degree angle. C.Patient becomes less agitated and is difficult to arouse. D.Patient who is using pursed-lip breathing to prolong expiration.
C.Patient becomes less agitated and is difficult to arouse.
In the ED, the patient is diagnosed with diabetic ketoacidosis (DKA). The arterial blood gas results are as follows: pH 7.20, PaC02 28 mmHg, HC03- 17 mEq/L, PaO2 85 mmHg. K+ 3.4 mEq. What's the nurse's priority action for managing this condition? A.Apply oxygen B.Start IV gtt insulin C.Start 0.9% IV fluids D.Give K+ supplementation
C.Start 0.9% IV fluids
Which statement describes the function of a buffer? A.To excrete weak acids B.To secrete H+ ions C.To convert strong acids to weak acids D.To convert ammonia to ammonium ions
C.To convert strong acids to weak acids
diagnosis is made for AIDS when
CD4 count is <200 OR CD4 count is accounting for <14% of total lymphocytes OR immunosuppression or actual opportunistic infections or cancer present
cardiogenic pulmonary edema
CHF, arrhythmias, shock
respiratory acidosis is due to
CO2 buildup
Which therapy should the nurse expect to be prescribed first by the healthcare provider for a patient who is bleeding from acute disseminated intravascular coagulation (DIC)? A.Aspirin. B.Whole Blood. C.Low molecular weight heparin D.Fresh frozen plasma.
D. Fresh frozen plasma
he nurse reviews the plan of care for a patient with chronic kidney disease (CKD) who is undergoing hemodialysis and questions which item listed on the plan? A.2 g sodium diet B.Oxygen via nasal cannula at 4L/min C.Furosemide (Lasix) 40 mg PO twice a day D.IV 0.9% sodium chloride at 125 mL/hr
D. IV 0.9% sodium chloride at 125 mL/hr (not a good thing to get all those fluids, going to retain)
The nurse is carefully monitoring a postpartum patient who experienced abruptio placentae for which sign of DIC? A.Pain and swelling in the leg B.Rapid clotting times C.Increased platelet levels D.Oozing from the injection sites
D. Oozing from the injection sites
The nurse is admitting a patient with acute respiratory acidosis to the medical unit, after assessment which of these diagnoses is the priority nursing diagnosis? A.Imbalanced Body Temperature B.Ineffective Activity Planning C.Chronic Confusion D.Risk for injury
D. Risk for Injury
A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3− 16 mEq/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive? A.Mechanical ventilation B.Furosemide 40 mg C.Indwelling urinary catheter D.Sodium bicarbonate
D. Sodium bicarbonate
The nurse is reviewing the weight change of a patient over the last 24 hours with acute kidney injury. The patient's weight increased from 76 kg to 78 kg. How much fluid retention does this change in weight represent in mL? A.10 mL B.100 mL C.1000 mL D.2000 mL
D.2000 mL
Which patient with respiratory failure is a good candidate for noninvasive positive pressure ventilation (NIPPV)? A.The patient whose heart rate and BP are unstable. B.The patient who has a head injury with loss of consciousness & decrease respirations C.The patient with cystic fibrosis who has copious respiratory secretions D.The patient who has decreased ventilation because of myasthenia gravis crisis
D.The patient who has decreased ventilation because of myasthenia gravis crisis
A diagnosis of AIDS can be made for a patient with HIV with A.a WBC count less than 3000/µL. B.a CD4+ T-cell count less than 500/µL C.development of oral candidiasis (thrush). D.onset of Pneumocystis jiroveci pneumonia.
D.onset of Pneumocystis jiroveci pneumonia.
Which disorder would the nurse suspect when a patient with septic shock has oozing bleeding from the IV site and elevated D-dimer? Mild anemia Multiple myeloma Hemophilia Disseminate intravascular coagulation (DIC)
DIC Rationale: DIC results secondary to other complications. Risk factors associated with acute DIC include septicemia, cardiopulmonary arrest, trauma (severe head injury, extensive burns, crush injuries), obstetric complications (abruptio placentae, toxemia, amniotic fluid embolus), cancer, and allergic reaction. Oozing blood from an IV site is one of the clinical manifestations of DIC. Elevated D-dimer is seen in acute DIC. Common assessment findings with hemophilia would be excessive bleeding from minor cuts or hemorrhages into the joints. Pain in the pelvis, spine, and ribs are the signs and symptoms seen in a patient with multiple myeloma. Mild anemia produces little to no manifestations.
Which of these are ways you can prevent sepsis? A.Wash your hands B.Keep cuts clean and covered until healed C.Know the signs and symptoms D.Get the flu vaccine annually E.All the above
E. All the above
increased anion gap >12 metabolic acidosis is due to
Excessive acid production (lactic acidosis)
Anyone can get an infection and almost any infection can lead to sepsis. Who is at higher risk? A.Adults 65 or older B.People with chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease C.People with weakened immune systems D.Sepsis survivors E.Children younger than one F.All the above
F. All the above
What are signs and symptoms of sepsis? A.High heart rate, low blood pressure, or shortness of breath B.Fever, shivering, or feeling very cold C.Confusion or disorientation D.Extreme pain or discomfort E.Clammy or sweaty skin F.All the above
F. All the above
A nurse is caring for a patient with acute sickle cell crisis. What is the priority intervention? Administer non-steroidal anti-inflammatory drug for pain Obtain order for bedrest with bathroom privileges Give supplemental oxygen via nasal cannula Position the patient on their left side
Give supplemental oxygen via nasal cannula Rationale: Increased perfusion and oxygenation are priority. Oxygen supplementation, blood product infusions and IV fluids are key.
Symptoms of dialysis disequilibrium syndrome
HA, restlessness, N/V, seizures, agitations, alteration of consciousness, cardiac arrhythmias, sudden cardiac arrest.
Anion gap within the normal range (non-anion gap) the metabolic acidosis is due to
HCO3 loss (diarrhea)
The nurse is providing immediate postoperative care for a patient after kidney transplantation surgery. Which parameter indicate possible kidney transplant rejection? (Select all that apply). Decreased serum creatinine levels Increased blood pressure Increased temperature Pain at transplant site
Increased blood pressure, Increased temperature, Pain at transplant site Rationale: Hyperacute rejection manifestations (within 48 hours), include fever, hypertension and pain at the transplant site. Serum creatinine levels decrease after kidney transplant, as the transplanted kidney start elimination the nitrogenous waste.
Nonvolatile
Kidneys regulate HCO3
Volatile
Lungs regulate CO2
normal creatinine
Men: 0.6-1.2 Women: 0.5-1.1
Renal failure patient admitted for shortness of breath (SOB). Missed last dialysis appointment.ABG's: pH 7.10 PaC02 34 HC03 10 Pa02 40
Metabolic acidosis partially compensated, hypoxemia
The nurse cares for a client with an ACTH secreting pituitary tumor with hypercorisolism. Upon assessment, the client has profound muscle weakness. Which ABG test result does the nurse expect?
Metabolic alkalosis
Which intervention does the nurse perform for a patient who is on peritoneal dialysis? Monitor bilirubin levels Monitor thyroxine (T4) levels Monitor for discharge at the exit site Monitor the color of the feces
Monitor for discharge at the exit site Rationale: Infection of the peritoneal catheter exit site is most often caused by Staphylococcus aureus or Staphylococcus epidermidis (from skin flora). The nurse should monitor the exit site for discharge because discharge likely indicates infection. Patients with liver disorders should have their bilirubin levels monitored. Kidney injury is not associated with changes in bilirubin. The color of fecal matter and T4 levels do not need to be monitored
Symptoms of ketoacidosis
N/V, blurred vision, hyperglycemia, abdominal pain, weakness, lethargy, fruit breath, weight loss, Kussmaul respirations (very deep/rapid),
65-year-old patient admitted with community acquired pneumonia.ABG's: pH 7.38 PaC02 44 HC03 25 Pa02 65
Normal ABG, hypoxemia
depolarization and contraction of atria
PR interval
Which patient is most likely to develop metabolic acidosis as a result of over production of hydrogen ions? Patient diagnosed with respiratory failure Patient diagnosed with diabetic ketoacidosis Patient with prolonged vomiting Patient diagnosed with kidney failure
Patient diagnosed with diabetic ketoacidosis. Rationale: Breakdown of fats for energy secondary to lack of insulin and subsequent inability to utilize glucose for energy. Ketones are an acid byproduct of fat breakdown. Ketoacids build up in the blood causing metabolic acidosis.
Which patient is most likely to develop respiratory acidosis? Patient who is anxious and breathing rapidly Patient with increased urinary output. Patient with IV normal saline bolus Patient with multiple rib fractures
Patient with multiple rib fractures
Examples of decreased V/Q
Pneumonia, atelectasis, mucous plug, secretions in airway, asthma
medications taken after kidney transplant
Prograf (tacrolimus), cellcept (mycophenolate), prednisone
depolarization of ventricles (contraction of ventricles-systole)
QRS complex
Occurs after ventricular depolarization has ended and before repolarization silent-time diastole
ST segment
what can hypercapnia respiratory failure be due to
Too slow respirations: opioid use, alcohol overdose, benzodiazepines, brain stem injuries, stroke Too shallow respiration: MS, ALS, morbid obesity Diminished lung function: obstruction/air trapped: severe COPD, cystic fibrosis, asthma
K should not be given until
UO is at least 30 mL/hr
The nurse cares for a group of clients with acid-base imbalances. Which client does the nurse assess first? a. Client with prolonged vomiting and metabolic acidosis who reports tingling in the fingers b. Client with diabetic ketoacidosis, metabolic acidosis, and a potassium level of 3.5. c. Client with emphysema, respiratory acidosis, and SpO2 of 89% on room air d. Client with renal failure and metabolic acidosis who is scheduled for hemodialysis in an hour.
a. Client with prolonged vomiting and metabolic acidosis who reports tingling in the fingers
The nurse cares for a client with metabolic alkalosis. Which condition does the nurse recognize as the possible cause of the client's acid-base imbalance? a. Hyperaldosteronism b. Hyperventilation c. CKD d. COPD
a.Hyperaldosteronism
Causes of intra renal AKI
actual damage to kidney tissue/tubulars (nephrotoxic agents, amphotericin B, lithium, pheytoin, acyclovir, NSAIDs, cisplatin, amnioglycoside antibiotics, ischemia, acute glomerulonephritis, malignant HTN, SLE)
hallmark signs of acute respiratory distress syndrome
acute onset usually 24-72 hours, but must be within 1 week of inciting lung injury. Hypoxemia despite 100% O2, infiltrates (radiographic opacities)
what is a vaso-occlusive crisis
acute pain crisis, symptoms of sickle cell disease, clumped sickle cells block blood flow
rapid accumulation of sickled erythrocytes in spleen, rapid drop of hgb by 2 with splenomegaly
acute sequestration crisis
what is sickle cell disease
affects the shape of RBCs which decreased their ability to carry O2 and get trapped in vasculature
Respiratory alkalosis is due to
any condition that causes hyperventilation (asthma, heart failure, hypotension, pneumonia, pulmonary edema, pulmonary emboli, severe anemia, COPD, anxiety, panic attack, infection, pregnancy, caffeine, salicylate intoxication, sodium bicarb
A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
b. Metabolic alkalosis
what does DIC involve
bleeding and thrombosis
The nurse cares for a client with sepsis who has an elevated serum lactate level. Which acid-base imbalance does the nurse expect? a. respiratory Acidosis b. metabolic alkalosis c. metabolic acidosis d. respiratory alkalosis
c. metabolic acidosis
first signs of hypoxemic respiratory failure
change in mental status
late phase symptoms of sepsis
cold shock: poor perfusion, hypotesnion, normal to hypothermic body temp, tachycardia, arrhythmia, tachypnea, altered mental status, skin cool, gray mottled, CRT delayed, oliguria, anuria
A patient with chronic kidney disease is most likely to complain of which symptom? A.Fatigue B.Thirst C.Constipation D.Excess bleeding
A. Fatigue
Which occurrence can be a result of hyperventilation? Hypocalcemia Respiratory alkalosis Rationale: Hyperventilation increases blowing out of CO2, resulting in decreased PaCO2 and respiratory alkalosis. Hypocalcemia is not associated with hyperventilation. Anxiety can cause hyperventilation, not the other way around. In metabolic alkalosis, there is an excess of bicarbonate, not decreased PaCO2. Anxiety Metabolic alkalosis
respiratory alkalosis
Kidneys have a higher blood flow compared to the brain. A.True B.False
A. True
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? "PEEP prevents the lung air sacs from collapsing during exhalation." "PEEP allows the breathing machine to deliver 100% O2 to the lungs." "PEEP will prevent lung damage while the patient is on the ventilator." "PEEP will push more air into the lungs during inhalation."
"PEEP prevents the lung air sacs from collapsing during exhalation." Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange & oxygenation. PEEP will not prevent lung damage, push more air into the lungs, or change the fraction off inspired oxygen (FiO2) delivered to the patient.
A patient with thrombocytopenia presents to the primary care center. During assessment, the nurse notices petechiae. Which laboratory result best supports the presence of this disorder of hemostatsis? 1. Decreased erythrocyte count 2. A platelet count below 150,000/mm 3. An elevated lymphocyte count 4. A hemoglobin values of 14 or more
2. A platelet count below 150,000/mm
The nurse is caring for a patient with chronic alcoholism being treated for portal HTN and malnutrition. Four days into the admission, the patient becomes confused, agitated, sleeping during the day, and awake all night. It is most important for the nurse to? 1. Keep a tracheostomy kit at the bedside. 2. Obtain an order for an ammonia level 3. Provide the patient with an emesis basin 4. Obtain an order for blood alcohol test
2. Obtain an order for an ammonia level Chronic liber damage due to chronic alcoholism. One of the functions of the liver is to remove toxins from your blood. High level of toxins in the blood due to liver damage is known as hepatic encephalopathy. Ammonia is not cleared building up in the blood.
You are working in an intermediate neurological intensive care unit. You have 4 patients are on Heparin. After receiving report, which of the following patients would you see first? 1. A patient with an INR of 2.0. 2. A patient with a platelet count of 80,000. 3. A patient with an aPTT of 41 seconds. 4. A patient with a PT time of 9 seconds.
3. A patient with an aPTT of 41 seconds. Normal aPTT is 30-40 seconds. When a patient is on Heparin the aPTT value, which should be between 1.5-2 times the patients baseline when therapeutic anticoagulation is achieved. The patient would require and increase in heparin dose.
The nurse is administering medications to a client experiencing heart palpitations who is scheduled to receive a dose of furosemide now. Based on the client's laboratory results, what is the nurse's priority actions? Labs: K (2.9), Mg (2.0), Ca (8.9), Na (148) 1. Contact the HCP 2. Conduct a focused cardiac assessment 3. Hold the dose of furosemide 4. Administer a scheduled dose of Metoprolol
3. Hold the dose of furosemide Furosemide decreases the K causing more arrhythmias. Normal K level (3.5-5).
Which order would the nurse perform the interventions listed on the plan of care for a patient with hemophilia who developed bleeding after a fall? 1.Administer prescribed analgesic 2.Rest the knee and pack in ice. 3.Administer specific coagulation factor 4.Encourage mobilization as soon as bleeding ceases.
3.Administer specific coagulation factor
Which patient will the nurse apply pressure to an injection site for 5 minutes because of an increased risk for bleeding? 1. 28 year old who has T1DM for 15 years. 2. A 42 year old newly diagnosed with T2DM. 3. A 58 year old with chronic HTN and heart failure. 4. A 62 year old with extensive liver damage from cirrhosis.
4. A 62 year old with extensive liver damage from cirrhosis. The liver is critically important in blood clotting because it produces a number of clotting factors. Whenever the liver function is reduced such as with liver damage from cirrhosis, the production of clotting factors is below normal and the risk of bleeding greatly increases even after the minor trauma of an intramuscular injection.
What lab would you check when a patient is receiving heparin? 1. Thrombin 2. aPT 3. Platelets 4. aPTT
4. aPTT Heparin is titrated according to the aPTT value, which should be between 1.5-2 times the patients baseline when therapeutic anticoagulation is achieved.
Which diagnostic finding would the nurse expect to find in a patient with acute disseminated intravascular coagulation (DIC) who experiences bleeding? A.Elevated D-dimer B.Elevated fibrinogen C.Reduced prothrombin time (PT) D.Reduced fibrin degradation products (FDPs)
A. Elevated D-dimer
Acidosis is associated with hyperkalemia? A.True B.False
A. True
Increases in carbon dioxide (CO2) or hydrogen ions (H+) in the blood stimulate the brain's respiratory center, increasing both the rate and depth of respiration A.True B.False
A. True
You review the lab work drawn on V.L. Select those results that are abnormal as a result of V.L.'s condition. There are 6 correct answers. A.Hbg 9.8 mg/dL B.Hct 27% C.Reticulocyte count 90,000/µL D.WBC 14,000 µ/L E.pH 7.41 F.PaCO2 38 G.HCO3 22 H.PaO2 74 mmHG I.SaO2 85%
A, B, C, D, H, I
Which parameters would the nurse assess while monitoring a patient for the development of disseminated intravascular coagulation (DIC) disorder? Select all that apply. A.Fibrinogen levels B.Hemoglobin levels C.Red blood cell count (RBC) D.White blood cell count (WBC) E.Partial thromboplastin time (PTT)
A, E
After a patient has returned from surgery, the nurse needs to report which urinary output to the physician? A.20 mL per hour B.40 mL per hour C.300 mL per 8 hours D.400 mL per 8 hours
A. 20 mL per hour
I am a substance that releases hydroxide ions (0H-) or accepts a H+ in solution. What am I? A.Base B.Acid C.Buffer D.Cation
A. Base
Practice QuestionA patient who is HIV positive informs the nurse about being pregnant. Which instruction should the nurse give to the patient? A."Continue taking antiretroviral therapy." B."Seek medical attention from a geneticist." C."I recommend you obtain an abortion." D."Refrain from taking any medications."
A."Continue taking antiretroviral therapy."
Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? A.24-year-old male admitted with blunt chest trauma and aspiration B.56-year-old male with a history of alcohol abuse and chronic pancreatitis C.72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells D.82-year-old female on antibiotics for pneumonia
A.24-year-old male admitted with blunt chest trauma and aspiration
L.V. continues to have pain (9/10) with the IVP morphine PRN. What action would the nurse take? A.Contact the doctor, for possible PCA pump. B.Give the PRN dose of morphine early. C.Apply cold compress over painful joint D.Encourage ambulating twice around unit.
A.Contact the doctor, for possible PCA pump.
Practice Question Which clinical manifestation should the nurse recognize as an indicator of early septic shock? (select all that apply). A.Hypotension B.Weakness C.Oliguria D.Warm, flushed skin E.Alert & orient mental status
A.Hypotension B.Weakness D.Warm, flushed skin
In considering the genetics of sickle cell anemia, you understand that V.L.'s inheritance of sickle cell anemia could have occurred A.If both of her parents had 1 gene for the HgSS B.if both of her parents have the CFTR gene. C.if one of her parents had the gene for HgSS. D.if one of her parents have the CFTR gene and one did not.
A.If both of her parents had 1 gene for the HgSS
Practice Question In order to accurately measure urine output in a patient with septic shock who is receiving fluid resuscitation, which action would the nurse take? A.Insert an indwelling urinary catheter. B.Obtain daily weights C.Strict input and output D.Record how many times the patient goes to the bathroom.
A.Insert an indwelling urinary catheter.
What is the most important nursing intervention to prevent AKI in the critically ill patient? A.Maintaining fluid volume and cardiac output B.Avoiding all potentially nephrotoxic drugs C.Administering antihypertensive drugs D.Assessing for a history of diabetes or systemic lupus erythematosus
A.Maintaining fluid volume and cardiac output
Which factors put a patient at risk for developing acute disseminated intravascular coagulation (DIC)? Select all that apply. A.Septicemia B.An extensive burn C.Abruptio placentae D.Severe head trauma E.Stroke
A.Septicemia B.An extensive burn C.Abruptio placentae D.Severe head trauma
Which findings will the nurse observe due to compensatory mechanisms in a patient who is in the earliest stage of acute respiratory distress syndrome (ARDS)? (Select all that apply). A.Tachycardia B.Hypoventilation C.Respiratory alkalosis D.Rapid & shallow respirations E.Increase in arterial carbon dioxide (PaCO2)
A.Tachycardia C.Respiratory alkalosis D.Rapid & shallow respirations
Practice QuestionA patient has HIV infection, and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory result? A.The patient has the virus, but the infection is well controlled. B.The syndrome has been cured, and the patient can discontinue all medications C.The patient will be prescribed lower dosed of antiretroviral medications for 2 months D.The patient is not taking antiretrovirals and needs to be taught the benefits of therapy
A.The patient has the virus, but the infection is well controlled.
A patient with human immunodeficiency virus (HIV) is hospitalized. The patient's assessment findings include a CD4 T cell count of 150 cells/uL and a 12% loss of ideal body mass. Which diagnosis does the nurse suspect? Kaposi sarcoma Cytomegalovirus (CMV) Pneumocystis jiroveci pneumonia (PCP) Acquired immunodeficiency syndrome (AIDS)
Acquired immunodeficiency syndrome (AIDS)
What is the priority intervention for a patient with diabetic ketoacidosis? Administer bicarbonate Administer antibiotic Administer oxygen Administer insulin The priority is administration of fluids to correct dehydration to restore circulatory volume, clear ketones, correct electrolyte issues caused by fluid shifts, quickly f/b insulin, & correction of any electrolyte imbalances
Administer insulin
Which information would the nurse include during the patient's education of immunosuppressive therapy and tacrolimus (Prograf)? A.Take this medication on an empty stomach or at least two hours after a meal. B.This medication has very few side effects or interactions with other medications. C.Avoid eating or drinking products with grapefruits while taking this medication. D.Flu-like symptoms will develop in the first few days of treatment.
C
Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm arteriovenous fistula? Irrigate the fistula site with saline every 8-12 hours. Assess the quality of the left radial pulse. Compare blood pressures in the left and right arms Auscultate for a bruit at the fistula site
Auscultate for a bruit at the fistula site Rationale: The presence of a thrill & bruit indicates adequate blood flow through the fistula. Pulse rate & quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, & typically only dialysis staff would access the fistula.
When teaching a patient with hemophilia about home management, which of the following is most important for the nurse to include? Avoid contact sports Minimize joint pain by walking Use 325 mg aspirin when severe pain occurs Increase iron-rich foods in the diet
Avoid contact sports Rationale: Patients with hemophilia have a high bleeding risk, so contact sports or other activities that cause tissue injury or bleeding should be avoided. Joint pain may be caused by bleeding in the joints and if this occurs the patient should seek medical care immediately. Iron-rich foods are not appropriate for this, unless they also have an anemia (but still wouldn't be answering the question). Aspirin is normally not used for severe pain and causes bleeding.
The nurse assesses a patient with disseminated intravascular coagulation (DIC) and expects to find which signs of hemorrhage? Select all that apply. A.azotemia B.Hemoptysis C.Hypotension D.Focal ischemia E.Abdominal distention
B, C, E
The nurse provides education to a patient with hemophilia about safety measures. Which statements made by the patient indicate an understanding of the teaching? (Select all that apply). A."I should participate in contact sports." B.I should wear a Medic Alert tag wherever I go." C."I should wear gloves while doing household chores." D.I should carry an epinephrine injection wherever I go." E."I should immediately consult my health care provider after severe injury."
B, C, E
An ICU nurse is reviewing the labs and urine output of a patient who is septic. Which of the following data supports the nurses concern that the patient may be experiencing an injury to the kidney? (Select all that apply). A.Change in serum creatinine from 2.2 mg/dL to 1.1 mg/dL over the last week B.Change in serum creatinine from 1.1 mg/dL to 2.2 mg/dL over the last 2 days C.Urine output 50 mL/hr for 24 hours D.Urine output of 200 mL for 8 hours
B, D
When providing discharge instructions for a patient with a successful kidney transplant, which instructions would the nurse include to identify signs of organ rejection? Select all that apply. A.Notify the health care provider if there is a weight loss B.If your BP increases, call the office. C.If you notice your urinary output increases, call someone D.Notify the health care provider if your temperature goes below 98.6° F.E.If your temperature exceeds 100° F, notify your provider right away.
B, E
I am a substance that releases hydrogen ions (H+) on dissociation in solution. What am I? A.Base B.Acid C.Buffer D.Anion
B. Acid
A patient with a platelet count of 52,000/mm3 is diagnosed with thrombocytopenia. The nurse would expect which clinical manifestations? (Select all that apply. A.Weakness B.Bruising C.Dizziness D.Vomiting E.Petechiae
B. Bruising, E. Petechiae
The nurse says, "I understand you have sickle cell disease". L.V. states, "I think I'm having a sickling episode. I have a lot pain and I want to get rid of this pain now." The nurse says, I'm going to get some oxygen, start an IV, throat culture, and draw some blood work".The ER physician ordered administration of D5/.45 NaCl at 125 mL/hr, oxygen at 6 L/min via nasal cannula, morphine 2 mg IVP PRN, and 650 mg acetaminophen orally. Of these orders, which is the highest priority to prevent complications related to sickling in this case? A.Oxygen B.IV fluids C.Morphine D.Acetaminophen
B. IV fluids
What laboratory value should the nurse check before administering captopril to a patient with stage 2 CKD? A.Glucose B.Potassium C.Creatinine D.Phosphate
B. Potassium (chronic kidney disease not working to get rid of potassium in system, potassium levels could increase, ace inhibitors can cause hyperkalemia)
A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patient's diet? A.Fat B.Protein C.Calories D.Carbohydrates
B. Protein (because it will leech out with peritoneal dialysis)
Practice Question The nurse is providing teaching about the risks of contracting HIV from sexual partners to an adolescent male who tested negative for HIV. Which statement by the patient indicates a need for further teaching? A."I will refrain from performing any sexual activity". B."I cannot contract HIV since I only have one sexual partner." C."I do not use intravenous drugs, so I would not be sharing needles." D."I should always use barrier contraception to decrease the risk of HIV infection."
B."I cannot contract HIV since I only have one sexual partner."
The nurse is caring for a client admitted with a diagnosis of acute renal failure. The client asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate? A."No, don't think that. You're going to be fine." B."Your condition can be reversed with prompt treatment and usually will not destroy the kidney." C."Kidney transplantation is highly likely, and it would be a good idea to start talking to family members." D."When the doctor comes to see you, we can talk about whether you will need a transplant."
B."Your condition can be reversed with prompt treatment and usually will not destroy the kidney."
Practice Question Which fluid amount would the nurse anticipate incorporating into an adult patient's plan of care for fluid replacement due to septic shock? A.10 mL/kg B.30 mL/kg C.50 mL/kg D.70 mL/kg
B.30 mL/kg
What is Sepsis? A.A disease that cannot be cured B.Life-threatening organ dysfunction due to a dysregulated host response to infection C.A mild, non-urgent medical condition
B.Life-threatening organ dysfunction due to a dysregulated host response to infection
You are caring for a patient admitted with a diagnosis of COPD who has the following ABG pH 7.33 PaCO2 60 mm/Hg HC03- 32 mEq/L O2 sat 92% PaO2 47 mmHg. Interpret the result. A.Fully compensated respiratory alkalosis with hypercapnia B.Partially compensated respiratory acidosis with hypoxemia C.Normal acid-base balance with hypoxemia D.Normal acid-base balance with hypercapnia
B.Partially compensated respiratory acidosis with hypoxemia
Which information would the nurse educator include when explaining respiratory failure to new nursing staff members? (Select all that apply) A.Respiratory failure is inevitable after cardiac failure. B.Respiratory failure is categorized as hypoxemic or hypercapnic. C.Respiratory failure is insufficient oxygen transfer into the blood. D.Respiratory failure is inadequate carbon dioxide removal from the lungs E.Respiratory failure is a disease that presents with various respiratory symptoms.
B.Respiratory failure is categorized as hypoxemic or hypercapnic. C.Respiratory failure is insufficient oxygen transfer into the blood. D.Respiratory failure is inadequate carbon dioxide removal from the lungs (respiratory failure is not a disease)
The nurse is caring for a patient with pneumonia. The ABG result is as follows: pH 7.30, PaCO2 58, HCO3 26 mEq/L, & PaO2 72. What is the priority nursing intervention? A.Place the patient in a left-sided lying position B.Sit the patient up to a semi-Fowler's position. C.Assist the patient to breath into a paper bag. D.Administer a sedative to the patient.
B.Sit the patient up to a semi-Fowler's position.
An older patient comes to the ER experiencing chest pain & SOB. An ABG is ordered. Which of these ABG results indicate respiratory acidosis? A.pH 7.54, PaCO2 28 mmHg, HCO3 22 mEq/L B.pH 7.32, PaCO2 46 mmHg, HCO3 24 mEq/L C.pH 7.31, PaCO2 35 mmHg, HCO3 20 mEq/L D.pH 7.50, PaCO2 37 mmHg, HCO3 28 mEq/L
B.pH 7.32, PaCO2 46 mmHg, HCO3 24 mEq/L
While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement? A.My body will treat the new kidney like my original kidney." B.I will have to make sure that I avoid being around people." C.The medications that I take will help prevent my body from attacking my new kidney." D.My body will only have a problem with my new kidney if the donor is not directly related to me."
C
The nurse provides education for a patient who is receiving hemodialysis and states that, during the treatment, which substances move from the blood to the dialysate? (Select all that apply). A.Glucose B.Bacteria C.Creatinine D.Phosphate E.Red blood cells (RBCs)
C, D (urea, creatinine, electrolytes, uric acid go through the membrane)
Which pH value on an arterial blood gas result should the nurse expect to see in an anxious client? A.7.45 B.7.38 C.7.50 D.7.20
C. 7.50
The nurse would monitor a patient with thrombocytopenia for which major complication? A.Fatigue B.Weakness C.Hemorrhage D.Abdominal pain
C. Hemorrhage
After the insertion of an AV graft in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? A. Tell the patient this is normal AVG function B. Remind the patient to take a daily low dose aspirin tablet C. Report the patient's symptoms to the health care provider. D. Elevate the patient's arm to pillows to above the heart level.
C. Report the patient's symptoms to the health care provider. (elevating patient's arm would not be a good thing)
When assessing V.L.'s current understanding of sickle cell anemia, which statement made by her indicates a need for further patient teaching? A.I should alternate my activities with rest periods so that I don't get so tired." B."I may use the oxycodone until my pain can be controlled with acetaminophen." C."I should use iron supplements to increase the normal hemoglobin in my blood." D."I will be sure to get the Pneumovax and H. influenzae vaccines when I completely recover."
C."I should use iron supplements to increase the normal hemoglobin in my blood."
Which statement made by a student nurse indicates the need for additional teaching regarding the etiology and pathophysiology of disseminated intravascular coagulation (DIC)? A."It is stimulated by a disease process or disorder." B."Bleeding occurs as a result of depletion of platelets." C."It results from the surplus production of clotting factors." D."DIC results from abnormally initiated and accelerated clotting
C."It results from the surplus production of clotting factors."
Which patient is at highest risk for hypoxemic respiratory failure? A.A patient who has respiratory muscle paralysis. B.A patient who has fractured ribs and a flail chest. C.A patient who has a massive pulmonary embolism. D.A patient who has slow breathing from a drug overdose.
C.A patient who has a massive pulmonary embolism.
The nurse is reviewing the latest ABG results for a patient with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? A.pH 7.32 B.PaC02 18 mmHg C.HCO3- 8 mEq/L D.PaC02 48 mmHg
D. PaCO2 48 mmHg (want CO2 to go higher)
Practice Question The nurse, who was accidentally stuck with a needle used for a patient with human immunodeficiency virus (HIV), reported the incident to the charge nurse. Which action would the injured employee implement next? A.Medical evaluation and testing of exposed nurse B.Postexposure prophylaxis via antiretroviral therapy C.Evaluation of the patient source, including testing D.Immediate care of the exposed site with soap and water.
D.Immediate care of the exposed site with soap and water.
Patients with acute respiratory distress syndrome (ARDS) are sometimes placed in the prone position. How does this position help the patient? A.It improves cardiac output B.It makes the patient more comfortable C.It prevents skin breakdown D.It recruits more alveoli
D.It recruits more alveoli
Which patient is most likely to experience hemophilia? Patient finding of: A.Bleeding time is 7 minutes B.Prothrombin time (PT) is 12 seconds C.Platelet level is 150,000/ mm3 D.Partial thromboplastin time (PTT) is 90 seconds
D.Partial thromboplastin time (PTT) is 90 seconds
Which patient is most likely to develop metabolic alkalosis as a result of base excess? Patient takes acetaminophen as needed for pain Patient with several days of vomiting due to food poisoning Patient takes a baby aspirin every day Patient frequently takes calcium carbonate (TUMs) for indigestion.
Patient frequently takes calcium carbonate (TUMs) for indigestion) Rationale: Metabolic alkalosis is caused by either an increase of bases or a decrease of acids. Base excesses are caused by excessive intake of bicarbonates, carbonates, acetates, and citrates. Tums is a calcium carbonate antacid.
The nurse is administering hemodialysis to a patient with chronic kidney disease. For which common complication does the nurse carefully monitor in this patient? Hypotension Hernias Lower back pain Pneumonia
Hypotension Rationale: A rapid removal of fluid results in reduced vascular volume, which can lead to a decreased cardiac output and decreased vascular resistance. Therefore, hemodialysis has the potential to cause hypotension during the process. Peritoneal dialysis is associated with hernias, lower back pain, and pneumonia due to increased intraabdominal pressure while infusing the dialysate and decreased lung expansion caused by frequent upward displacement of the diaphragm.
A client with acute kidney injury has passed the oliguric phase and is producing urine. The creatinine is returning to normal but serum electrolytes are decreased. The nurse identifies which of the following processes as causing the loss of electrolytes? Increasing glomerular filtration rate Decreasing blood urea nitrogen Increasing glomerular permeability Damage to the basement membrane of kidney
Increasing glomerular filtration rate
An adult client with chronic kidney disease tells the nurse they are interested in peritoneal dialysis. Which condition in the client's history causes the nurse to explain that hemodialysis might be a safer option than PD? Appendectomy CHF Chronic HTN Inflammatory bowel disease
Inflammatory bowel disease
Assessment findings of a patient with chronic kidney failure include a glomerular filtration rate (GFR) of 10 mL/min, numbness and burning sensation in the legs, and a blood urea nitrogen (BUN) level of 26 mg/dL. The nurse anticipates that which intervention will be included on the patient's plan of care? Make a referral for dialysis Restrict sodium bicarbonate Administer potassium chloride Provide a magnesium containing antacid.
Make a referral for dialysis Rationale: Dialysis is begun when the patient's uremia can no longer be adequately treated with conservative medical management. Generally, this is when the GFR is less than 15 mL/min. Numbness and burning sensation in the legs are manifestations of peripheral neuropathy caused by nitrogenous waste accumulation in the brain. A patient with a chronic kidney disease (CKD), increased BUN levels, and a very low GFR of 10 mL/min should undergo dialysis to remove nitrogenous wastes and prevent fluid accumulation due to impaired excretion. Potassium is restricted in patients with CKD, high potassium can cause life-threatening changes in cardiac rate and rhythm. Sodium bicarbonate treats metabolic acidosis. A patient with CKD must not take antacids containing magnesium or aluminum because they are excreted by the kidneys.
Which finding is the best indicator that a patient with viral pneumonia is developing acute respiratory distress syndrome (ARDS)? Intercostal retractions noted bilaterally with inspiration Cough productive of thick green mucus Crackling sounds in lung bases No improvement in O2 saturation with increasing oxygen administration
No improvement in O2 saturation with increasing oxygen administration (Rationale: Refractory hypoxemia is the hallmark characteristic of ARDS. Crackles in the lung bases may occur in the early stages of ARDS, but crackles could also be caused by atelectasis or be a symptom of the patient's viral pneumonia. A productive cough is more typical of pneumonia than of ARDS. Intercostal retractions occur with increased work of breathing in ARDS but may also be present with viral pneumonia.)
Which patient who has just arrived in the emergency department will the nurse assess first? The patient who is sitting in tripod position and unable to speak The patient who needs to take a breath after saying five words The patient who is experiences labored breathing with ambulation The patient who reports difficulty sleeping because of dyspnea
The patient who is sitting in tripod position and unable to speak (Use of the tripod position, especially in a patient who is unable to speak because of dyspnea, indicates severe respiratory distress; this patient needs rapid assessment and intervention. A patient who can say 5 words before needing to take a breath may be experiencing mild to moderate respiratory distress and needs assessment, but the patient who is in the tripod position should be assessed first. Nighttime dyspnea needs further assessment for problems such as asthma or obstructive sleep apnea, but this patient is not in any current respiratory distress and can wait to be assessed by the nurse. A patient who experiences labored breathing with ambulation needs assessment but can be asked to rest quietly to decrease work of breathing and does not need immediate assessment or intervention.)
Which intervention would the nurse anticipate incorporating into the plan of care for a patient newly diagnosed with disseminated intravascular coagulation (DIC)? Administer albumin Restrict fluid replacement Treat the causative problem Administer aspirin
Treat the causative problem Rationale: Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Maintenance of organ function is achieved by fluid replacement to sustain adequate circulating blood volume to maintain optimal tissue and organ perfusion. Albumin and aspirin are not interventions for DIC.
Which cardiac dysrhythmia is life threatening and requires immediate intervention? Ventricular fibrillation Sinus bradycardia Atrial fibrillation Sinus tachycardia
Ventricular fibrillation (Rationale: Ventricular fibrillation is a life-threatening dysrhythmia that requires immediate intervention. During ventricular fibrillation, the ventricles are quivering and no longer able to contract to produce effective cardiac output. Because there is no cardiac output, the body is left without oxygenation. Sinus tachycardia requires treatment to slow the rate to 60 to 100 beats/min. Atrial fibrillation requires treatment to convert the rhythm back to a normal sinus rhythm with one atrial contraction for every ventricular contraction. Sinus bradycardia has a normal sinus rhythm, but rate is <60/minute. It may be a normal condition. Only those with symptoms receive treatment.)
What two minerals are dependent for coagulation cascade
calcium and vitamin K
A patient newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the patient is at risk for disequilibrium syndrome, the nurse assesses the patient during dialysis for: a. Hypertension, tachycardia, and fever b. Hypotension, bradycardia, and hypothermia c. Pain, dizziness, and generalized weakness d. Headache, deteriorating level of consciousness, and twitching
d. Headache, deteriorating level of consciousness, and twitching
