HURST: Module 1 Elevate

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How to preform a proper dressing change?

- hand hygiene before dressing change -dressing tape is removed in the direction of the hair growth -soiled dressing in the biomedical waste bag - clean area closest to the wound first then outside

Which client would the nurse monitor for the development of cariogenic shock?

-admitted with pericardial tamponade -admitted with pulmonary embolism -diagnosis with left sided heart failure.

Nurse assess a patient one day post thyroidectomy and identifies an arrhythmia upon auscultation. While taking the patients blood pressure the patients hand starts to tremble. What should the nurse initiatie?

-continuous cardiac monitoring -draw blood for phosphorus level -initiate seizure precautions

An elderly patient that has a G-tube placed is having behavioral changes and hallucinations. What should the nurse initiate?

-frequent oral care -provide 250 ml of water via G-tube every 6 hours -seizure precautions

An emergency department nurse is caring for a client who has sustained a high-voltage electrical injury. What should the nurse evaluate?

-initiate continuous cardiac monitoring -identify entrance and exit wounds -cover burned areas with clean sheets

The nurse is caring for a client 8 hours post colectomy who is receiving 40% humidified oxygen. The patients ABGs are pH: 7.30, pO2:91, pCO2: 50, HCO3: 24. Based on this information, which nursing action should she initiate?

-reposition the client every 2 hours -initiate incentive spirometry -assess mental status

clinical manifestations of electrolyte disturbance due to malabsorption from celiac disease

anorexia, arrhythmia, seizure

What should the nurse assess for after a fasciotomy?

capillary refill color

Carbon monoxide poisoning symptoms to assess for?

dizziness premature ventricular contractions

What is the nurses priority when treating a client admitted with a full thickness burn over 30% of the body?

establish IV access of Normal Saline

hypertonic solutions are considered

high risk drugs; fluid shift can cause fluid volume excess & heart failure

Fluid volume deficit

high sodium, high hematocrit, high urine SG

hypervolemia symptoms

hypertension increase workload on heart

IV solutions to cause hypervolemia

isotonic and hypertonic solutions

fluid volume excess lab values

low values dilute makes numbers go down

A client experiencing protracted vomiting is experiencing what electrolyte imbalance?

metabolic alkalosis - high levels of bicarb HCO3 can indicate & match the pH of metabolic alkalosis


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