Q7: A3 FINAL EXAM

What should the nurse do in the first hour to prevent further sepsis in a patient that is septic

-Administer antibiotics 1. Manage fluid overload 2. Manage increased cardiac output 3. Manage inadequate tissue perfusion 4. Manage vasoconstriction of vascular beds

Tracheostomy suctioning procedure

-Confirm length -Apply gloves -Connect to pulse ox -Check vitals -Evaluate for airway obstruction or hypoxia -Semi-fowlers -Connect suction -Hyperoxygenate -Apply suctioning for 10-15 seconds at a time

To prevent pulmonary complications after surgery, patients should be instructed to perform

-Diaphragmatic breathing via incentive spirometry -Ambulation

S/S of right sided heart failure

-JVD -Hepatomegaly -Weight gain -Peripheral edema

S/S of fluid overload

-Moisture in the lungs -Edema -Swelling -SOB -Rapid weight gain -High BP -Fatigue -Confusion -Distended neck veins -N/V Frequent urination

Manifestations to monitor for Myasthenia gravis

-Muscle weakness -Diplopia -Ptosis -Fatigue -Dysphagia -SOB

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor vehicle crash. Identify the sequence of actions the nurse should take

-A: Open airway using jaw-thrust maneuver -B: Determine effectiveness of ventilator efforts -C: Establish IV access -D: Glasgow coma scale assessment -E: remove clothing

What does a CKD patient limit on their dietary intake?

-Potassium (bananas, oranges, tomatoes, potatoes) -Phosphorus (dairy, nuts, seeds) -Sodium (processed food, canned food, salty snacks) -Oxalates and phytates (beets, chocolate, tea, whole grains, legume) -Protein -Alcohol -Caffeine

What to monitor for patient in acute respiratory failure

-Respiratory rate -Oxygen -ABGs -EtCO2 -BP -HR -LOC -Breath sounds -Chest movement -Use of accessory muscles -Ventilator settings, tidal volume, PEEP, and FiO2

Cervical injury risk

-Respiratory rate -Oxygen saturation -Breath sounds -Equal chest risse and fall -EtCO2 -Use of accessory muscles indicate respiratory distress -LOC -BP -Skin color/temp -Cough -Pain that restricts chest movement

Tuberculosis primary meds

-Rifampin -Isoniazid (INH)

Most important factors for dysphagia

-Swallowing function -Intake and weight -Sit up during meals -Signs of aspiration pneumonia (liquid or food entering lungs)

The nurse is assigned to care for a client with emphysema. Which of the following findings should the nurse expect while collecting data? (SATA)

-dyspnea -barrel chest -clubbing of the fingers -shallow respirations

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (SATA) 1.Restrict fluids. 2.Assess for airway patency. 3.Administer oxygen as prescribed. 4.Place a cooling blanket on the client. 5.Elevate extremities if no fractures are present. 6.Prepare to give oral pain medication as prescribed.

2.Assess for airway patency. 3.Administer oxygen as prescribed. 5.Elevate extremities if no fractures are present.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? (SATA) 1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

A patient presents with a Troponin T 0.7 ng/mL (less than 0.1 ng/mL), reports of chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort . O2 is 88%. What are your TWO priority interventions. (NGN: BOWTIE) 1. Request a prescription for Morphine 6mg IV bolus 2. Request a prescription for verapamil 100 mg PO 3. Administer transdermal nitroglycerin 4. Administer oxygen via nasal cannula 5. Request a prescription for aspirin 325 mg.

4. Administer oxygen via nasal cannula 5. Request a prescription for aspirin 325 mg.

A nurse is caring for a patient who has a chest tube in place attached to water-seal drainage. Which of the following observations about the drainage should be reported if found 5 hr after insertion?

About 150 mL/hr over the past 2 hr.

The nurse should include all of the following in the plan of care for the client with a chest tube r/t hemothorax? SATA: A) Report drainage of 100 ml/hr B) Teach the patient to cough and deep breath frequently C) Report intermittent bubbling in the water seal chamber D) Keep the patient on bedrest with bedside commode E) Loop tubing to keep it off of the floor

A) Report drainage of 100 ml/hr B) Teach the patient to cough and deep breath frequently C) Report intermittent bubbling in the water seal chamber

The nurse is concerned that a client is demonstrating early signs of hypovolemic shock. What did the nurse assess in this client? Select all that apply. A) Slight increase in pulse B) Prolonged capillary refill time C) Rapid weak pulse D) Normal respirations E) Normal blood pressure

A) Slight increase in pulse B) Prolonged capillary refill time D) Normal respirations E) Normal blood pressure

Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching? A. "I will not have any menstrual cycles because of this disease" B. "I should avoid people who have respiratory infections." C. "I should not take a hot bath or swim in cold water." D. "I will drink at least 2,500 mL of water a day."

A. "I will not have any menstrual cycles because of this disease"

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and warfarin work together to dissolve the clots." D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."

A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."

A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first? A. A client experiencing a tension pneumothorax B. A client who has a closed upper extremity fracture C. A client who has full-thickness burns over 80% of his body D. A client who has agonal respirations

A. A client experiencing a tension pneumothorax

A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A. Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B. Administer atropine as a continuous infusion until symptoms resolve. C. Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D. Administer atropine 1.0 mg sublingually.

A. Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg.

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus

A. Airway obstruction

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? A. Airway patency B. Tissue integrity C. Wound drainage D. Pain severity

A. Airway patency

A patient with an opening in the chest wall, such as from a gunshot, stab wound or impalement, resulting in "sucking chest wound" can be said to have: A. An open pneumothorax B. A closed pneumothorax C. A hemothorax D. A pleural effusion

A. An open pneumothorax

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. C. Strip the drainage tubing every 4 hr. D. Clamp the tube once a day. E. Obtain a chest x‑ray.

A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. E. Obtain a chest x‑ray.

A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and dropped to the ground." Which of the following techniques should the nurse use to open the client's airway? A. Head-tilt, chin-lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head A

A. Head-tilt, chin-lift

A patient is receiving treatment for a complete spinal cord injury at T4. As the nurse you know to educate the patient on the signs and symptoms of autonomic dysreflexia. What signs and symptoms will you educate the patient about? Select all that apply: A. Headache B. Low blood glucose C. Sweating D. Flushed below site of injury E. Pale and cool above site of injury F. Hypertension G. Slow heart rate H. Stuffy nose

A. Headache C. Sweating F. Hypertension G. Slow heart rate H. Stuffy nose

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A. Hyperoxygenate before and after suctioning B. Repeat suctioning until the tube is clear C. Apply suction during insertion of the tube D. Suction for 30 seconds

A. Hyperoxygenate before and after suctioning

A nurse is caring for a client who experience a femur fracture 8 hours ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high flow oxygen B. Check the client for positive Chvostek's sign C. Administer an IV vasopressor medication D. Monitor the client for headache

A. Provide high flow oxygen

A patient develops flushing, rash, and pruritus during an IV infusion of vancomycin. Which action should the nurse take? A. Reduce the infusion rate B. Administer diphenhydramine (Benadryl) C. Change the IV tubing D. Check the patency of the IV

A. Reduce the infusion rate

A nurse is caring for a patient who is postop and whose respirations are shallow at 9/min. Which of the following acid-base imbalances should the nurse identify the patient as being at risk for developing initially? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. Systolic blood pressure is increased B. Cardiac output is reduced C. Apical heart rate is increased D. Urine output is reduced

A. Systolic blood pressure is increased

Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique? Select all that apply A. preoxygenate the patient for at least 30 seconds before suctioning B. Instruct the patient that he or she is going to be suctioned C. quickly insert the suction catheter until resistance is met D. suction the patient for at least 30 seconds to remove secretions E. repeat suctioning as needed for to five total suction passes

A. preoxygenate the patient for at least 30 seconds before suctioning B. Instruct the patient that he or she is going to be suctioned C. quickly insert the suction catheter until resistance is met

Primary status starts with

AIRWAY

Chief complaint of patient with 2 day history of diarrhea, headache, nausea, and abdominal pain

Abdominal pain (?)

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis

A school-age client is brought to the emergency department with complaints of lethargy, a fever obtained orally of 101.2 ° F, and feeling "weaker than usual." The client has a history of leukemia that has been treated with oral chemotherapy, and the physician suspects a systemic inflammatory response. Which physician order would receive the highest priority by the nurse? A) Administer an antipyretic. B) Initiate intravenous therapy. C) Administer intravenous antibiotics. D) Obtain a complete blood count with differential (CBC).

B) Initiate intravenous therapy.

Which ocular or facial signs/ symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? A) Weakness & Fatigue B) Ptosis & diplopia C) Breathlessness & dyspnea D) Weight loss & Dehydration

B) Ptosis & diplopia

he nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.

B) Stop the transfusion immediately.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased heart rate B. Dyspnea C. Increased blood pressure D. Thready pulse

D. Thready pulse

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? A. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of < 2 seconds B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds C. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of < 2 seconds D. An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results

B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess respiratory status

B. Apply sterile gauze to the insertion site

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) A. Use the Glasgow Coma Scale when assessing the client. B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake. E. Instruct the client to perform deep breathing and coughing exercises.

B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake.

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration D. Exposed sutures without dressing E. Drainage system upright at chest level

B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A home health nurse is teaching a client who has active TB. The provider has prescribed the following medication regimen: isoniazid (Nydrazid) 50mg PO daily, rifampin (Rifadin) 500mg PO daily, pyrazinamide 750mg PO daily, and ethambutol (Myambutol) 1mg PO daily. Which of the following client statements indicate understanding of the teaching (SATA). A. i can substitute one medication for another if I run out because they all fight infections B. I will wash my hands each time i cough C. i will wear a mask when i am in a public area D. i am glad i dont have to have any more sputum test E. i dont need to worry where i go once i start taking my medications

B. I will wash my hands each time i cough C. i will wear a mask when i am in a public area

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include? A. Increase intake of red meat B. Limit sodium intake to less than 3,000 mg/day C. Increase intake of foods high in trans fat D. Drink whole milk

B. Limit sodium intake to less than 3,000 mg/day

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the wheelchair on the client's left side.

B. Place the bedside table on the right side of the bed.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of hemolytic transfusion reaction? A. Report of metallic taste B. Report of low back pain C. Pallor D. Hypertension

B. Report of low back pain

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning B. Use tracheostomy covers when outdoors. C. Use sterile technique when performing tracheostomy care at home. D. Reusable supplies should be disinfected after each use.

B. Use tracheostomy covers when outdoors.

A nurse is evaluating an older adult client Whois receiving end-of-life care and has Cheyne-stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern

Breathing ranging from very deep to very shallow with periods of apnea

A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following nursing statements indicates an understanding of the condition? A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving vitamin K deficiency."

C. "DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client? A. "I will be placing electrodes on your breasts." B. "Try to hold your breath until this procedure is complete." C. "Try to remain still once I have attached the gel pads." D. "I will lower the head of your bed so you can lie flat."

C. "Try to remain still once I have attached the gel pads."

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? A. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site D. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

C. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

A nurse is responding to a mass casualty incident. Place in order the clients to be triaged, from most important to least A. A client with a broken arm & no other injuries B. A client who was killed in the accident C. A client with a sucking chest wound who is having breathing difficulties D. A client with a large scalp laceration who is walking around the scene E. A client who is scared & crying about the incident

C. A client with a sucking chest wound who is having breathing difficulties D. A client with a large scalp laceration who is walking around the scene A. A client with a broken arm & no other injuries E. A client who is scared & crying about the incident B. A client who was killed in the accident

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has A. Kussmaul breathing. B. Apneustic breathing. C. Cheyne-Stokes respirations D. stridor.

C. Cheyne-Stokes respirations

A nurse is caring for a client who has hypovolemic shock. Which of the following is an expected finding? A. Hypertension B. Purpura C. Oliguria D. Bradypnea

C. Oliguria

A nurse is triagaing vitims of a multiple motor vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take? A. Start CPR B. Place a red tag on the client's upper body and obtain immediate help from other personnel C. Place a black bag on the client's upper body and attempt to help the next client in need D. Reposition the client's upper airway a second time before assessing his respirations

C. Place a black bag on the client's upper body and attempt to help the next client in need

A nurse is caring a for a client who has a new diagnosis of TB and has been placed on a multimedication regiment. Which of the following instructions should the nurse give the client related to the medication ethambutol (Myambutol)? A. your urine may turn dark orange B. watch for a change in the sclera of your eyes C. watch for any changes in vision D. take vitamin B6 daily

C. watch for any changes in vision

A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. Which of the following is an appropriate statement by the nurse about this medication? A. you may notice yellowing of your skin B. you may experience pain in your joints C. you may notice tingling of your hands D. you may experience a loss of appetite

C. you may notice tingling of your hands

A nurse in a clinic is collecting data from a client who reports nausea, headache, weakness, and vertigo after turning on his furnace. The clients oral mucous membranes are cherry red. Then nurse should associate the clients manifestations with which of the following conditions ?

Carbon Monoxide poisoning

What to do for occluded circulation in cardiac catheter in left antecubital

Check distal pulses

A nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart failure. Which of the following instructions should the nurse include?

Contact the provider for heart rate less than 60/min.

A nurse is caring for a client who is 12-hour post op and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Continuous bubbling in the water seal chamber

A nurse is caring for a patient who is 6 hr postoperative and has a chest tube in place attached to a closed-chest water-seal drainage system. The nurse should observe for which of the following indications of a problem in the drainage system?

Continuous bubbling in the water-seal chamber.

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? A. "I can walk a mile a day." B. "I've had backache for several days." C. "I am urinating more frequently." D. "I feel nauseated and have no appetite."

D. "I feel nauseated and have no appetite."

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? A. "Suctioning the patient requires sterile technique." B. "I'll apply suction while rotating and withdrawing the suction catheter." C. "I'll suction the mouth after I suction the endotracheal tube." D. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

D. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

A triage nurse in an emergency department (ED) is caring for a client who has a gunshot wound to the right side of her chest. the dressing on the chest and a sucking noise coming from the wound. the client has a blood pressure of 100/60 mm Hg and a weak pulse rate of 118/min and a respiratory rate of 40/min. which of the following actions should the nurse take A. Raise the foot of the bed to a 90 degree angle B. Remove the dressing to inspect the wound C. Prepare to insert a central line. D. Administer O2 via nasal cannula

D. Administer O2 via nasal cannula

A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse expect to administer first? A. Fluticasone B. Budesonide C. Montelukast D. Albuterol

D. Albuterol

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks. B. Check the suction control outlet on the wall. C. Clamp the chest tube. D. Continue to monitor the client's respiratory status.

D. Continue to monitor the client's respiratory status.

A nurse is caring for a client who has hypovolemic shock. Which of the following blood products does the nurse anticipate administering to this client? A. Cryoprecipitates B. Platelets C. Fresh Frozen Plasma D. Packed RBC

D. Packed RBC

A patient injured in a motor vehicle crash is transported to an emergency department. The provider determines the need for immediate thoracotomy and chest-tube insertion and anticipates the need for maximal suction pressure. The appropriate type of closed-chest drainage system for this patient is a: A. Pneumostat B. Water-seal system C. Hemligh valve D. Dry suction-control system

D. Dry suction-control system

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? A. Fluid overload B. Left ventricular failure C. Intracardiac shunt D. Hypovolemia

D. Hypovolemia

A nurse is monitoring a client who has two chest tubes inserted for a right-sided pneumothorax. The client complains of chest burning. Which of the following is an appropriate nursing action? A. Increase the client's wall suction B. Strip the client's chest tube C. Clamp the client's chest tube D. Reposition the client

D. Reposition the client

What should we pay attention to for cervical disc hernation? What is the most critical?

Disc herniation in the cervical spine can compress the spinal cord and cause: -Numbness -Stiffness -Weakness in the legs -Bowel and bladder control issues

S/S of left sided heart failure

Dyspnea Orthopnea Pulmonary crackles Tachycardia Cool, pale, skin Frothy sputum Restlessness

Secondary interventions for patient who has blood pressure with weak pulses

Give oxygen and make sure dressing is on

EKG changes of a patient with prolonged vomiting

Hypokalemia -Flat or inverted T wave -ST segment depression -U wave -Prolonged QT interval

A nurse is caring for a client who has end-stage kidney disease and reports having SOB and swelling in lower extremities. Upon assessment, the nurse notes the client has crackles in his lungs and an elevated blood pressure. The nurse should suspect which of the following based on the client's manifestations?

Hypovolemia

To prevent a common complication of continuous enteral tube feedings, a nurse should

Limit the time the formula hangs to 4 hours

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea toward the unaffected side.

To prevent aspiration during the administration of an enteral tube feeding, the nurse should

Place the patient in fowler's position (elevate the bed at 30 degrees)

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

Return of distal pulses

Symptoms of hemorrhagic stroke

Severe headache, nausea, and vomiting

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? A. Vomiting

Stridor

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? a. Increased heart rate b. Widening pulse pulse pressure c. Increased deep tendon reflexes d. Pulse oximetry 96%

a. Increased heart rate

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

b. 400 mL of blood in the collection chamber

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

b. Tape a nonporous dressing on three sides over the chest wound.