Complex exam 2

Autonomic dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) Above the lesion: HTN, tachy, diaphoresis Below the lesion: no sensation, nothing

What's a normal ICP?

0-10

3 major complications of cirrhosis

ascites, esophageal varices, encephalopathy

44. Do we want patients to access or assess their fistulas?

ASSESS (DON'T SKIM, READ

Where do you palpate for an enlarged liver

RLQ, under ribs

You have a 16 y.o patient, MVC and whispers "im pregnant". What is your priority?

MOM! (aka. incubator) and make sure her ABC are okay

Client developed cardiogenic shock after suffering a severe MI and heart failure. The client has now developed acute renal failure. The family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was: A decrease in the blood flow through the kidneys (pre renal failure) An obstruction of urine flow from the kidneys A blood clot formed in the kidney Structural damage to the kidney resulting in acute tubular necrosis

A decrease in the blood flow through the kidneys (pre renal failure)

Nursing problem or diagnosis with facial burn?

Airway issue

During the peritoneal dialysis, the nurse observes that the solution draining from the client's abdomen is consistently blood-tinged. The client has a permanent dialysis catheter in place. The place should recognize that the bleeding: -Is expected with a permanent peritoneal catheter -Indicates abdominal blood vessel damage -Can indicate kidney damage -Is caused by too-rapid infusion of the dialysate

Indicates abdominal blood vessel damage

What are the three big complications of cirrhosis we need to pay attention to?

Ascites hepatic encephalopathy esophageal varices

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all. -Remind HCP to draw blood from veins on the left side -Avoid sleeping on the left arm -Wear wristwatch on the right arm -Assess finger on the left hand for warmth -Obtain BP form the left arm

Avoid sleeping on the left arm -Wear wristwatch on the right arm -Assess finger on the left hand for warmth

What is a dangerous ammonia level to cause confusion?

Individualized to each pt. Look subjectively to see how each pt behaves

Blunt vs. penetrative trauma

Blunt = no skin tear, use imagination to understand the trauma

Dialysate solutions should be

Clear to slightly yellow (can read through it) No red, no brown flakes

The client with acute renal failure is recovering and asks the nurse "will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's status will most likely: -Continue to improve over a period of weeks -Result in need for permanent hemodialysis -Improve only if the client receives a renal transplant -Result in end-stage renal failure

Continue to improve over a period of weeks

Pt complaining of burning in the chest after sclerotherapy. What should a nurse do first?

Differentiate between sclerotic pain in chest versus MI EKG

Late s/s of increased ICP

Dilated, NONREACTIVE pupil UNRESPONSIVENESS ABNORMAL posturing patterns (flexion, extension, flaccidity) Changes in RR pattern Cushing's Triad (LATE LATE SIGN)

T5 complete SCI. Flushed skin, diaphoresis above t5, bp of 162/96. Client reports severe pounding headache. Appropriate interventions? -Elevate head of bed -Loosen constrictive clothing -Use fan to reduce sweating - NO (overstimulation) -Assess for bladder distention and bowel -Administer antihypertensive -Place client supine with legs elevated - NO (will increase blood return to core)

Elevate head of bed loosen constrictive clothing Assess for bladder distention and bowel Administer antihypertensive

What are signs and symptoms of possible upper airway damage?

Facial burns Singed nasal hairs Progressive hoarseness Stridor Inability to swallow Edema of oropharynx

Client experienced an electrical injury with an entrance wound on his left hand and exit on his left foot. Priority assessment data? Urine output Heart rate and rhythm (think ABCs) Orientation to time, place, and situation Sensation in all extremities

HR and rhythm- think ABC's

Early s/s of increased ICP

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

How do meds need to be given in a burns patient in the first 24-48 hours?

IV due to decreased perfusion and absorption

Best way to check for patency of arteriovenous fistula for hemodialysis? -Pinch the fistula and note filling speed -Check for capillary refill of the nail bed -Palpate the fistula throughout its length to assess for a thrill or auscultate for a bruit

Palpate the fistula throughout its length to assess for a thrill or auscultate for a bruit

For total shut down for chronic pancreatitis, what medication do you want to ensure that the patient gets

Pancreatic enzyme, ends with -ase

A client with chronic renal failure receives hemodialysis three times a week. In order to protect the fistula, the nurse should: -Take the BP in the arm with the fistula -Report the loss of a thrill or bruit on the arm with the fistula -Maintain a pressure dressing on the shunt -Start a second IV in the arm with the fistula

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

Secondary assessment includes hx. IF while doing secondary assessment pt starts to have issues such as breathing, bleeding, etc....

START primary assessment again

Peritoneal dialysis. You note returned fluid is cloudy and slightly pink tinged. Best action? -Irrigate peritoneal cath -Stop the dialysis flow and notify the health care provider -Document the finding as the only action -Change the dialysate

Stop the dialysis flow and notify the health care provider

The client has been admitted with acute renal failure. What should the nurse do? Select all. Elevate the HOB 30-45 degrees Take vitals Establish IV site Call admitting HCP for orders Contact the hemodialysis unit

Take vitals, call HCP

what should we teach patients with hemodialysis fistulas?

Teach pts with hemodialysis fistulas to listen for their bruit

Doing peritoneal dialysis, load up 2 L of fluid, 2 L don't come back out. What do you do?

Turn the patient to allow the catheter to flow

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of the client? -Use the unaffected arm for BP measurements -Draw blood from the cannula for routine lab work -Percuss the cannula for bruits each shift -Inject heparin into the cannula each shift

Use the unaffected arm for BP measurements

The client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should: -Assess the dialysis access for a bruit and thrill -Insert an indwelling catheter and drain all urine from the bladder -Ask the client to turn towards the left side -Warm the dialysis solution in the warmer - don't want to put in cold solution to the abdomen, causes vasoconstriction and makes dialysis difficult

Warm the dialysis solution in the warmer - don't want to put in cold solution to the abdomen, causes vasoconstriction and makes dialysis difficult

Asterixis

a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings.

What causes major confusion/hepatic encephalopathy?

elevated ammonia levels

Doctor 200 cc fluid per hour, tylenol, etc. What do you question?

fluids

When caring for a client with a head and neck trauma.. Initial action? --Perform oral and nasal suctioning -Provide O2 -Intiatie IV -Immobilize the cervical area

immobilize the cervical area

Neurological damage is done, do you expect pt to be tachycardic?

no

Burn on both legs white and leather like. No blisters or bleeding, no pain.

third degree burn- full thickness

Pt with chronic alcohol abuse is admitted with liver failure. You closely monitor the pt's BP because of which change that is associated with liver failure? Hypoalbuminemia - liver is not regulating protein Increased capillary permeability Abnormal peripheral vasodilation Excess renin release from kidneys

Hypoalbuminemia - liver is not regulating protein

Diagnostic peritoneal lavage output is cloudy. What does this indicate?

Infection

What do we give pts with hepatic encephalopathy?

Lactulose given to pt to poop and get rid of ammonia

Pt has a compression device in place and complains of SOB, first thing to do?

PULL it out Pair of scissors at bedside to cut