HURST: Module 1 Elevate
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
