CRITICAL CARE EXAM 3 UPDATED

The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should provide what answer?

"Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain."

Select three findings in a client's medical record that will increase their risk for peptic ulcer disease?

(Go over indications and causes) • Smoking, alcohol use, spicy foods, frequent NSAIDS use, h-pylori, un-treated stress,

Which of the following IV solutions is most likely to resuscitate to an adult who is in hypovolemic shock due to a GI bleed?

0.9% sodium chloride

Following an assessment of the blood glucose via fingerstick, a value of 54 mg/dl was obtained on the critical care patient. What is the priority intervention using the 15/15 rule for glucose management?

1 tablespoon (15 grams) of sugar and repeat fingerstick in 15 minutes to determine effectiveness of intervention

Following an assessment of the blood glucose finger stick, a value of 54 was obtained on the cc patient, what is the priority intervention using 15/15?

1 tbsp of sugar and repeat in 15 mins

The palmar surface, including the fingers of the patient's hand represents what percent of his or her total body surface?

1%

Normal ICP is

10-15. 20 over 5 mins is life threatening.

Appropriate initial management of a patient with a documented inhalation injury includes:

100% humidified oxygen to decrease carboxyhemoglobin levels

A 22 year old male comes to the emergency department following a MVA. his eyes open to speech, he is confused and localizes to pain. What is his GCS score?

12

The patient admitted with acute pancreatitis is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient has what morality rate?

15%

Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count at what level?

1500 cells/microliter or higher.

GCS scores range from

3 (deep coma) to 15 (normal functioning)

A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg.; blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?

90 (subtract MAP from ICP)

A nurse is assigned to triage after a mass casualty due to an explosion, which of the following clients should be the priority for treatment?

A client with an open fracture of the left tibia and fibula

Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)

Administer levothyroxine as ordered. Initiate passive rewarming interventions. Monitor airway and respiratory effort.

The nurse caring for a patient with acute pancreatitis implements what intervention in order to provide adequate pain control?

Administers pain medication on a routine schedule.

Rule of nines

Adult: Head and arms 9%, chest, back, legs 18% Kid: head, back, chest 18%, legs 14%, arms 9%

What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.)

Altered sleep/rest patterns. Eating disorder. High levels of stress. Lack of financial resources.

An elderly patient who is being admitted for anemia of unknown cause has been on multiple medications at home for various ailments. In assessing the patient's medication list, the nurse notes which medications that may alter hemostasis? (Select all that apply.)

Aminoglycosides. Antiplatelet agents. Cephalosporins. Sulfonamides.

A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to monitoring for what cardiac rhythm while providing care to this patient?

Atrial fibrillation

An example of a pathological reflex in an adult is?

Babinski reflex

The nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

Decrease fluid intake/restrict fluids

Which of the following would be seen in a patient with myxedema coma?

Decreased reflexes

Which statement about mass casualty triage during a disaster is true?

Disaster victims with the greatest chances for survival receive priority for treatment.

15 in 15

Eat 15 grams of carbs, then recheck 15 mins later. 4 glucose tablets, 1 tube of glucose gel, 4 oz of fruit juice, 1 tbs. Corn syrup, 8 ounces of milk, 1 tbsp of jam, jelly, or sugar.

An older adult patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis?

Elevated thyroid-stimulating hormone

A nurse is caring for a client with hypovolemic shock. Which of the following is the nursing priority action?

Elevating the clients legs

A nurse is providing care for a patient who has developed Kaposi's sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?

Endothelial cells lining small blood vessels

The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower than normal ratio may indicate acquired immunodeficiency syndrome (AIDS). What is the role of T4 cells?

Enhances humoral immune response.

Early clinical signs of liver disease include all of the following except?

Esophageal varices

A construction worker is admitted after falling approximately 15 feet from scaffolding, what diagnostic intervention does the nurse anticipate in the care of this trauma patient to evaluate sources of potential bleeding?

FAST or E-FAST

Which nursing diagnosis is a high-priority for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?

Fluid volume deficit

A nurse is assessing a client with HYPERthyroidism. The nurse should expect the client to report the following manifestations.

Frequent mood changes

A nurse is interviewing a client with acute pancreatitis. Which of the following factors would the nurse anticipate finding in the patient's history?

Gallstones

Nurse is reviewing a client with acute pancreatitis which of the following should the nurse anticipate finding in the client's history

Gallstones

A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. What should the primary survey of this patient upon arrival to the ED include?

Getting a baseline assessment and establish priorities.

The patient admitted with anemia caused by blood loss and thrombocytopenia has a platelet count of 22,000/microliter. The patient is scheduled for a transfusion of red blood cells (RBCs) and a transfusion of platelets. The nurse should take what action?

Give the platelets before the RBCs.

What strategies are appropriate for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE) in an at-risk patient? (Select all that apply.)

Graduated compression stockings. Heparin or low-molecular weight heparin. Sequential compression devices.

The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned about acquired immune deficiency syndrome (AIDS). The patient's blood work shows the presence of HIV antibodies. The nurse should explain that?

HIV infection and AIDS are considered chronic diseases.

Which of the following activities may help decrease increased cranial pressure?

Head elevation to 30 degrees

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as priority?

Hematolysis (massive bleeding, bleeding out)

A nurse is assessing a client with peptic ulcer disease which of the following findings should the nurse identify as a priority

Hemoptysis coughing up blood /bleeding out

What diagnostic procedure is required to make a definitive diagnosis of pulmonary embolism?

High resolution multidetector CT angiogram.

What differences would you expect to see in patients experiencing hyperosmolar hyperglycemic syndrome rather than diabetic ketoacidosis?

Higher serum glucose, higher osmolality, and no ketosis

Which 3 elements are commonly referred to as the "trauma triad of death"?

Hypothermia, acidosis, coagulopathy

In the trauma patient, what is the most common cause of symptoms of decreased cardiac output?

Hypovolemia

While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?

ICP is high; CPP is normal.

The patient admitted with neutropenia, should have regular assessments focus on what?

Identifying signs of systemic infection.

The nurse caring for a patient with an acute ischemic stroke anticipates?

Identifying the precise time of stroke symptom onset when possible

Trends in nutritional management of the patient with pancreatitis are changing regarding what aspect of care?

Immediate oral feeding in patients with mild pancreatitis may help recovery.

Which patient symptoms require further urgent evaluation to address possible compartment syndrome?

Increasing pain

What is the treatment for an acute exacerbation of asthma?

Inhaled bronchodilators and intravenous corticosteroids

The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for what intervention?

Insertion of a percutaneous catheter at the bedside.

What is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants?

Insertion of a vena cava filter.

The patient receiving hemodialysis 3 days a week is 74 inches tall and weighs 100 kg. In planning the care for this patient, the nurse provides what nutritional recommendation?

Intaking 2500 to 3500 kcal diet per day

How is peritoneal dialysis different from hemodialysis?

It uses the patient's own semipermeable membrane (peritoneal membrane).

Which laboratory value indicates that the patient is under-resuscitated?

Lactate of 5

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for escharotomy. The clients spouse asks the nurse what the procedure entails. Which of the following statements is appropriate?

Large incisions will be made in eschar to improve circulation.

Cardiac tamponade

Life threatening condition caused by rapid accumulation of fluid in the pericardial sac. Should be suspected if patient does not respond to fluid resuscitation Needs a pericardiocentesis by physician

A nurse is caring for a client who hemorrhaged postoperatively one day ago. The client has had onset of excessive clotting followed by severe bleeding. Which disorder is this client most likely affected with?

Life-threatening acute disseminated intravascular coagulation

What are the nursing priorities for the management of acute pancreatitis? (Select all that apply.)

Managing respiratory dysfunction. Assessing and maintaining electrolyte balance. Utilizing supportive therapies aimed at decreasing gastrin release.

The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which order should the nurse institute first?

Mannitol 1 g intravenous

The nurse assessing a patient being admitted for anemia observes no overt signs of bleeding. The nurse understands what fact about the clinical presentation of anemia?

Many patients have bleeding that is not obvious.

Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.)

Mean arterial pressure 48 mm HG. Non-reactive pupils. Respiratory rate of 10 breaths per minute.

Autonomic dysreflexia

Medical Emergency: Can result in stroke, seizures, or other compilations.

The nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Metformin

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which intervention?

Mobility

A nurse is caring for a client who has a full thickness burn over 75% of his body. The nurse should use which of the following methods to monitor his cardiovascular system?

Monitor pulmonary artery pressure

The nurse assesses a patient with a skull fracture and notes a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?

Monitor the patient's airway patency.

The patient admitted with pancreatitis presents with severe ascites. In caring for this patient, the nurse should take what action?

Monitor the patient's blood pressure and evaluate for signs of dehydration.

A nurse is assessing a client with Hyperthyroidism. The nurse should expect the client to report which of the following clinical manifestations?

Mood swings

Hyperthyroidism

Most common causes: toxic diffuse goiter (Graves' disease), toxic multinodular goiter, toxic uninodular goiter

A nurse is assessing a client who was transported to the ER with neurological deficits after falling off a ladder. What client assessment is included in the GSC?

Motor response to a stimulus

Possible treatments for acute respiratory in the patient with COPD include:

Noninvasive ventilation. bronchodilators. corticosteroids.

The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?

Notify the primary care provider immediately.

The critical care nurse has just completed the second blood glucose bedside assessment. The results are as followed: 315 at 0900 and 350 at 1300. What is the priority in terms of nursing actions?

Notify the provider as two consecutive blood glucose measurements are greater than 300 in a 12 hour period

A nurse is caring for a pt who is in a myxedema coma. Which of the following actions should the nurse take?

Place the client on aspiration precautions.

A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect to be decreased?

Platelets

A nurse is caring for a client who was just admitted to the ED with severe burn injury. Which of the following orders would the nurse question for the client?

Potassium

A nurse is caring for a male client with extensive 2nd and 3rd degree burn injuries, which of the following lab values should be reported to the provider?

Potassium of 6.1

An 80 year old female arrives at the ED with a temp of 94 degrees, blood pressure of 88/60, heart rate of 52, respirations of 40, and oxygen of 84%. She has a history of hypothyroidism but lives alone and does not remember taking her medication in the past 4 weeks. She appears lethargic. Which of the following is the appropriate initial nursing action?

Prepare for endotracheal intubation

A nurse on the medical-surgical unit is assigned to a client who has a sengstaken-blakemore tube in place for treatment of bleeding esophageal varices. Which of the following assessments should the nurse prioritize?

Rales on chest auscultation

When collecting data from a client with kaposi's sarcoma (KS) the nurse should expect to observe which of the following?

Reddish-purple skin lesions

Evidence based interventions for the prevention of ventilator-associated pneumonia (VAP) include?

Regular antiseptic oral care.

A nurse is caring for an adult client who is being treated with pancreatitis and requires mechanical ventilator for assistance with breathing. The physician orders an arterial blood gas, which provides the following results: Ph 7.28; pCO2: 52, HCO3 24, and sa02 of 92 % bast on these results which best describes the client's condition?

Respiratory acidosis

A nurse is caring for a client with 3rd degree burns over 15% of his body surface. Which of the following indicates adequate fluid replacement during the first 24 hours?

Slowing of a previously rapid heart rate

Autonomic dysreflexia

Sudden, severe, pounding headaches, elevated uncontrolled bp, bradycardia, nasal congestion, blurred vision, profuse diaphoresis above the level of injury, pallor chills, and pilomotor erection below the level of injury

The nurse discharging a patient diagnosed with asthma instructs the patient to prevent exacerbation by taking what action?

Taking all asthma medications as prescribed.

What is an advantage of peritoneal dialysis?

The danger of hemorrhage is minimal.

When the patient's hematological and immunological systems are compromised, it is not uncommon to require transfusions of several different types of blood products. What patient condition would warrant the administration of platelets as the first consideration?

Thrombocytopenia

A patient presents to the emergency department (ED) with the following clinical signs: Pulse: 132 beats/min, Blood pressure: 88/50 mm Hg, Respiratory rate: 32 breaths/min, Temperature: 104.8° F, Chest x-ray: Findings consistent with congestive heart failure, Cardiac rhythm: Atrial fibrillation with rapid ventricular response. These signs are consistent with which disorder?

Thyroid storm

A client is admitted after severe burn injury and is undergoing fluid resuscitation. Which of the following is most accurate assessment of successful fluid resuscitation?

Urine output greater than 30

Lung-protective ventilation strategies include?

Vt at 4-8 ml/kg predicted ideal body weight.

A nurse and UAP are caring for a client in the ICU with increased ICP after rupture of cerebral aneurysm.

Which of the following actions by the UAP will promote intervention by the nurse? The UAP assists the client to a prone position

Which of the following medical conditions is least likely to predispose a patient to disseminated intravascular coagulation (DIC)?

acute renal failure.

Initial fluid resuscitation requirements are calculated based on the following parameters?

age. total body surface area burned. patient weight. cause of burn injury.

The Berlin criteria for acute respiratory distress syndrome( ARDS) include?

all of the above. Acute onset within 1 week after clinical insult. bilateral pulmonary opacities not explained by other conditions. altered partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio.

Patients at risk for the development of deep vein thrombosis may include?

all of the above. Those older than 75 years. those who are immobile for longer than 3 days. pregnant women, patients with burn injury.

A nurse is performing an assessment of an unconscious client. The nurse knows that GCS is designed to:

assess the level of consciousness

An elderly patient presented to a hospital's emergency department with a chief complaint of constipation for 1 week. The patient has a medical history of hypertension, diabetes, and hyperlipidemia. The patient had been taking calcium supplements for a year. What should the nurse perform first?

assess the patient for abdominal pain and usual diet.

Upon admission to the critical care unit, the patient's serum potassium is 8.1 mEq. Tall peaked T waves, prolonged QRS duration, and bradycardia are noted. Which pharmacological intervention would be most appropriate for this situation?

calcium chloride 5-10 ml of a 10% solution given by slow IV injection.

Which one of the following common diagnostic tests is most accurate in assessing kidney function?

creatinine clearance.

A provider orders a cosyntropin test to assess adrenal status. Which of the following statements is true regarding the test?

dexamethasone administration does not affect cortisol values and can be administered in emergency situations.

all of the following are true about the brainstem functions except?

he brainstem is responsible for temperature control.

Which of the following activities may help decrease increased intracranial pressure?

head elevation to 30 degrees.

Myxedema coma is an extreme form of hypothyroidism and is characterized by signs of?

hypometabolism. including bradycardia. hypotension. hypothermia. cold intolerance. neurological sluggishness.

Which three elements are commonly referred to as the "trauma triad of death?" (select all that apply).

hypothermia. acidosis. coagulopathy.

An immunocompromised patient has a high risk of developing a life threatening infection. An awareness of abnormal laboratory results can be key to early detection and intervention. The term shift to the left is indicative of an acute bacterial infection and observed with the following laboratory results?

increased number of band neutrophils compared to mature neutrophils.

Which patient symptom requires further urgent evaluation to address possible compartment syndrome?

increasing pain.

Based on kidney disease improving global outcomes (KDIGO) acute kidney injury (AKI) guidelines, oliguria is defined as urine output?

less than 0.5 ml/kg/h

Glomerular filtration rate is directly influenced by?

mean arterial pressure.

The secondary survey is more

methodical and involves identifying injuries and specific treatment priorities.

The primary goal of continuous venovenous hemofiltration(CVVH) is to?

optimize fluid balance

Which laboratory values would be more common in patients with diabetic ketoacidosis?

pH 7.24

lower tidal volumes are an evidence-based method for

preventing ventilatior induced lung injury

Acid-base regulation of the kidney is performed primarily in which section of the nephron?

proximal and distal tubules.

The key purpose of the primary survey is to?

quickly identify and treat the greatest life-threatening emergencies.

Which acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?

respiratory acidosis

The patient is admitted with acute pancreatitis. The nurse should be prepared to take what action?

Evaluate C-reactive protein as a gauge of severity.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Fatigue

When the patients hematological and immunological systems are compromised, it is not uncommon to require transfusions of several different types of blood products. What patient condition would warrant the administration of platelets as the first consideration?

Thrombocytopenia

Which statement is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?

PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE.

Why is pain control a nursing priority in patients with acute pancreatitis?

Pain increases pancreatic secretions.

While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient's left naris. What is the best nursing action?

Place a nasal drip pad under the nose.

A patient diagnosed with severe pancreatitis is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and should have taken what action?

Places the patient on seizure precautions.

A patient is admitted to the critical care unit with a diagnosis of possible meningitis. Actions the nurse anticipates include all of the following except:

Placing the patient on contact precautions

A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring?

Potassium

The patient is diagnosed with hepatitis. In caring for this patient, the nurse should be prepared to take what action?

Provide rest, nutrition, and antiemetics as needed.

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.)

Recording ICP as a "mean" value. Zero referencing the transducer system.

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?

An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza

Which leads to inadequate oxygenation of tissues?

Anemia

neurogenic shock is characterized by

hypotension, bradycardia, and hypothermia

When caring for a patient with HIV, the nurse should?

monitor the patient's medication regimen.

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?

"This injection is being given to prevent blood clots from forming."

A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered for a patient who presented to the emergency department experiencing diabetic ketoacidosis. What is the targeted blood glucose value after the first hour of therapy?

A decrease of 50 to 75 mg/dL compared with admitting values

What is the most common cause of a pulmonary embolus?

A deep vein thrombosis from lower extremities.

What is a cause of a secondary immunodeficiency that involves the loss of a previously functional immune defense system? (Select all that apply.)

AIDS. aging. nutritional deficiencies. immunosuppressive therapies.

What is responsible for maintaining the body's oncotic pressure?

Albumin

Sudden, severe, pounding headaches, elevated uncontrolled bp, bradycardia, nasal congestion, blurred vision, profuse diaphoresis above the level of injury, pallor chills, and pilomotor erection below the level of injury

Assess for a kinked urinary catheter and assess for bowel impaction.

The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly reports experiencing abdominal pain and chills. The patient's temperature is elevated. The nurse should take what action?

Assess peritoneal dialysate return.

The nurse is assessing the patient admitted diagnosed with pancreatitis. In doing so, the nurse takes what action?

Assesses symptoms that could indicate involvement of the stomach.

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?

Assist the patient to the floor and provide soft head support.

a superficial partial-thickness (second degree) burn is characterized by?

Blistered skin with pink or moist base

A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.)

Blood glucose 524 mg/dL, HCO3-10 mEq/L, pH 7.23

Which of the following assessment findings indicate that the patient with an acute cervical spinal cord injury is experiencing neurogenic shock?

Blood pressure of 84/56 and heartrate of 41

AIDS is defined by the presence of

CD4 count lower than 200/mm and the presence of an indicator condition. Is also the final stage of HIV

The nurse is caring for a patient with an intracranial pressure ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol, which assessment finding by the nurse requires further action?

CVP of 2 mm Hg

The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells, "my abdomen is killing me". When the nurse notes that the patient's abdomen is rigid should action should be taken next?

Call the healthcare provider (PCP) immediately.

Increased intracranial pressure

Can be caused from stroke or brain injury

A nurse is caring for a client who had an evacuation subdural hematoma. Which of the following actions should the nurse take first?

Check the oximeter

Neutropenia

Classified based in the pt's predicted risk for infection: mild (1000 to 1500), moderate (500 to 1000) and severe (< 500)

A nurse is planning care for a client that has cirrhosis. Which of the following interventions should the nurse include in the plan of care?

Decrease fluid intake

A patient diagnosed with type 1 diabetes is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of what possible complication?

Diabetic ketoacidosis

The patient getting hemodialysis for the second time reports a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of what possible complication?

Dialysis disequilibrium syndrome

A nurse is caring for a client who has burns to his face ears and eyelids. The nurse should identify which of the following as priority finding?

Difficulty swallowing

HHS (Hyperosmolar hyperglycemic syndrome)

Dx: serum glucose concentration is significantly more elevated may exceed 3000, plasma osmolarity is higher, acidosis is not present, ketosis is usually absent

What medications are prescribed to patients recently diagnosed with peptic ulcer disease (PUD) from Helicobacter pylori?

Esomeprazole, amoxicillin, and clarithromycin.

Which of the following statements is true regarding thyroid storm?

Marked tachycardia may be observed.

A nurse is teaching a client with acute kidney injury about ((oliguria phase???)). Which of the following information should the nurse include in the teaching?

Urine output of less than 400 ml in 24 hours

Which of the following statements is true about the medical management of diabetic ketoacidosis?

Volume replacement and insulin infusion often correct the acidosis.

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started?

When the blood glucose reaches 250 mg/dL

What causes anemia? (Select all that apply.)

blood loss. impaired production of red blood cells. increased destruction of red blood cells.

Dialysis disequilibrium syndrome

caused by the rapid removal of urea during hemodialysis; CNS disorder Rx factors: elevated BUN above 175 Manifestations: headache, nausea, vomiting, decreased LOC, seizures, restlessness; when severe, patient progress to confusion, seizures, coma, death

A GCS of 8 or less is

consistent with coma.