Sh*t you should know assshole

When a client enters the emergency department in a psychiatric emergency, the nurse should perform an assessment in an organized manner. Place the following interventions in their order of priority, beginning with number 1 as the highest priority.

A brief collection of demographic information, particularly the client's name, should be part of the beginning of the nurse-client relationship. The client's perspective of the situation should be obtained after demographic information is collected. While talking with the client, the nurse assesses the client's presenting physical, emotional, and mental status. A psychosocial history is the least important of the assessments. Documentation may be done last. Continuous documentation may interfere with the nurse-client relationship.

What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? Pectus carinatum Pectus excavatum Kussmaul breathing Cheyne-Stokes respirations

Cheyne-Stokes = alternating periods of apnea and deep rapid breathing. Pectus carinatum is a prominent abnormal protrusion of the sternum. Pectus excavatum is an abnormal indentation of the lower sternum above the xiphoid process. Kussmaul breathing is a rapid and deep breathing abnormality.

What sort of breath sounds does someone with a pneumothorax?

Diminished breath sounds

Iatrogenesis

Greek: Iatros-, "healer" -genesis, "origin"

an overdose of enoxaparin is treated with which drug?

Protamine sulfate

A nurse witnesses a client collapse during a home care visit. Place the basic life support actions in the order they should be performed by the nurse. 1. Use physical and auditory stimulation to attempt to elicit a response. 2. Palpate to determine the presence of a carotid pulse. 3. Listen and observe for spontaneous breaths. 4. Direct the client's spouse to call the emergency management system. 5. Perform 30 chest compressions. 6. Open the airway with the head tilt-chin lift method and give two breaths.

Stimulation is required to determine if the person is actually unresponsive. Immediate activation of the emergency management system. Observing the rise of the chest and listening for the presence of breathing. Palpation of the pulse. Begin 30 chest compressions to a depth of 2 inches (5 cm). Opening the airway results in spontaneous breathing

Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Cyanosis Cool, clammy skin Unexplained restlessness Retraction of interspaces on inspiration

Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.

What breathing exercises should the nurse teach a client with the diagnosis of emphysema? An inhalation that is prolonged to promote gas exchange. Abdominal exercises to limit the use of accessory muscles. Sit-ups to help strengthen the accessory muscles of respiration. Diaphragmatic exercises to improve contraction of the diaphragm

With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration that are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema.

Client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply. Dry cough Chest pain Hemoptysis Shortness of breath Fever greater than 100.4° F (38° C)

Between two and seven days after the onset of SARS, which is caused by a coronavirus, clients exhibit a dry cough. SARS is an acute viral respiratory infection that results in respiratory signs and symptoms, including difficulty breathing and shortness of breath. SARS, a viral infection, generally begins with a fever greater than 100.4° F (38° C), headache, and muscle weakness. Although clients may exhibit sinus tachycardia, chest pains are not a typical symptom associated with SARS. The cough associated with SARS is nonproductive, and hemoptysis does not occur.

A client had thoracic surgery. The nurse should monitor for which clinical manifestations that may indicate acute pulmonary edema? Select all that apply. Crackles Cyanosis Chest pain Bradypnea Frothy sputum

Crackles signify fluid in the alveoli because of increased capillary permeability associated with pulmonary edema. Cyanosis is evidence of inadequate oxygenation. Frothy sputum results because of the large amount of fluid in the lungs; it may or may not be blood tinged. Chest pain is not a symptom of acute pulmonary edema; this is associated with a pneumothorax. Dyspnea, not bradypnea, is associated with pulmonary edema.

Are you able to identify these if heard? Rhonchi Wheezes Fine crackles Coarse crackles

Fine crackles-short-duration, discontinuous, high-pitched sounds caused by rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open. They are heard just before the end of inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur due to obstruction of large airways with secretions. Wheezes are continuous high-pitched squeaking or musical sounds that result from rapid vibration of bronchial walls. Coarse crackles are series of long-duration, discontinuous, low-pitched sounds associated with pulmonary edema or pneumonia with severe congestion. They sound like air is blowing through a straw underwater and are caused by air passing through an airway intermittently occluded by mucus, unstable bronchial walls, or folds of mucosa.

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention? Administer oral fluids. Encourage deep breathing. Increase the oxygen flow rate. Perform nasotracheal suctioning.

Hypoventilation because of pain is the usual cause of respiratory acidosis after lung surgery. Respiratory regulation corrects 50% to 75% of pH imbalances; this is accomplished by either increasing (for acidosis) or decreasing (for alkalosis) the rate and depth of respirations. Therefore, deep breathing will decrease carbon dioxide levels in the blood, thereby decreasing respiratory acidosis. Oral fluids are helpful in liquefying respiratory secretions but will not decrease carbon dioxide levels in the blood. The client has emphysema, and increasing delivery of oxygen if the client is not hypoxic may precipitate CO2 narcosis. The situation does not indicate the presence of excessive respiratory secretions.

A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. How should the nurse interpret these findings? Increased leukocyte development in response to infection Decreased extracellular fluid volume secondary to infection Decreased red blood cell proliferation because of hypercapnia Increased erythrocyte production as a result of chronic hypoxia

Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen. White blood cell production increases with infection; infection is not the cause of the increase in the hemoglobin and hematocrit. There is a loss of extracellular fluid in an acute infection with a fever; however, in a chronic condition, this fluid is replenished and the hematocrit usually is unaffected. Hypercapnia is an increase in PCO2 in extracellular fluid; this does not have a direct effect on the hemoglobin and hematocrit levels.

A blood transfusion of packed cells has been prescribed for a client. The nursing unit is extremely busy. In delegating the task of blood administration: Assign a licensed practical nurse (LPN) and a nursing assistant to verify the blood is correct and have the LPN monitor the client 15 minutes after hanging the product. Have two registered nurses ascertain that the client identification and blood product are correct with no discrepancies, hang the blood, and check in 15 minutes. Have all identification verified by registered nurses, then the registered nurse can hang the product and monitor client, staying with client during the initial 15 minutes. Have the product and name band verified by a registered nurse, hang, and monitor every hour until infused within a 10-hour period or discontinued

The blood product must be checked by two RN's, and pt ID verified. A RN hangs the product and stay for initial 15 minutes. Packed cells are infused in 2 hours and cannot be hung longer than 4 hours.