ECCO Multisystem Disorders
A pt at risk of AWS is receiving IV Thiamine, Folate, and vitamins. He is now tachycardic, agitated, and feverish, and says that ants are crawling on his arms and legs. Which provider order should the nurse anticipate?
- Administer benzodiazepines
A pt with septic shock/MODS shows evidence of volume overload, is hemodynamically unstable, and has elevated BUN and creatinine levels. If the patient develops AKI, which intervention should the nurse anticipate?
- Continuous Renal Replacement Therapy (CRRT)
A patient diagnosed with rhabdomyolysis is receiving NS at 500 mL/h and furosemide. Which other intervention to prevent AKI should nurse anticipation?
- IV Bicarbonate administration to alkalinize the urine Urinary alkalization with IV bicarb is thought to prevent myoglobin precipitation
A patient who fell down a flight of stairs is admitted with a C-collar in place. Vital signs are BP 84/32 (49), HR 52 sinus bradycardia, RR 16, temo 36 C. The patient has warm extremities but is unable to move the lower extremities. Which of the following interventions should the nurse initially anticipate?
- IV fluid bolus - A vasopressor
A patient who admits to using illicit street drugs including cocaine is admitted after being involved in a motor vehicle crash. In addition to fluids, diuretics, and alkalinizing agents, which of the following interventions for rhabdomyolysis should the nurse anticipate?
- Initiate interventions for hyperkalemia Hyperkalemia is common with rhabdo
A pt was admitted 5 hours ago with sepsis due to pneumonia. Review the EMR. Which of the following should the nurse anticipate?
- Initiating daily IV hydrocortisone Daily IV hydrocortisone may be added if a patient remains hemodynamically unstable despite fluids and pressors
A patient with diabetes reports that the site of a resolving pressure ulcer has now become very painful. The nurse observes edema at the site. What other signs are likely for a patient developing necrotizing fasciitis?
- bullae - erythema - fatigue
A patient who reported being a social drinkers undergoes surgery and is admitted. Vital signs are BP 156/92 (113), HR 105 ST, RR 22, temp 38.3C, and SPO2 94% on 2L n/c. The patient is inquiring why voices are coming from the air vent and is chewing on the IV tubing. Which of the following interventions is of highest priority?
AWS management includes maintaining a patent airway. Have suction set up
Following a diagnosis of sepsis, a nurse draws the patient's blood cultures and lactate level. Broad spectrum IV antibiotics are started. Which additional step is essential for the nurse to complete within 3 hours of presentation?
Administer 30 ml/kg crystalloid for hypotension of lactate >/= 4
Within 5 minutes of receiving IV contrast, a patient develops itching and hives on the neck and chest, and reports feelings of tongue swelling. Vital signs are as follows: BP 82/42 (55), HR 114 ST, RR 26. The provider is notified. Which of the following should the nurse initially anticipate?
Administration of epinephrine
A patient was admitted with septic shock due to a urinary tract infection. The 3 hour bundle has been completed. Norepi and vasopressin are infusing with MAP trending 55-58 mmHg. Which of the following should the nurse anticipate being ordered?
An inotropic agent
A patient admitted with an anterolateral wall MI develops cardiogenic shock. Which of the following should the nurse anticipate will be initiated?
Dobutamine
A patient with intractable vomiting is admitted with decreased LOC. Vital signs are as follows: BP 88/50 (63), HR 114 ST, RR 24, temp 37.7 C. Which of the following should the nurse anticipate doing first?
IV fluid bolus
A patient with a positive urine culture has been receiving fluid resuscitation and a norepi infusion. Admission lactate was 6.2. Which of the following shows patient condition improvement?
Lactate 2.5
A patient with a history of headaches has taken an unknown number of acetaminophen ES tabs over the past few days. She reports having a cold for a few days for which she has taken an OTC remedy (containing acetaminophen) as started on the product label for the entire course of the cold (approx 5 days). Treatment for her overdose has been completed. Which of the following should indicate to the nurse that the treatment for this patient was effective?
Liver function tests remain within range
Which of the following patients with sepsis is responding to vasopressor therapy? A patient with:
MAP 69
A pt being treated for a drug overdose remains with a decreased BP despite fluid resuscitation. Initiation of which agent should the nurse anticipate?
Norepi
A patient reports pain after a sports injury, saying it feels like a muscle has been pulled. The nurse notes that the painful area has black spots on it and it is expanding rapidly. The provider has been notified. Which of the following is an anticipated treatment priority for this patient?
Prepare pt for ct scan
A patient with a history of chronic alcohol abuse is admitted for respiratory failure that required intubation and mechanical ventilation. For which of the following signs of symptoms should the nurse observe?
Shaky hands and seizures
A patient with sepsis had blood glucose levels of 185 and an hour later 191 the nurse implements glucose management protocol. What is the nurse's goal for maintenance of glucose levels in sepsis patients?
Target glucose
Which of the following patients should the nurse suspect as having SIRS? A patient:
With Pancreatitis and VS: BP 88/40 (56), HR 112, RR 22, WBC 4.3
A patient develops confusion and has the following vital signs: BP 90/40 (56), HR 112 ST, RR 24, temp 38.1 C. Serum glucose is 135, and H+H 11.3/33 (L). Urine appears cloudy in the drainage bag. Which of the following should the nurse anticipate?
obtain BLD CX in 45 minutes, intiating ABX within 1 hour
Which of the following are signs and symptoms consistent with a diagnosis of rhabdo
profound muscle weakness and pain
Which of the following is a sign or symptom of necrotizing fasciitis?
ulcerated ares of blistering
A patient admitted with hyperthermia reports muscle weakness, leg swelling, and pain. Which additional sign of rhabdomyolysis should the nurse be alert for in this patient?
urinalysis positive for blood but negative for RBCs
