Critical Care Content Flashcards
(102 cards)
1
Q
Shock
A
Critical condition where the body has decreased tissue perfusion eventually leading to organ failure and death
Classic sign = low blood pressure
2
Q
4 Stages of Shock
A
- Initial
- Compensatory
- Progressive
- Irreversible
3
Q
Initial Shock
A
1st stage Too little oxygen in the blood to feed the organs resulting in anaerobic metabolism (metabolism without oxygen)
Signs and symptoms are absent in this stage
4
Q
Compensatory Shock
A
2nd stage
Body is trying to compensate for the low oxygen, so the heart will pump faster going into tachycardia the resp rate will increase to get more oxygen so we will see tachypnea (body compensates with the sympathetic nervous system to speed up the vital Signs)
renin angiotensin activation to maintain blood pressure and oxygenation to keep the organs refused
As compensatory mechanisms fail clients progress into the progressive phase
5
Q
Progressive stage Shock
A
3rd stage of shock Key sign: Cold and clammy skin = priority
Early sign that the body is lacking perfusion and getting worse not being able to compensate anymore its progressing into the progressive stage
Its not tachycardia and its not low oxygen saturation those are compensatory, cold and clammy skin is priority for progressive stage
6
Q
Irreversible shock
A
Last stage of shock, basically meaning death is imminent
7
Q
5 types of shock
A
- Septic Shock
- neurogenic shock
- Hypovolemic shock
- Cardiogenic shock
- Anaphylactic shock
8
Q
Septic Shock
A
Most tested
Caused by widespread blood borne infection, sepsis infection causes septic shock
Typically caused by a bacterial infection like pneumonia, UTI or kidney infection that progressively gets worse
Whatever the cause, causes extreme vasodilation and fluid leaking from the capillaries
9
Q
Septic Shock Signs and symptoms
A
Severely low blood pressure (less than 80 systolic)
Cold, clammy skin (pale and cool extremities)
Delayed capillary refill
mental status change: confusion and disorientation: result of hypoxia
High WBC over 10,000
Temp high in the early stage and then very low as septic shock progresses
decreased urinary output
10
Q
Hypovolemic Shock (hemorrhagic)
A
Caused by blood loss from a trauma, gun shot wound, surgery or burns caused by anything that can lower the blood volume
Excess fluid volume loss through diarrhea, vomiting or fluid shifts in burn patients for from bleeding.
11
Q
Hypovolemic shock Signs and symptoms
A
Cold and clammy skin
indicates client is getting worse
Hypotension
Tachycardia
Low central venous pressure (normally between 2-6mmHg)
Low urine output less than 30ml per hour = body in distress
Start IV normal saline and notify HCP
12
Q
Which vital sign would alert the nurse to potential hemorrhage following a nephrectomy
A
HR 110 (tachycardia)
13
Q
Hypovolemic Shock
A
Priority: Hemodynamic stability
Lower head of bed right away
Never place the HOB in high fowlers position = worsens low BP and will drop BP even more
Hypo = put the bed LOW
IV normal saline before vasopressin = bolus will increase blood volume and perfuse tissues then only after we give the vasopressors - IV norepinephrine and dopamine to maintain the blood pressure long term
CRITICAL: do not delay a new bag of norepinephrine when the first bag is almost done even if the client is showing signs of improvement with stabilized blood pressure
Goal is to maintain MAP (mean arterial pressure) over 65mmHg
This means the average blood pressure all over the body for tissue perfusion to oxygenate the body and keep the organs alive
Vasopressors can cause the O2 monitor to be inaccurate. The sensor should be placed ed on the forehead instead of extremities since there will be lack of perfusion there
CVP should be maintained between 2-6 mmHg less than 2 = needs more fluid
over 6 = too much fluid, Needs diuretics
14
Q
A client in shock develops a central venous pressure (CVP) of less than 2 mmHg. Which prescribed intervention should the nurse implement first?
A
Increase the rate of IV fluids
15
Q
Cariogenic Shock
A
Heart fails to pump, like end stage heart failure or heart failure exacerbation and even and MI
Cardiac Fails
16
Q
Cardiogenic Shock treatment
A
Dopamine and digoxin which both have inotropic properties meaning it helps the heart to pump more forcefully
Positive inotropic = more forceful beats
Dopamine (vasopressor): presses down on blood vessels (vasoconstriction) to bring up HR and Blood pressure
Caution: Vasopressors may cause adverse effects like tachycardia and arrhythmias
17
Q
Client with heart failure exacerbation and suspected state of shock. The nurse knows which intervention is the priority for this client?
A
Administration of Digoxin (dig for deeper contraction)
18
Q
Anaphylactic shock
A
From a severe allergic reaction
Epinephrine, epiPen injetor
Inject straight into the outer thigh for IM injection
Anaphylactic shock can lead to deadly hypotension and brochoconstriction leads to death via cardiac and respiratory distress
Epi is the 1st drug to use for anaphylaxis
First signs of anaphylaxis reaction (hives dyspnea, hypotension) always use epic first
Repeate every 5-15 minutes until symptoms resolve
19
Q
How to know if its a severe or mild reaction
A
Any allergy that affects the ABCs for induces hives = anaphylactic reaction. Don’t delay epi injection
Epi first
then diphenhydramine (Benadryl) then albuterol and steroids
20
Q
Administration of ampicillin and client reports itchiness and difficulty breathing
A
- Stop infusion
- Assess the lungs
- Prepare to administer epinephrine
21
Q
EPI patient education
A
Inject into outer thigh at 90 degree angle at onset of s/s
Hold in place for 10 seconds
Seek immediate medical attention after use (epi wears off iim 10-20min)
Store epi pens in a dark place at room temperature
22
Q
Neurogenic shock
A
neurogenic shock, caused by spinal cord injury T6 or higher
Autonomic nervous system is damaged resulting in a blockage of sympathetic nervous system which is suppose to speed up the vital signs and cause vasoconstriction
only the parasympathetic nerves system is intact which puts the brakes on the vitals
Causing widespread vasodilation and hypotension = bradycardia and hypotension making it difficult for blood to return back to the heart which leads to decreased blood flow out of the heart (decreased cardiac output)
This results in poor tissue perfusion from the lack of oxygen and impaired cell metabolism resulting in organ failure and death
23
Q
Neurogenic shock Symptoms
A
Bradycardia < 60
Low BP
Skin warm, pink and dry (vasodilation, blood pools in the body because it can’t get back to the heart)
24
Q
Neurogenic Shock Interventions
A
IV normal saline immediately to increased the blood pressure and stabilize it
25
Autonomic dysreflexia
Spinal cord injury above T-6
severe hypertension that can kill the client
triggered by a full bladder, constipation or tight fitting clothes: anything with constriction
Place foley in spinal injury patients too keep the bladder empty and offering laxatives and loose clothes
26
a client is admitted to the hospital with a diagnosis of neurogenic shock. After a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis?
bradycardia
27
Systematic Inflammatory Response Syndrome
28
Multiple Organ-Dysfunction Syndrome (MODS)
29
Acute Respiratory Distress Syndrome (ARDS)
30
Lead II ECG interpretation
31
Mechanical Ventilation
32
Hemodyamic Monitoring
33
Pacing Devices
34
Hemodialysis
35
Client who reports muscle cramps and tingling in hands
Prepare to give calcium carbonate
36
Priority assessment finding for hemodialysis clients?
Restlessness (disequilibrium syndrome) = Solutes are removed too quickly from the blood which causes the brain cells to swell with fluid, deadly ICP
restless and disoriented
vomiting
headache
Stop/slow infusion and report to HCP
37
Care for Fistula (AV shunt)
Connection between artery and vein
High pressure flow through low pressure vein
Squeeze rip rubber ball or sponge to help blood flow and strengthen
Pitting edema = normal
avoid pressure and monitor for infection and bleeding, should always feel a thrill - check this multiple times per day
Monitor for thrombosis
Report to HCP:
Palor
Paresthesia (numbness and tingling)
Pt can lose arm from lack of oxygen
Early intervention saves life and limb
No restrictive clothing or jewelry
No BP on affected arm
No sleeping on arm
No creams or lotions
No lifting over 5lbs
38
Medical Emergencies (BLS)
Cardiac arrest living saving measures
Caused by Hypoxia, resp failure, toxins, blood clots and electrolyte imbalances
Clients present without a pulse, resp rate and unresponsive
Asysytaole on cardiac monitor
Immediate CPR with high quality chest compressions
Before calling for help if you’re the only care giver (immediate oxygen and perfusion to the brain and vital organs)
Adult CPR: Chest compressions mediately 100-120 per min, depth 2-2.4 inches (5-6cm)
Hands in centre of chest lower half of sternum
Breaths: manual = 30 compressions, 2 rescue breaths
Intubated: every 6 seconds without interruption
after each compression the chest should fully recoil to allow heart to refill with blood, compressions are paused every 2 minutes to asses pulse. Do not pause for more than 10 seconds
AED: automated external defibrillator - 8 years and older place in upper right chest near the shoulder
Left lateral chest near the anterior axillary line below the nipple
How to shock:
Defibrillator pads are placed
Call out and look to make sure everyone is all clear
Continue chest compressions immediately after shock is delivered
Pediatrc AED: can use adult pads if paediatric pads aren’t available
1 AED pads on chest and 1 on back
do not overlap or touch pads
No shocking Asystole (flat line)
PEA (pulseless electrical activity)
For Asystole:
High quality CPR priority
Epinephrine even 3-4 minutes
Intubate and ventilate
treat the causes
CPR with pregnancy
Chest compressions slightly higher on the sternum
Uterus manually displaced to left side or place a rolled blanket under right side
Not Supine
Regular chest compressions not affective
Iim ciiruclaton does not return after 4mins immediate C section must take place
Infant CPR less than 1 years old
Brachial pulse 10 seconds or less
bicep area located between elbow and shoulder
Call for help activate an emergency response
2 minutes cpr 100-120 compression
single rescuer 30:2
two rescuer 15:2
Reteriiive AED after 2 min CPR single rescuer unwitnessed event
Adequate ventilation
Roll under shoulders
Neck slightly extentented
Two thumbs middle of sternum below nipple line
two fingers in middle of sternum. other hand supporting the back
Post resuscitation care
Comatose: not following commands
Cold fluids for therapeutic hypothermia done within 6 hours of event
39
ABG interpretation
Body loves too keep in perfect balance, to much of one thing can be deadly
Acid = more dangerous than base
Too much acid in the body can turn the lungs off = hypercapicnic respiratory failure, CO@ builds up in the blood and pushes the body into an acidic state this turns off the drive to breathe
40
Respiratory acidosis
Low and slow breathing = respiratory acidosis
acid kills the quickest
retaining too much CO2
Opioid overdose
COPD (high CO2)
Main intervention for resp acidosis: Bipap machine to forcefully push air into the lungs and force gas exchange
41
Respiratory alkalosis
Fast breathing (panting) = respiratory alkalosis CO2 being blown off
Pancreatitis attack
Grasping for air - try to calm them down
42
Metabolic acidosis
if its to the lungs its a metabolic issue
Base left the the butt leaving the client in a acidic state
Diarrhea
43
Metabolic alkalosis
If its not the lungs its a metabolic issue
Acid in the Stomach
GI suctioning
Vomiting
44
ABG Numbers
PH: 7.35-7.45
PaCo2 Lungs: 35-45
HCO3 Bicarb: 22-36
45
Compensated vs Uncompensated
Compensated = PH is in the normal range
Uncompensated = PH is out of normal range
Partially compensated: everything is out of range
46
Four clients in a critical care unit have been diagnosed with Pseudomonas aeruginosa. The Infection Prevention and Control Department has determined that this is probably a nosocomial infection. What should the nurse do to prevent spread of the disease?
Ensure that staff members do not have artificial fingernails.
47
A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although they are medically stable, they have begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. They are picking at the air to “catch these baby angels flying around my head.” While the client is waiting for medical and psychiatric consults, which need(s) would have the highest priority? Select all that apply.
decreasing as much abnormal stimuli as possible
avoiding challenging the client's perceptions about "baby angels”
gently presenting reality as needed
The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate, but orienting the client to their condition is unlikely to be helpful. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium,
48
The nurse is caring for a client in the post anesthesia care unit (PACU) following an adrenalectomy. What is the nurse’s priority action?
Assessing blood pressure
49
A client is admitted to the trauma center with a spinal cord transection at T4. Which of the physical limitations does the nurse anticipate when planning care? Select all that apply.
The client will be unable to independently ambulate
The client will have no control of the bladder
The client will be cognitively impaired.
50
After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant?
Provide extra oxygen by using a ventilator or through manual bagging.
51
After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises?
The alveoli expand and increase the lung surface available for ventilation.
Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes.
52
A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the client's heart rate and rhythm. When interpreting the client's electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents
ventricular depolarization.
53
The nurse is palpating the radial pulse of a client who has atrial fibrillation. Which finding should the nurse report to the health care provider (HCP)?
irregular rhythm with a pulse rate higher than 100 bpm
Characteristics of atrial fibrillation include a pulse rate higher than 100 bpm, a totally irregular rhythm, and no definite P waves on the electrocardiogram.
54
An adult comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. What should the nurse do first?
Administer the morphine.
Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse’s priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action.
55
A client with refractory angina pectoris is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab. Before beginning the infusion, the nurse should ensure the client has
up-to-date partial thromboplastin time (PTT) result in his record.
Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation and, thereby, reduces cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date PTT result available.
56
Following a coronary artery bypass graft (CABG), a client reports chest "fullness," anxiety, and dizziness. Vital signs are pulse 108, respirations 24, and blood pressure 94/62mmHg on inhalation, and 108/70mmHg on expiration. The nurse prints a lead II electrocardiogram (ECG) strip for interpretation and identifies an amplitude decrease in the QRS complex. What intervention would have the highest priority?
Prepare the client for emergency pericardiocentesis.
An amplitude decrease in the client with these symptoms would suggest cardiac tamponade. Following a CABG, there is a risk for fluid surrounding the heart, which would suppress the amplitude of the QRS complexes on an ECG. The nurse's highest priority would be to prepare the client for a pericardiocentesis, which will aspirate pericardial fluid in which the client should feel immediate relief.
57
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram [ECG] strip). What should the nurse do first?
Assess the client for changes in the rhythm.
The client is experiencing a single premature ventricular contraction (PVC). PVCs are characterized by a QRS of longer than 0.12 seconds and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted. PVCs are potentially serious and can lead to ventricular fibrillation or cardiac arrest when they occur more than 6 to 10 times an hour in clients with myocardial infarction. The nurse should continue to monitor the client and note if the PVCs are increasing.
58
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. What should the nurse do first?
Assess for changes in vital signs.
The nurse should first obtain vital signs because changes in the vital signs will reflect the severity of the sudden drop in cardiac output: a decrease in blood pressure, an increase in the heart rate, and an increase in the respiration rate.
59
The nurse is preparing to interpret an ECG rhythm strip. Place the following steps for ECG rhythm analysis from first to last, in chronological order. All options must be used.
Determine the rate and rhythm.
Analyze the P waves.
Measure the PR interval.
Measure the QRS duration.
Interpret the rhythm.
60
An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. Changes in which leads of a 12-lead ECG indicate damage to the left ventricular septal region?
leads V3 and V4
61
A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, the nurse correctly identifies which ECG changes associated with an evolving MI? Select all that apply.
T-wave inversion
ST-segment elevation
62
An older adult is admitted to the emergency department (ED) at 2000 hours with syncope, shortness of breath, and reported palpitations (see nurse’s notes below). At 2015, the nurse places the client on the electrocardiogram (ECG) monitor and identifies the following rhythm (see below). What should the nurse do? Select all that apply.
Apply oxygen
Monitor vital signs
Have the client sign consent for cardioversion as prescribed.
63
A nurse is caring for a monitored client on the telemetry unit. When analyzing a cardiac monitor strip, the nurse notes an abnormality in the QRS wave on lead II. Identify the area in the conduction cycle of the heart where this abnormality occurs.
The correct location is the left ventricle.
64
A parent brings their 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement the health care provider's prescriptions? All options must be used.
Obtain vital signs and weight.
Apply a urine collection bag.
Insert an IV and infuse fluids as prescribed.
Draw blood for laboratory tests.
65
A client is experiencing hypovolemic shock. Which assessments best assist in evaluating the client’s fluid status? Select all that apply.
blood pressure
heart rate
respiratory rate
skin turgor
daily weight
66
The nurse is assessing a client who is being admitted to the hospital with upper gastrointestinal (GI) bleeding. Which finding(s) is significant? Select all that apply.
decreased urine output
tachycardia
rapid respirations
thirst
67
A client returns to the medical–surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/min, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse’s response should be based on which data? Select all that apply.
cyanotic mucous membrane
vital sign changes
oxygen saturation
68
Throughout the first 3 weeks after a client has had a C7 spinal cord injury, the nurse should particularly assess the client for which finding(s)? Select all that apply. tachycardia
tachycardia
rapid respirations
bladder incontinence
Within the first weeks after a C7 spinal injury, the nurse should assess the client for spinal shock. Spinal shock is noted by tachycardia, rapid respirations, and bladder incontinence. Spinal shock produces massive vasodilation and subsequent pooling of blood in the peripheral circulation, and the client could have a drop in blood pressure. The client will have dry, warm skin and an absence of sweating.
69
A nurse should be prepared to manage complications following abdominal aortic aneurysm resection. Which complication is most common?
renal failure
70
The nurse has received a telephone call from the emergency department indicating that a multigravid client in early labor and diagnosed with probable placenta previa will be arriving soon. What is the priority invention when the client arrives at the unit?
continuous blood pressure monitoring
For a client diagnosed with probable placenta previa, hypovolemic shock is a complication. Continuous blood pressure monitoring with an electronic cuff is the priority assessment after the client's admission.
71
A 4-month-old infant is brought to the emergency department following a seizure. What finding(s) would lead the nurse to suspect the infant has experienced abusive head trauma or shaken baby syndrome? Select all that apply.
vomiting
difficulty breathing
lack of vocalization
72
A postoperative client is experiencing urinary retention, and the nurse is inserting an indwelling catheter. Immediately, 750 mL of clear yellow urine is collected in the drainage bag. What should the nurse do next?
Clamp the catheter for 20 minutes.
73
A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of the body. Admission vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.
Begin an intravenous (I.V.) infusion of lactated Ringer's solution.
Administer 6 mg of IV morphine.
Administer tetanus prophylaxis, as ordered.
74
Following a cesarean birth, what should the nurse do first?
Palpate the fundusEvery postpartum client, regardless of the type of birth, is at risk for uterine atony and hemorrhage, and following childbirth, the nurse should first palpate the fundus to determine if there is uterine atony. Even though an abdominal incision and abdominal dressing are present, the nurse should palpate the fundus gently while supporting the incision every 15 minutes for at least 1 hour, more frequently if vaginal bleeding is moderate or severe and if the fundus is soft or boggy.
75
A nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation. Why is this check so important?
The defibrillator will not deliver a shock if the synchronizer switch is turned on.
76
A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, the client's vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.
starting an I.V. infusion of lactated Ringer's solution
administering 6 mg of morphine I.V.
administering tetanus prophylaxis as ordered
The goal of immediate interventions for this client should be to stop the burning and relieve the pain. To prevent hypovolemic shock and maintain cardiac output, the nurse should begin I.V. therapy with a crystalloid such as lactated Ringer's solution. To treat pain, the nurse should administer 2 to 25 mg of morphine or 5 to 15 mg of meperidine I.V. in small increments. The nurse should also administer tetanus prophylaxis as ordered. Hydrogen peroxide and povidone-iodine solution could cause further damage to tissue, and saline-soaked towels could lead to hypothermia. Placing ice directly on burn wounds could cause further thermal damage.
77
A client presents to the ED in shock. During what phase of shock does the nurse know that metabolic acidosis is going to most likely occur?
decompensation
78
A nurse is developing a care plan for a client with hepatic encephalopathy. Which would be the goal(s) for the care for this client? Select all that apply.
Prevent constipation
Administer lactulose to reduce blood ammonia levels.
Monitor coordination while walking
Check the pupil reaction
Provide food and fluids high in carbohydrates
79
The nurse is positioning a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. To improve oxygenation, which is the best position for this client?
Prone positioning is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for the recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity.
80
A client with disseminated intravascular coagulation develops clinical manifestations of microvascular thrombosis. What signs should the nurse report to the health care provider (HCP)?
focal ischemia
Clinical manifestations of microvascular thrombosis are those that represent a blockage of blood flow and oxygenation to the tissue that results in the eventual death of the organ. Examples of microvascular thrombosis include acute respiratory distress syndrome, focal ischemia, superficial gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium, and coma. Hemoptysis, petechiae, and hematuria are signs of hemorrhage.
81
A client with acute respiratory distress syndrome (ARDS) has become hypotensive and hypoxic. Which intervention is most appropriate?
placing client in the prone position
82
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in the prone position for 30 minutes. Which factor(s) would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.
The percutaneous oxygen saturation (SpO2) and partial pressure of arterial oxygen (PaO2) have decreased
The client is tachycardia with a drop in blood pressure
The face has increased skin breakdown and edema.
83
A client with acute respiratory distress syndrome (ARDS) has fine crackles at the lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply.
Monitor serum creatinine and blood urea nitrogen levels
Administer humidified oxygen
Auscultate the lungs.
84
An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.
acute respiratory distress syndrome
pneumoniapulmonary edema
85
Which symptoms would the nurse anticipate in a child with Kawasaki disease? Select all that apply.
strawberry tongue
desquamation of hands and feet
irritability
86
A child is undergoing testing to rule out a diagnosis of Kawasaki disease. Which test results would support this diagnosis? Select all that apply.
elevated C-reactive protein levels
leukocytosis
87
The nurse prepares discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) following treatment with intravenous immunoglobulin (IVIG). Which information should the nurse include in the discharge instructions?
Take the child's temperature daily for several days.
88
A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. What should the nurse do first?
Engage the child in quiet activities.
89
A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which assessment findings are consistent with this syndrome?
fever, decreased level of consciousness (LOC), and impaired liver function
90
The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN?
72-year-old client with diverticulitis
91
To assess the client’s renal status, the nurse should monitor which laboratory test(s)? Select all that apply.
serum blood urea nitrogen (BUN)
creatinine levels
92
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client’s condition. What will the nurse report? Select all that apply.
arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84
nasal flaring with abdominal retractions
lung sounds of stridor
increased respiratory effort
93
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?
respiratory acidosis
94
A nurse reviews the arterial blood gas (ABG) values of a client who reports difficulty breathing: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3, 24 mEq/L. What assessment finding would the nurse anticipate based on these blood gases?
tachypnea
95
A client has been admitted with a left tibial fracture and extensive soft-tissue injuries, and there is a concern for the development of disseminated intravascular clotting (DIC). Which interventions by the nurse are priorities for this client? Select all that apply.
Improve tissue oxygenation, replace fluids, and correct electrolyte imbalances
Assess for any signs of bleeding in the gums and other mucous membranes.
96
The nurse is working in the emergency department with a client after endotracheal intubation. The nurse must verify tube placement and secure the tube. List in order the steps that are required to perform this function. All options must be used.
Check end-tidal carbon dioxide levels.
Auscultate the chest during assisted ventilation.
Confirm that breath sounds are equal bilaterally.
Secure the tube in place.
Obtain an order for a chest x-ray to document tube placement.
97
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyper oxygenates the client. What is the rationale for these interventions?
They help prevent cardiac arrhythmias.
98
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by
using the minimal-leak technique with cuff pressure less than 25 cm H2O.
99
Blood transfusion
Universal Donor = 0 neg
Universal recipient = A pos
Rh neg should not receive Rh pos blood
100
Pressure ulcer staging
1. skin intact, non blanchable with local redness
2. Open shallow, red/pink, colour, no slough, intact or open blister
3. Full thickness skin loss, possible visible fat, no none/muscle showing
4. Full thickness skin loss with bone, tendon or muscle showing
Unstageable: Full thickness with slough (scabbing) or eschar (necrotic tissue)
101
Wound exudate
Serous: clear/straw: part of normal healing process
Serosanguineous: Pink (mix of blood and serous drainage): part of normal healing process
Sanguineous: red (blood vessel trauma) uncommon in wounds
Hemorrhage: frank blood from leaking blood vessel; uncommon
Purulent: yellow, grey or green due to infection
102
Ventilator Alarms
Always check to first
Pt not in distress: Check ventilator to determine source of problem
Pt in distress: Have RT/physician notified STAT and follow steps below—assist with reintubation as needed
