Multi-Client Priority Flashcards

Question

# Immediate Complication What is a **hypertensive crisis**?

Answer 1

A hypertensive crisis is **blood pressure greater than 200/120.** ## Footnote *It not controlled, it can cause a hypertensive stroke.*

Answer 2

Angina is **chest pain** caused by inadequate myocardial blood and oxygen supply. ## Footnote *Give OANM: oxygen, aspirin, nitroglycerin, and morphine.*

Answer 3

An aortic aneurysm is **stretching of the arterial wall in the abdomen**. ## Footnote *If it ruptures the client will experience pain, difficulty breathing and signs of shock.*

Answer 4

Cardiogenic shock is **low blood pressure caused by damage to the heart** that impairs pumping ability. ## Footnote *It can be from myocardial infarction, tamponade, or heart failure.*

Answer 5

Asystole is a **fatal dysrhythmia**: * start CPR * epinephrine * NO defibrillation

Answer 6

* **Pulseless V-tach** * CPR * defibrillate * epinephrine * amiodarone (or lidocaine) * **With a pulse** * amiodarone (or lidocaine)

Answer 7

* ***"defib the V-fib"*** * CPR * epinephrine * amiodarone (or lidocaine)

Answer 8

A myocardial infarction is a **fatal heart condition**: * give **"OANM"** * oxygen * aspirin * nitroglycerin * morphine * "clot busters" if caused by a clot * T-PA * cardiac catheterization if caused by plaque

Answer 9

Supraventricular tachycardia can be a **fatal dysrhythmia**: * vagal maneuvers (carotid sinus massage, beardown/Valsalva) * cardiovert with adenosine

Answer 10

* typically **less than 60 beats per minute** * have an **elongated PR interval** * will receive **atropine** if showing symptoms * if atropine doesn't work, client will either get **cardioversion or a pacemaker.**

Answer 11

An Addisonian crisis **can cause severe fluid and electrolyte imbalances**. ## Footnote *It is caused by stress, infection, trauma, or abrupt discontinuation of steroids.*

Answer 12

Myxedema coma is when the client has **extremely low metabolism and goes into a coma**.

Answer 13

A thyroid storm is when the client has an **extremely high metabolism** and can get elevated temperature, blood pressure, seizures and then a **coma**.

Answer 14

HHS and DKA are **extremely high blood sugar.** ## Footnote *If not treated the client can go into a coma.*

Answer 15

Compartment syndrome is when there is **too much pressure in a cast or enclosed space due to edema.** ## Footnote *The client will either get a fasciotomy (cut the skin open) or the cast will be cut off.*

Answer 16

Hemorrhage is **severe bleeding** that causes the client to go into hypovolemic shock. ## Footnote *The client gets a very low blood pressure and tachycardia.*

Answer 17

Severe fluid and electrolyte imbalances can cause **life-threatening complications** such as: * dysrhythmias * seizures * respiratory depression * coma

Answer 18

Septic shock is a **systemic infection** throughout the entire body. ## Footnote *It can cause very low blood pressure and tachycardia.*

Answer 19

Peritonitis is when **the bowel perforates** **causing infection** and eventually septic shock if not treated. ## Footnote *The client gets a rigid, hard abdomen.*

Answer 20

Acute angle-closure glaucoma is **sudden eye pain** and possible nausea and vomiting, resulting in blindness. ## Footnote *The client will receive antiglaucoma meds to lower the pressure.*

Answer 21

* DO **_NOT_** remove the object * cover the eye with a cup and tape in place * no bending, no straining * surgery to remove object

Answer 22

flush eyes with water for at least 15 to 20 minutes

Answer 23

An acid-base imbalance is a **circulation or breathing issue** where the client has a high risk of death if it becomes severe.

Answer 24

Autonomic dysreflexia is when the client with **a spinal injury** overreacts to stimuli such as unable to urinate or have a bowel movement. ## Footnote *It can cause a hypertensive crisis if it becomes severe.*

Answer 25

A myasthenic crisis and cholinergic crisis is when the client with myasthenia crisis **does not get the correct amount of medicine** at the correct time. *This causes muscle weakness and **respiratory muscle weakness** if not treated.* * myasthenic crisis is undermedicated * cholinergic crisis is overmedicated

Answer 26

**Increased intracranial pressure** (ICP) ## Footnote *Increased pressure in the brain due to edema.*

Answer 27

Steven's Johnson syndrome and toxic epidermal necrolysis are really bad adverse reactions of many meds that cause a **severe rash all over the body**. ## Footnote *Always let the HCP know if you notice a rash, especially after the client starts a new med.*

Answer 28

* _Dehiscence_ is when the **surgical incision opens.** * _Evisceration_ is when the **abdominal organ comes out of the incision.** ## Footnote *Immediate intervention is to put a sterile, saline-soaked dressing over site.*

Answer 29

* respiratory distress, dyspnea, dizziness, shortness of breath * chills, diaphoresis * back or chest pain ## Footnote *Antibodies are attacking the red blood cells causing decreased oxygen.*

Answer 30

1. FIRST: stop the blood transfusion 2. change out the tubing, but keep the IV line in 3. start a new bag of normal saline, 0.9% 4. tell the HCP and blood bank 5. return the blood and tubing to the blood bank 6. stay with the client 7. may have to give epinephrine for severe symptoms such as difficulty breathing

Answer 31

Suicide is a psychological disorder when the client wants to **kill themselves.** ## Footnote *It is an emergency and someone needs to stay with the client at all times.*

Answer 32

Pinch the opening shut and apply an **occlusive sterile dressing taped on 3 sides**.

Answer 33

* drainage is \>70 - 100 mL/hour * drainage suddenly becomes bright red or increases in the amount * chest tube comes out of client

Answer 34

* **a clamp** * *to check for leaks* * **sterile occlusive dressing** * in case the tube comes out of the client * **a bottle of sterile water** * in case the tube comes out of the CDU

Answer 35

Put the **chest tube in a bottle of sterile wate**r to act as a water seal so air doesn't go into the client.

Answer 36

1. evacuate clients who can walk first 2. evacuate clients in wheelchairs next 3. evacuate bedridden clients last

Answer 37

1. **anaphylactic shock** or **difficulty breathing** 2. **rash** 3. **significant changes** in vital signs or level of consciousness ## Footnote *Notify the HCP immediately.*

Answer 38

Delirium tremens is **withdrawal of alcohol that occurs 48 - 72 hours after stopping alcohol.**

Answer 39

* approach the client calmly and communicate with a calm and clear tone of voice * maintain a safe distance away from client * maintain a non-aggressive posture * listen actively and acknowledge anger * determine what their need is * call security if client does not calm down

Answer 40

Serotonin syndrome is when a client's **serotonin level increases to dangerous levels.** ## Footnote *It is caused by taking too many sedatives at once.*

Answer 41

Neuroleptic malignant syndrome is a **rare and fatal reaction to antipsychotics.**

Answer 42

A positive/abnormal result indicates a **bad finding** and that late decelerations of the fetal heart rate were noted. ## Footnote *Late decelerations are never a good finding.*

Answer 43

Disseminated intravascular coagulation is a serious **bleeding and clotting complication** in a pregnant client with eclampsia, placenta abruptio, a dead fetus, placenta retention or infection. ## Footnote *The clotting factors are becoming over or underactivated.*

Answer 44

HELLP syndrome is a condition that can cause **severe bleeding** in a pregnant client. ## Footnote *The cause is not known but associated with gestational hypertension and preeclampsia.*

Answer 45

Eclampsia is the onset of **seizures** for a pregnant client with preeclampsia.

Answer 46

* put mom in Trendelenburg position * give oxygen 8-10 liters by mask * give IV fluids * blood transfusion if needed * prepare for cesarean delivery

Answer 47

A prolapsed umbilical cord is when the **umbilical cord drops through the open cervix** into the vagina ahead of the baby. ## Footnote *The cord can then become trapped against the baby's body during delivery.*

Answer 48

Abruptio placenta is when the **placenta has separated off the uterine wall.**

Answer 49

Amniotic fluid embolism is when there is an escape of amniotic fluid into maternal circulation which can **lead to respiratory failure and bleeding**.

Answer 50

* fetal heart rate is \< 110 or \> 160 beats/minute * meconium-stained amniotic fluids * fetal hypo or hyperactivity * severe variable or late decelerations

Answer 51

**Late decelerations caused by placenta compression.** ## Footnote *There is a gradual decrease in fetal heart rate. The lowest heart rate occurs after the contraction peak.*

Answer 52

**Bleeding and Infection**

Answer 53

**Hemorrhage is:** * \> than 1 pad per hour or * one pad that gets saturated within 15 minutes

Answer 54

* Vaginal delivery: \> 500 mL after delivery * Cesarean delivery: \> 1000 mL after delivery

Answer 55

Respiratory distress syndrome is caused by the newborn **unable to produce enough surfactant**. It can occur in preterm infants. ## Footnote *Surfactant helps open up the lungs to breathe better.*

Answer 56

Pathological jaundice is an **increase in bilirubin and yellowing of the skin.** It is caused by a hemolytic disease such as Rh incompatibility or liver disease. ## Footnote ***It occurs before 24 hours** and is a serious life-threatening condition.*

Answer 57

Meconium aspiration syndrome is when **meconium gets into the lungs** and causes respiratory distress and/or pneumonia.

Answer 58

1. hold infant face down with head lower than feet 2. support head and jaw 3. give 5 back slaps 4. then put baby face up and give 5 chest thrusts 5. repeat until obstruction clears ## Footnote Click [HERE](http://www.youtube.com/watch?v=I3pvuYMcPg4) for a video on infant CPR and Choking treatment.

Answer 59

1. check for pulse with brachial artery 2. use 2 fingers or 2 thumbs for chest compressions 3. go down 1 1/2 inches (2 cm) for compressions * 1 rescuer: 30 compressions then 2 breaths * 2 rescuers: 15 compressions and then 2 breaths ## Footnote Click [HERE](http://www.youtube.com/watch?v=I3pvuYMcPg4) for a video on infant CPR and choking treatment.

Answer 60

Esophageal atresia and tracheoesophageal fistula is when the **esophagus forms an unnatural connection with the trachea** causing food to enter the airway. ## Footnote *There is a high risk of aspiration.*

Answer 61

* give acetylcysteine * use activated charcoal with gastric lavage

Answer 62

give activated charcoal

Answer 63

* give water or milk * don't induce vomiting as it can cause damage to the esophagus

Answer 64

A sickle cell anemia crisis is when **RBCs clump together and block small blood vessels** that carry blood to organs. ## Footnote *It causes severe pain.*

Answer 65

Epiglottitis is an **infection of the epiglottis** which can be caused by Influenza type B or Strept. ## Footnote *There is a high risk of airway obstruction.*

Answer 66

Status asthmaticus is a **severe asthma attack** that doesn't respond to inhalers. ## Footnote *Intubation and ventilator may be needed.*

Multi-Client Priority Flashcards

Review the ABCs and priority conditions.