HESI/ NCLEX-RN Flashcards
An RN is assessing a pregnant pt. w/ a dx of ABRUPTIO PLACENTAE. Which manifest. of this cond. would the RN expect to note? SATA
1 Uterine Irritability
2 Uterine tenderness
3 Painless Vaginal bleeding
4 ABD and low back pain
5 Strong and frequent contractions
6 Nonreassuring fetal HR patterns
Uterine Irritability; Uterine tenderness; ABD and low back pain; Nonreassuring fetal HR patterns
—> AKA PLACENTAL ABRUPTION- sep. of placenta before the fetus is born. Occurs b/c there is a hematoma on the maternal side of the placenta
—>SX: uterine irritability, frequent LOW-intensity contractions, uterine tenderness, aching and DULL ABD and low back pain, painful vaginal bleeding, & high uterine resting tone, nonreassuring fetal HR patterns, S of hypovolemic shock, & fetal death
The RN is caring for a pt. who is receiving blood transfusion therapy. Which clinical manifestations would alert the RN to a HEMOLYTIC TRANSFUSION RXN? SATA
1 Headache
2 Tachycardia
3 HTN
4 Distended Neck Veins
5 A sense of impending doom
(IGGY; pg. 835)
*Headache; Tachycardia; Apprehension; A sense of impending Doom
—>RXNs are caused by Rh incompatibility. These complexes destroy the transfused cells & start inflammatory responses in blood vessels and organs.
—>SX: Fever and chills, headache, tacky, sense of impending doom, Chest pain, low back pain, tachypnea, hypotension, & hemoglobinuria
* (Lethal=intravascular coagulation and circulatory collapse)
SX: Dark red vaginal bleeding
uterine pain &/or tenderness
uterine rigidity
Abruptio Placentae
Manifestations
SX:
Painless
Bright red vaginal bleeding
Uterus is soft, relaxed, & non-tender
Placenta Previa
Manifestations
The pt. reports or frequent diarrhea that is both watery and formed multiple times a day. Labs show Elevated WBC, Seg. Neutrophils, Band Neutrophils, & BUN. Vitals include a High HR and Low BP. Doc ordered a stool culture. What is a possible DX?
C. Diff
Rationale
-High HR and Low BP mean dehydration due to diarrhea as well as the High BUN
-Elevated WBC and Neutrophil labs indicate infection
The client is diagnosed with acute delirium related to hypoglycemia.
What Nursing Interventions/ Generate Solutions should be implemented?
-Perform a mental status assessment every shift.
-Assess for hypoglycemia and hyperglycemia and treat accordingly with available prescribed interventions.
-Identify contributing factors, such as medications, hypoglycemia, infection, or other problems that may result in acute confusion.
-Promote adequate hydration, nutritional intake, and sleep.
-Facilitate sensory awareness and use sensory aids as appropriate, such as glasses and hearing aids.
-Provide orientation to surroundings as often as needed.
-Encourage visitation from family and support persons.
-Assist with toileting needs frequently.
-Communicate and document changes with cognition.
After the client undergoes the paracentesis, which nursing assessment warrants immediate intervention?
a. Cloudy, yellow tinge fluid draining from the puncture site
b. unchanged abdominal girth measurement
c. faint, hypoactive bowel sounds
d. increasing abdominal pain
d. increasing abdominal pain
rational
- This may be a result of a diaphragmatic, liver, or spleen perforation and may be life-threatening
In the client with cirrhosis, which lab values does the nurse anticipate will be increased from the normal value? SATA
a. Total serum bilirubin
b. ALT/AST
c. serum albumin
d. APTT, PT/INR
e. Sodium and Potassium
A,B,& D
Albumin will be decreased;
INR is prolonged/elevated because the liver produces less clotting factors
Based on the prolonged APTT and PT/INR what clinical manifestation would the nurse anticipate visualizing upon assessment?
a. weight loss
b. peripheral edema
c. jaundice
d. petechia
d. petechia
What would a pt. the have peripheral edema r/t cirrhosis be administered albumin via IV?
Albumin is administered to pull fluid out of the peritoneal cavity and peripheral tissues.
-If edema reduces during tx/infusion from +3 to +2 then the TX is effective
