Medsurg Final Flashcards
Right ankle: Red, swollen, decreased ROM
Inflammation w/o infection
Anaphylactic reaction priority assessment
maintaining patent airway
Warmth around injured area
“the warmth indicated increased blood flow”
Wrist: red, warm, edematous
assess circulation + evaluate extremity
Kidney transplant
the immune system will try to destroy the new kidney if we do not suppress it
the nurse receives a report that a client with purulent wound drainage has lab results that shows a left shift. whats the next action?
obtain a wound culture
a nurse is caring for a client in the ED who has an allergy to bee venom. what action should the nurse take first?
administer epinephrine
the nurse is assisting planning care for a client with a diagnosis of immunodeficiency. whats the priority action?
protecting the client from infection
which client is at highest risk of compromised immunity?
client who just had surgery
client is scheduled to receive a flu vaccination. pt. asks “how do these work?” best response:
immunizations work by sensitizing your body to prepare antibodies against this virus if exposed in the future to the same antigen
the charge nurse observes the primary nurse interacting with a client. which action by the primary nurse warrants immediate intervention by the charge nurse?
administering a med without checking allergies
the client diagnosed with anaphylaxis to bee venom is now stable and being discharged from the ED. which priority discharge instruction should be taught to the client?
demonstrate how to use an epipen
the client comes into the ED complaining for dyspnea and wheezing after eating at a seafood restaurant. the pt can’t speak and has bluish color around the mouth. what intervention?
administer oxygen at 100% via nonrebreather
which statement is true about pathologic conditions of the immune system?
in autoimmune disease the bodys immune system treats some of the body’s own tissues as foreign invaders
For years after seroconversion, an HIV-infected client has a CD4+ cell count of 800 ul and low viral load. the nurse teaches the client that:
the body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity
the client is taking spironolactone. what complication would you assess for?
hyperkalemia
greatest risk for dehydration?
older adult with cognitive impairment
a client is found unresponsive and their ABGs are: pH 7.12, PCO2 90mm Hg, and HCO3-22. whats the condition?
respiratory acidosis wo/o compensation
a client has the following ABG results: pH 7.12, HCO2-22, PCO2 65. The nurse correlates with what clinical situation?
tracheal obstruction related to aspiration
the client has the following ABGs: pH 7.19, PaCO2 35, PAO2 95, HCO3 19. What med would you administer?
IV sodium bicarb
Partially compensated metabolic acidosis?
ph 7.32, HCO2 17, PCO2 25, PO2 98
The nurse correlates which condition with the following ABGs? pH 7.48, HCO2 22, PCO2 28, PO2 98
anxiety-induced hyperventilation
a nurse is caring for a client with an NG tube that is attached to low suction. What disorder could they develop?
metabolic alkalosis
a client who is intubated has the following ABGs: pH 7.30, HCO3 22, PCO2 55, PO2 86. what is priority intervention?
assessing the airway
a nurse is caring for a pt. who is receiving IV diuretics suspects that the pt. is experiencing a fluid volume deficit. what assessment finding would she note?
increased hematocrit
the nurse is caring for a pt. with heart failure. on assessment, the nurse notes that the client is dyspneic and that crackles are audible with auscultation. what additional assessment would show excess fluid volume?
high blood pressure
the client is admitted to the nursing unit from a long term care facility with a hematocrit of 56% and a serum sodium level of 152. which condition is a cause for these findings?
dehydration
the client is admitted with serum sodium level of 110, what nursing intervention should be implemented?
encourage fluids orally
the client’s arterial blood gasses confirm metabolic acidosis for a client diagnosed with DKA. which statement best explains the scientific rationale for irregular respirations?
lungs speed up to release carbon dioxide and increase the pH
the client diagnosed with an exacerbation of COPD in respiratory distress. which intervention should the nurse implement first?
assist the client into a sitting position at 90 degrees
the nurse is assessing the client diagnosed with COPD. which data requires immediate intervention?
O2 flowmeter set at 8 liters
Which outcome is appropriate for the client problem: ineffective gas exchange for a pt. with COPD?
demonstrate the correct way to pursed-lip breathe
health maintenance strategies of COPD?
yearly flu immunizations
medication for mild intermittent asthma?
use of a rescue inhaler
acute exacerbation COPD expected finding?
hyper-inflated chest noted on xray
purpose of pursed-lip breathing?
promote CO2 elimination
COPD teaching?
“i may experience palpitations or a fast heart rate after taking my albuterol nebulizer”
generalized rash + urticaria after a dose of salmeterol inhaler?
call the HCP immediately
assessments before administering albuterol?
lung sounds and presence of dyspnea
