nsg 233 final Flashcards
Alcoholic- 1st assessment
Vital signs every 4 hours
Burns- agitation
Sign of inhalation injury; also a sign of inadequate hydration
ET tube-verify:
The nurse should first auscultate all lung fields to
verify safe placement of the endotracheal (ET) tube by assessing for
the presence of breath sounds in all lung lobes. Verifying ET tube
placement should be confirmed by chest x-ray.
What things should be done to determine if an ETT tube is in place. This
is the select all that apply. There will be 3 answers.*
Chest Xray, the chest rises and falls bilaterally, and auscultate breath
sounds
CO2 detector changes color, chest rise & fall, auscultation, IF you
don’t hear something on one side, it’s in the right main, pull the tube
back. Check placement with XRAY
Burns- electrical
Assessment: burn odor, leathery skin, cardiac arrest
Patient is at risk for acute kidney injury
Electrical burn pt put him in a cardiac telemetry monitor
Electrical burns: cardiac monitor for 24 hr. b/c dysrhythmias are
common
The victims of a large-scale near-drowning incident are brought to the
emergency department. What is the minimum length of time all such
victims should be kept under observation in the hospital?
23 hours
A nurse must establish and maintain an airway in a client who has
experienced a near-drowning in the ocean. For which potential danger
should the nurse assess the client?
Pulmonary Edema
Following an ileal conduit urinary diversion, a male pt voices several
complaints. Which complaint indicates to the nurse that he is
experiencing a complication?
dark purplish colored stoma
Auto dysreflexia- S&S
This medical emergency usually occurs after the period of spinal
shock has finished and is usually triggered by a noxious stimulus such
as bowel or bladder distention.
S/S of autonomic dysreflexia
HTN, diaphoresis, bradycardia, flushing; IV
Labetalol
Which action should the nurse take when caring for a client with a
spinal injury who suddenly begins showing signs of autonomic
dysreflexia?
Elevate HOB
s/s
●Diaphoretic and headaches
Occurs in lesions @ T6 or higher - the BP increases and diaphoresis
Elevate HOB and look for source of it
What assessment findings should the nurse document in the electronic
medical record for a client who is experiencing autonomic dysreflexia
after a T-4 spinal cord injury?
Severe diaphoresis, and flushing above the lesion
The nurse is caring for a client who had gastric bypass surgery
yesterday. Which intervention is most important for the nurse to
implement during the first 24 postoperative hours?
Measure hourly urinary output
Patient is septic. What do you do first?
● Give fluids first
● Then cultures
● Then broad-spectrum antibiotics
(possible negative question - in septic shock, massive vasodilation
occurs)
Constriction happens
A client with acquired immunodeficiency syndrome (AIDS) has impaired
gas exchange from a respiratory infection. Which assessment finding
warrants immediate intervention by the nurse?
Pain when swallowing
The nurse assesses a female client following surgery for a gunshot to
the abdomen and determines that the dressing is saturated with blood
and petechiae on the extremities. His current blood pressure is 80/40
and his heart rate is 130 Beats a minute. Which laboratory finding
confirms the presence of DIC?
Answer: positive D dimer
DIC Uses up all of the clotting factors. Pts bleed everywhere besides
fingers and toes.
DIC
first sign is often gums bleeding (PT/INR)
TX of DIC
Give heparin (even though they are bleeding); treat symptoms
Those at risk for DIC: trauma patients, pregnancy, those on bleeding
precautions
A client develops peritonitis and sepsis after the surgical repair of a
ruptured diverticulum. What signs should the nurse expect when
assessing the client?
a. Fever
b. Tachypnea
d Abdominal rigidity
A middle-aged client who was admitted for a multi-traumatic accident is
suspected of developing “Systemic Inflammatory Response” (SIRS).
Which set of vital signs would the nurse anticipate the client to display?
a. RR- 24 breaths/min; HR- 120 beats/minute; and temperature of
100.8???
Increased ICP=Space out nursing interventions
s/s =
Decreased pulse and increased BP with changes in LOC
In developing a care plan for the patient that has a chest tube and
hemothorax, the nurse should recognize which intervention is essential?
Encourage the client to breathe deeply and cough at frequent intervals
Chest tubes- transport
Keep chest tube below level of insertion point when transporting
If a PT has a chest tube and they want to walk, how do you carry the
chest tube container?
Keep it below the incision point
If the chest tube is inadvertently dislodged from the client, the nurse
should cover with a dry sterile dressing taped on three sides.
A client reports left-sided chest pain after playing racquetball. The
client is hospitalized and diagnosed with left pneumothorax. When
assessing the client’s left chest area, the nurse expects to identify
which finding?
Absence of breath sounds on auscultation
Client has a pneumothorax and has a chest tube with NO fluctuation in
the water seal. What should the nurse do?
Assess lung sounds
On admission to the intensive care for sepsis due to a ruptured
appendix, a female client’s temperature is 39.8°C and her blood
pressure is 68/42. Other hemodynamic findings include cardiac output
of 10.71 L/minute, systemic vascular resistance (SVR) of 480
dynes/sec/cm3, and white blood cell count (WBC) of 28000 mm3.
Which classification of medications is likely to stabilize this client?
Vasoconstrictor
On admission, the client is septic due to a ruptured appendix; vitals of
temp 39.8 , WBC 18,000, BP 68/42. What class of meds is needed?
vasoconstrictor
MODS- hypotension
Can result from sepsis or trauma. VS change (tachypnea, high HR, low
BP) if MAP is consistently low, it is indicative of MODS.
A client who had a craniotomy yesterday develops an oral temperature
of 103°F. The nurse gives the client a tepid sponge bath. With instituting
measures to reduce the clients fever what additional action should be
taken to prevent an increase in intracranial pressure?
Limit exposure to prevent shivering
SCI- immediate intervention
Spinal cord shock cause hypotension from decreased reflexes not
fluid depletion
Give IV fluids; check for pul edema
Check gag reflex bc inc risk aspiration
Hesi Hint: Physical assessment should concentrate on respiratory
status, especially in clients with injury at C3 to C5, because the
cervical plexus innervates the diaphragm.
Maintain client in extended position with cervical collar on during
transfer.
You might need traction to stabilize or align your spine. Options include
soft neck collars and various braces
Dissection aneurysm
Symptoms of rupture:
hypovolemic or cardiogenic shock with sudden,
severe abdominal pain
The most common symptom is abdominal pain or low back pain, with the
complaint that the client can feel his or her heart beating.
Cardiogenic shock- S&S
Decreased cardiac output is a primary cause of cardiogenic shock.
The majority of cases of cardiogenic shock are caused by:
acute myocardial infarction.
Mechanical ventilation- shock
HESI Hint #2: Interventions to prevent complications on mechanical
ventilation with ARDS
Elevate HOB to at least 30 degrees. Assist with daily awakening
(“sedation vacation”). Implement a comprehensive oral hygiene program.
Implement a comprehensive mobilization program
Cardiac tamponade- PEA
Tamponade is the MCC of PEA
prepare the client for pericardiocentesis
What is the therapeutic effect of head-of-the-bed elevation and
neutral head and neck alignment on increased intracranial pressure
(ICP)?
Lowering ICP by facilitating venous drainage and decreasing venous
obstruction
Look for sx of increased ICP. Even subtle behavior changes, such as
restlessness, irritability, or confusion, may indicate increased ICP.
A patient is receiving CPR. After asystole is confirmed in 2 leads and
sending the transcutaneous pacemaker, which IV mediation should be
administered?
epinephrine
A female client has been in asystole for 20 minutes. She is intubated
and epinephrine 1 mg and atropine sulfate 1 mg were administered with
no change in rhythm or client status. What should the nurse implement?
Bring members of the family to a private area to discuss the desire
to continue life support efforts
The nurse plans to administer a low dose prescription for dopamine to
a client who is in septic shock. What parameter should the nurse use
to evaluate a therapeutic response to dopamine?
monitor urinary output
septic shock and dopamine
do not give dopamine until fluids are replaced
A client arrives in the emergency department via ambulance with
injuries that resulted from being hit by a bus. Vitals signs on admission
are: BP 126/78 mmHg, heart rate 100/minute, respirations 28
breast/minute, temperature 99°F. Bloody drainage is noted at the
clients left ear canal. What should the nurse do to assess for possible
basilar skull fracture and cerebral spinal fluid (CSF) leak?
Dab blood from ear with sterile gauze and observe for halo
Auto dysreflexia- document
T6 or higher - the BP increases and diaphoresis; Elevate HOB and look
for source of it
Change in level of responsiveness is the most important indicator of
increased ICP.
A client is admitted with a closed head injury sustained in a motor
vehicle accident (MVA). The nursing assessment indicates increased
intracranial pressure (ICP). Which intervention should the nurse
perform first?
a. Place the head and neck in alignment.
Tx: osmotic diuretics
The nurse is caring for a client with multiple organ dysfunction
syndrome (MODS). What expected patient outcome should the nurse
include in the plan of care?
The client will remain free of infection.
A client with a long history of alcohol abuse develops cirrhosis of the
liver. The client exhibits the presence of ascites. What does the nurse
conclude is the most likely cause of this client’s ascites?
Impaired portal venous return
HIV- candidiasis
Thick white exudate in the mouth
* Unusual taste to food
* Retrosternal burning
* Oral ulcers
Esophageal varices- rep
Results from liver failure, HTN in esophagus, or lower & upper GI
bleeds. May rupture and bleed
TX of esophageal varices
Place NG tube; monitor the amount of blood loss. Replace with blood
(PRN) and fluids.
Portal HTN, in turn causes esophageal varices to occur, what med will
be prescribed to prevent further bleeding from esophageal varices:
propranolol….and vasopressin stop bleeding
Blakemore tube
blow up sections of it so it applies pressure (pt. can aspirate) when
they can’t breathe, pull the tube- they have aspirated .
Blackmore tube = tamponade tube
Consists of Gastric balloon and esophageal balloon
Gastric balloon gets dislodged = patient will aspirate
Complains of dyspnea or SOB – tube come out
Medication for esophageal varices
Use sandostatin (octreotide)- decreases pressure in the splenic blood
supply
The nurse is assessing a group of older adults. What factor in a male
pt’s hx puts him at greatest risk for developing colon cancer?
Polyps. Intestinal polyps are precancerous lesions and are a major risk
for colon cancer
prevent rupture of the AAA, the client’s must be maintained
normotensive, so the elevated blood pressure (D) should be reported
to the healthcare provider.
Assess all peripheral pulses and vital signs regularly
The nurse has been caring for a client who required a
Sengstaken-Blakemore tube because other treatment measures for
esophageal varices were unsuccessful. The health care provider (HCP)
arrives on the nursing unit and deflates the esophageal balloon. Which
assessment found by the nurse is the most important and should be
reported to the HCP immediately?
Hematemesis
client is receiving external beam radiation to the mediastinum for
treatment of bronchial cancer. Which of the following should take
priority in planning care?
B) Leukopenia
Pneumonectomy- chest tube
Chest tubes are not usually used.
Thoracotomy- water seal functionality
- bubbling in water-seal chamber should be gentle and indicate air
drainage from the client - Fluctuation of water in the tube of the water-seal chamber during
inhalation and exhalation - Gentle (not vigorous) bubbling should be noted in the suction-control
chamber
The nurse is completing a head to be assessment for a client admitted
for observation after falling out of a tree. Which finding warrants
immediate intervention by the nurse?
Clear fluid leaking from the nose
Dysrhythmias and calcium
One of the most frequent electrolyte abnormalities in critical care,
hypocalcemia accounts for 55% to 77% of all electrolyte imbalance
If someone has a AAA, what would you be looking for post-op on
them?
Pulses in lower extremities (Aware of bending extremities)
■ keep them lying low and not in high fowlers
○ Guarding in abdomen
○ Urinary output might be decreased
A Snake skin bite leads to anaphylactic shock. What should we do?
- leave a tourniquet on if they have one on
- Give them the antivenom
- Elevate the extremity
- Ice would worsen the bite
Obtaining intravenous access by inserting an IV catheter is
the priority intervention so that fluids and medications can
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be administered to increase the client’s blood pressure,
which is lowered because of massive vasodilation
A male client with skin grafts covering full-thickness burns on both
arms and legs is scheduled for a dressing change. The client is nervous
and requests that the dressing change be skipped at this time. What
action is most important for the nurse to take?
Pt is at risk for
ANS: A. Acute kidney injury
B. Dysrhythmia
C. Iceberg effect
E. Bone fractures
Skin lesions- possible kaposi’s sarcoma
Purple-blue lesions on skin, often arms and legs
* Invasion of gastrointestinal tract, lymphatic system, lungs, and brain
Colon cancer- tumor markers
CEA. Carcinoembryonic antigen (CEA) serum level is used to evaluate
effectiveness of chemotherapy.
What might be an acute complication of liver failure that may be an
emergent situation?
Esophageal varices burst
The patient has been in the progressive care unit for the past 7 days
with the diagnosis of liver failure. The nurse notes that the patient has
developed a flapping tremor of the hand. The nurse should:
notify the provider because this is a sign that the disease is
progressing.
The nurse is assessing a client with a chest tube that is attached to
suction and a closed drainage system. Which finding is most important
for the nurse to further assess?
Upper chest subcutaneous emphysema.
Rationale: Subcutaneous emphysema is a complication and indicates air
is leaking beneath the skin surrounding the chest tube
