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
