N480 Final Overview
Patient arrives at emergency dep with deep partial thickness burns RR; 26 bpm, nursing interventions SATA
- IV LR
- Admin morphine IV
- Admin tetanus prophylaxis as ordered
Low pressure alarm sound of vent, nurse assess and tries to determine the cause. Unsuccessful at dete...
N480 Final Overview
Patient arrives at emergency dep with deep partial thickness burns RR; 26 bpm, nursing interventions SATA
-IV LR -Admin morphine IV
-Admin tetanus prophylaxis as ordered
Low pressure alarm sound of vent, nurse assess and tries to determine the cause. Unsuccessful at determining and takes what action
-Ventilate the client manually
Client admitted to ED with chest trauma. S/S that support pneumothorax
-Absent breath sounds
-Tachypnea
Nurse assessing cranial nerves, what could detect potential problem with cranial nerve 2
-Snellen chart
Nurse performing assessment and finds client has cool clammy skin P: 130, urine output of 20 ml per hour
-Decreased cardiac output and decreased tissue perfusion
Vitals of client with cardiac disease BP 104/76, P 53, RR 16. Atropine administered. What is therapeutic effect of med
-Pulse rate increases to 76 bpm
Older adult client comes to ED with no appetite, N/V , on digitalis for more than a year, nursing action
-Obtain ECG, K+, and digoxin levels
Nurse admin atiplase tpa with pt with diagnosis of acute coronary syndrome. What is important implementation
-Place the client on bleeding precautions (atiplase is clot buster)
Nurse caring for client with cardiac cath 1 hour ago, nursing action
-Maintain pressure over catheter site and maintain circulation status
Nurse determines that client with diabetes is experiencing fat breakdown. What expect in urine
-Ketones
Nurse obtaining history, pt complaints of severe HA, nurse identifies following as modifiable rf for stroke
-Smoking
-Alcohol -Decrease exercise
-Obesity
Pt comes into Er with midsternal chest pain radiating to neck unrelieved by nitro. What indicates to nurse to identify MD
-ST segment elevation from the baseline
Nurse gives client morphine 2 mg IVP, nurse evaluated client. What is adverse effect
-RR of 8 breaths per minute
Nurse collecint info on group of lient experiencing renal disrders. Who should qualify for dialysis
-Cleint bleeding with minimal urine outputThis study source was downloaded by 100000871695925 from CourseHero.com on 10-16-2023 06:03:34 GMT -05:00
https://www.coursehero.com/file/67250646/N480-Final-Overviewdocx/ Nurse assessing cleinet with asthma. What is indicator of cyanosis?
-Oral mucosa
Math = 33 drops per min
Nurse caring for client who has diag of DM and HTN, started taking propanolol. Dizziness upon standing. What
nurse do?
-Monitor BP sitting and standing
Nurse admin desmopressin to pt with DI, what is therapeutic effect
-Increase in urine specific gravity (1.015)
Nurse caring for pt with burns to face, ears, eyelids. Priority to report
-Difficulty swallowing
Nurse in burn tx, pt admitted with burns to extremity. Escherotomy, client asks
-Large insicisons are made in eschar to improve circulation
Nurse teaching pt with acute renal failure about oliguric phase. Include
-Fluid output is less than 400 ml in 24 hours
Nurse planning low protein diet for pt with chronic enal failure. Why does pt have to be concerned
-Kidneys unable to rid the body of urea a waste product of protein
Talking with client with end stage liver disease. Pt unable to stay awake and falls asleep in convo.
-Increase in blood ammonia levels
Pt with massive trauma, spinal cord injuries. Finding confirming diagnosis of cardiogenic shock
-Apical heart rate of 44 beats per minute
Which finding is best indicator that fluid rescusitation has been successful for pt with hypovolemic shock
-UO is 16 ml for the last hour
Which assessment is most important for nurse to make whether the tx for pt with anaphylactic shock has been effective
-Oxygen saturation
Received change of shift report, who does nurse assess
-Pt with smoke inhalation with wheezes and altered mental status
Dietary trays are walked to the nurse unit at 8 am, nurse should plan to admin intermediate acting insulin
-6:30 and 7 am
Nurse monitorinf client with sever burn therapy. How know adequate fluid replacement
-Heart rate
Nurse planning care for client with end stage cirrhosis with encephalopathy. How to redue ammonia
-Reduce intake of protein
Nurse caring for adolescent with DM, admit to ER with acetone odor. DKA suspected. What insulin use
-Regular insulinThis study source was downloaded by 100000871695925 from CourseHero.com on 10-16-2023 06:03:34 GMT -05:00
https://www.coursehero.com/file/67250646/N480-Final-Overviewdocx/
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