what fluids to give to a burn patient - ANS lactated ringers
intraarterial catheter with heparin why? - ANS it is patent
normal ABG values, what to do? - ANS keep monitoring
RN action for pt in cardiogenic shock? - ANS - monitor BP and HR
pt has chest pain, difficulty breathing,...
what fluids to give to a burn patient - ANS lactated ringers
intraarterial catheter with heparin why? - ANS it is patent
normal ABG values, what to do? - ANS keep monitoring
RN action for pt in cardiogenic shock? - ANS - monitor BP and HR
pt has chest pain, difficulty breathing, and is hypovolemic - ANS assess VS and O2 sat
pt w/ cancer has tumor lysis syndrome, what is the priority RN intervention??
- make sure they have what
- Fluids? - ANS make sure the pt has IV access and increase fluids
lab value leads RN to suspect it is tumor lysis
- k+
= Ca
- Uric acid
- phosphorous - ANS - serum Ca of 5
[hyperkalemia, hypocalcemia, hyeruricemia, hyperphosphotamea]
diet for chronic renal failure
- protein
- na
-k
- carb - ANS - low protein
- high carb
- low Na
- Low K+
cancer pt has extravasation s/sx, RN action? - ANS - look at the IV site while the med is
running
what to teach pt with ALS. SATA
- PT
- IS
- what techniques to teach - ANS - chest PT
,- Incentive spirometer
- give breathing techniques
student has a laceration in school, RN action. SATA
- position of body
- legs
- arms
- what to aaply - ANS - supine position
- life legs
- raise arms
- apply pressure
hyperosmolar hyperglycemic nonketotic state RN action SATA
- what to adjust
- hr
= ssx of what after ivf infusion - ANS - adjust infusion rate
- assess for tachycardia and other
- s.sx of hypervolemia
what electrolyte to monitor for DKA - ANS - K+
Pt with head injury RN action - ANS - monitor for CSF leakage
(dab the ear and look for halos)
pt w/ guillian barre syndrome. what to report to HCP? - ANS - injury below T8 weakness in the
legs ?
pt with MS had a fall and was transferred to the ICU. RN action? - ANS - full head to toe neuro
exam
what the SLE exacerbation lead to - ANS hematuria (kidney failure)
pt had right coronary artery infarction what do you see in TELE - ANS - ST elevation with
presence of u waves?
how does cancer happen? - ANS uncontrolled growth of abnormal cells
pt w/ COPD w/ diminished breath and a DNR form, RN action - ANS gve pain meds for comfort
PRN
what to do post op of a throacic aneurysm - ANS - check urine output
pt on vent, ARDS the issue is tissue perfusion. what should the RN do - ANS stck breaths
before suction
,pt has mout should, what is the UAP action - ANS soft toothbrush
how to prevent VAP - ANS - keep HOB 45
pt with stiff neck, fever 6 hours, what is the RN actin? - ANS isolate the pt (suspect meningitis)
pt has tylenol poisoning and is hypothermic. RN action? - ANS give warm IVF to offset
hypothermia
pt has arthroplasty and has tenderness in calves. RN action? - ANS - measure calf
circumference
pt w/ AAA and is bleeding. what is the primary RN action? - ANS - stop the medication that is
infusing
sinus arrhythmia tele strip - ANS
ventricular fibrilation tele strip - ANS
how to prvent further MI RN action SATA
- what to provide
- what med to give
- what to encourage - ANS - O2
- morphine
- rest
pt with parkinsons disease what to monitor? - ANS - I/O2
Pt with C7 damage has autonomic dysreflexia what should the RN check? - ANS bladder
distention
pt with abdominal distention is pale, cool and has a normal BP. What should the RN do? - ANS
- call HCP
pt w. unequal chest expansion what should RN do? - ANS - check trach placement
truck driver has DVT and DM. what is the priority nursing action? - ANS - check edema and
measure calf circumference
pt has AV fistula and RN is able to auscultate a bruit? RN action - ANS document findings
pt recovered after being rescucitate, another pt asks about their status? what is RN response -
ANS - info is confidential
, pt with neutropenia and has low VS, RN action - ANS - report HCP
preop pt is in for a liver transplant and is talking to spouse and pt is suddenly confused. what
should the RN do ? - ANS - assess labs?
GCS is 9. RN action? - ANS check prior scores to see if they are improving or getting worse
what are the first s/sx of ARDS
-c
-r
- a - ANS - confusion
- restlessness
- agitation
pt with AKI goes from oliguric to the diuretic phase. what to monitor? - ANS - s/sx of
hypovolemia
pt skipped dialysis what should be reported to the HCP immediately? - ANS - K+ 6.0
pt on chemo and is vomiting. RN action - ANS - give ondansetron (antiemetic)
precautions for patient after radiation - ANS - pt will feel weak and need help with ADLs
pt has a chest tube to suction. what should the RN make sure of - ANS - there is sterile gauze
at the bedside
pt has a chest tube and is getting transferred to X-ray. what should the RN do - ANS - keep the
chamber below the insertion site
pt is getting dopamine due to hypotension what to do - ANS - check I/Os
pt has low BP and low HR, RN action? - ANS check I/Os
pt has v-fib. what will the RN find
HR - ANS - no pulse
pt has increased ICP, how to decrease? - ANS - rest
- do not elevate head with pillow
tylenol OD - ANS - give antidote (acetylcysteine)
what requires immediate intervention
- neutrophils ? - ANS <500 neutrophils
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