Podcast
Questions and Answers
Where can an ABG be drawn from? Select all that apply.
Where can an ABG be drawn from? Select all that apply.
- Vein
- Radial (correct)
- Cephalic
- Artery (correct)
- Median
- Brachial (correct)
- Femoral (correct)
Who can draw an ABG? Select all that apply.
Who can draw an ABG? Select all that apply.
- Lab
- LPN's
- RN's (correct)
- Pulmonary (correct)
- RT's (correct)
- CNA's
What are the signs and symptoms of hypovolemia? Select all that apply.
What are the signs and symptoms of hypovolemia? Select all that apply.
- Increased respiratory rate
- Warm, moist skin
- Tachycardia (correct)
- Crackles in lungs
- Hypotension (correct)
- SOB
- Thirst (correct)
What are the signs and symptoms of fluid overload? Select all that apply.
What are the signs and symptoms of fluid overload? Select all that apply.
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because
An older woman was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem are (select all that apply)
An older woman was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem are (select all that apply)
The nursing care for a patient with hyponatremia and fluid volume excess includes
The nursing care for a patient with hyponatremia and fluid volume excess includes
The nurse should be alert for which manifestations in a patient receiving a loop diuretic?
The nurse should be alert for which manifestations in a patient receiving a loop diuretic?
It is important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)?
It is important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)?
The nurse expects the long-term treatment of a patient with hyperphosphatemia secondary to renal failure will include
The nurse expects the long-term treatment of a patient with hyperphosphatemia secondary to renal failure will include
The lungs act as an acid-base buffer by
The lungs act as an acid-base buffer by
A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate
A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate
The typical fluid replacement for the patient with a fluid volume deficit is
The typical fluid replacement for the patient with a fluid volume deficit is
Shock, aspirin overdose, infection, renal disease, DKA, and diarrhea are all common causes of:
Shock, aspirin overdose, infection, renal disease, DKA, and diarrhea are all common causes of:
Antacid use, vomiting, GI suction, and potassium wasting diuretics are all common causes of:
Antacid use, vomiting, GI suction, and potassium wasting diuretics are all common causes of:
Hypoventilation related to disease process, airway obstruction, narcotic/anesthetic use are all common causes of:
Hypoventilation related to disease process, airway obstruction, narcotic/anesthetic use are all common causes of:
Hyperventilation related to situation is a common cause of:
Hyperventilation related to situation is a common cause of:
Mrs. Smith is a diabetic who has not been taking her insulin. pH 7.26; PaCo2 42; HCO3 17. Diagnose.
Mrs. Smith is a diabetic who has not been taking her insulin. pH 7.26; PaCo2 42; HCO3 17. Diagnose.
Mr. Jones is brought into the emergency department. He is okay, but his wife is hysterical. They end up admitting her! pH 7.49; PaCo2 30; HCO3 23. Diagnose.
Mr. Jones is brought into the emergency department. He is okay, but his wife is hysterical. They end up admitting her! pH 7.49; PaCo2 30; HCO3 23. Diagnose.
Mr. Ruiz suffers from COPD, today he comes to the urgent care with symptoms of upper respiratory infection. pH 7.26; PaCo2 52; HCO3 34. Diagnose.
Mr. Ruiz suffers from COPD, today he comes to the urgent care with symptoms of upper respiratory infection. pH 7.26; PaCo2 52; HCO3 34. Diagnose.
Mr. Chin has a long history of heart failure; he takes digoxin and furosemide. He presents at his primary care physician office with complete weakness. pH 7.47; PaCo2 51; HCO3 29. Diagnose.
Mr. Chin has a long history of heart failure; he takes digoxin and furosemide. He presents at his primary care physician office with complete weakness. pH 7.47; PaCo2 51; HCO3 29. Diagnose.
Ms. Nusz has a long history myasthenia gravis, but presents now in emergency department with complaints of increased dyspnea. pH 7.36; PaCo2 50; HCO3 34. Diagnose.
Ms. Nusz has a long history myasthenia gravis, but presents now in emergency department with complaints of increased dyspnea. pH 7.36; PaCo2 50; HCO3 34. Diagnose.
Mr. Flynn has a stressful job, and takes Rolaids on a daily basis. Lately, he has been eating over a roll a day. pH 7.43; PaCo2 29; HCO3 30. Diagnose.
Mr. Flynn has a stressful job, and takes Rolaids on a daily basis. Lately, he has been eating over a roll a day. pH 7.43; PaCo2 29; HCO3 30. Diagnose.
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?
A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved?
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved?
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?
A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately?
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately?
Flashcards
ABG Draw Sites
ABG Draw Sites
Drawn from an artery to measure blood gas levels.
Who can draw an ABG?
Who can draw an ABG?
RN's, RT's, and Pulmonary specialists.
Signs of hypovolemia
Signs of hypovolemia
Hypotension (low BP), tachycardia (fast heart rate), thirst
Signs of fluid overload
Signs of fluid overload
Signup and view all the flashcards
Fluid balance in older adults
Fluid balance in older adults
Signup and view all the flashcards
Manifestations of fluid volume deficit
Manifestations of fluid volume deficit
Signup and view all the flashcards
Hyponatremia treatment
Hyponatremia treatment
Signup and view all the flashcards
Loop diuretic side effects
Loop diuretic side effects
Signup and view all the flashcards
Post-thyroidectomy signs
Post-thyroidectomy signs
Signup and view all the flashcards
Hyperphosphatemia treatment
Hyperphosphatemia treatment
Signup and view all the flashcards
Acid-base buffer of lungs
Acid-base buffer of lungs
Signup and view all the flashcards
pH 7.52, PaCO2 30, HCO3− 24
pH 7.52, PaCO2 30, HCO3− 24
Signup and view all the flashcards
Typical fluid replacement
Typical fluid replacement
Signup and view all the flashcards
Shock, aspirin OD, DKA
Shock, aspirin OD, DKA
Signup and view all the flashcards
Antacid use, Vomiting
Antacid use, Vomiting
Signup and view all the flashcards
Hypoventilation, narcotic use
Hypoventilation, narcotic use
Signup and view all the flashcards
Hyperventilation related to situation
Hyperventilation related to situation
Signup and view all the flashcards
pH 7.26; PaCo2 42; HCO3 17
pH 7.26; PaCo2 42; HCO3 17
Signup and view all the flashcards
pH 7.49; PaCo2 30; HCO3 23
pH 7.49; PaCo2 30; HCO3 23
Signup and view all the flashcards
pH 7.26; PaCo2 52; HCO3 34
pH 7.26; PaCo2 52; HCO3 34
Signup and view all the flashcards
pH 7.47; PaCo2 51; HCO3 29
pH 7.47; PaCo2 51; HCO3 29
Signup and view all the flashcards
pH 7.36; PaCo2 50; HCO3 34
pH 7.36; PaCo2 50; HCO3 34
Signup and view all the flashcards
pH 7.43; PaCo2 29; HCO3 30
pH 7.43; PaCo2 29; HCO3 30
Signup and view all the flashcards
Hypovolemia concern
Hypovolemia concern
Signup and view all the flashcards
SIADH finding to report
SIADH finding to report
Signup and view all the flashcards
Accurate measure of fluid balance
Accurate measure of fluid balance
Signup and view all the flashcards
Fluid intake advice-dehydration
Fluid intake advice-dehydration
Signup and view all the flashcards
Diuretic and weakness
Diuretic and weakness
Signup and view all the flashcards
Effective teaching about Spironolactone
Effective teaching about Spironolactone
Signup and view all the flashcards
Hyponatremia room assignment
Hyponatremia room assignment
Signup and view all the flashcards
pH 7.48, PaO2 85, PaCO2 32
pH 7.48, PaO2 85, PaCO2 32
Signup and view all the flashcards
DKA with rapid respirations
DKA with rapid respirations
Signup and view all the flashcards
Low serum protein symptom
Low serum protein symptom
Signup and view all the flashcards
Monitoring 3% NaCl
Monitoring 3% NaCl
Signup and view all the flashcards
Effective Protein Supplements
Effective Protein Supplements
Signup and view all the flashcards
pH 7.32, PaO2 88, PaCO2 37
pH 7.32, PaO2 88, PaCO2 37
Signup and view all the flashcards
Low potassium risks
Low potassium risks
Signup and view all the flashcards
Hypercalcemia care plan
Hypercalcemia care plan
Signup and view all the flashcards
Food to remove, renal failure
Food to remove, renal failure
Signup and view all the flashcards
Priority Report finding
Priority Report finding
Signup and view all the flashcards
Study Notes
Arterial Blood Gas (ABG) Draws
- ABGs can be drawn from an artery.
- Acceptable artery locations are the radial, brachial and femoral arteries.
- Only RNs, Rts and Pulmonary staff are allowed to draw ABGs.
Hypovolemia
- Key signs and symptoms include hypotension, tachycardia, and thirst.
Fluid Overload
- Key signs and symptoms include shortness of breath (SOB), increased respiratory rate, warm, moist skin, and crackles in the lungs.
Postoperative Care in Older Adults
- Older adults are at risk for fluid and electrolyte imbalances postoperatively.
- This is because small fluid losses are significant, as body fluids account for only 45% to 50% of body weight in this population.
Fluid Volume Deficit
- Clinical manifestations include weight loss, dry oral mucosa, and decreased central venous pressure.
Hyponatremia and Fluid Volume Excess
- Nursing care includes fluid restriction.
Loop Diuretics
- Monitor for manifestations such as a weak, irregular pulse and poor muscle tone.
Post Thyroidectomy
- The nurse should assess the patient for confusion, circumoral numbness, and a positive Chvostek's sign.
Hyperphosphatemia Secondary to Renal Failure
- Long-term treatment includes calcium supplements.
Lungs as an Acid-Base Buffer
- The lungs increase respiratory rate and depth when CO2 levels in the blood are high, which reduces the acid load.
Arterial Blood Gas Interpretation: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L
- Indicates respiratory alkalosis.
Fluid Replacement for Fluid Volume Deficit
- Lactated Ringer's is the typical fluid replacement
Common Causes of Metabolic Acidosis
- Shock, aspirin overdose, infection, renal disease, DKA, and diarrhea are common causes.
Common Causes of Metabolic Alkalosis
- Antacid use, vomiting, GI suction, and potassium-wasting diuretics are common causes.
Common Causes of Respiratory Acidosis
- Hypoventilation related to disease process, airway obstruction, or narcotic/anesthetic use are common causes.
Common Causes of Respiratory Alkalosis
- Hyperventilation is a common cause.
Acid-Base Imbalance Case Studies
- Mrs. Smith (Diabetic, not taking insulin): pH 7.26, PaCO2 42, HCO3 17 - Metabolic acidosis
- Mr. Jones (Wife Hysterical): pH 7.49, PaCO2 30, HCO3 23 - Respiratory alkalosis
- Mr. Ruiz (COPD, Upper Respiratory Infection): pH 7.26, PaCO2 52, HCO3 34 - Respiratory acidosis, partially compensated
- Mr. Chin (Heart Failure, Digoxin & Furosemide): pH 7.47, PaCO2 51, HCO3 29 - Metabolic alkalosis, partially compensated
- Ms. Nusz (Myasthenia Gravis, Increased Dyspnea): pH 7.36, PaCO2 50, HCO3 34 - Respiratory acidosis, full compensation
- Mr. Flynn (Stressful Job, Daily Rolaids): pH 7.43, PaCO2 29, HCO3 30 - Metabolic alkalosis, full compensation
Hypovolemia from Burns
- A blood pressure of 90/40 mm Hg is the most concerning assessment data.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
- A serum sodium level of 120 mg/dL should be reported to the health care provider.
Evaluating Fluid Balance
- Daily weight is the most accurate way to evaluate fluid balance.
Dehydration in Older Adults
- Instruct the patient to increase fluids if their mouth feels dry.
Potassium-Wasting Diuretics
- If a patient on a potassium-wasting diuretic complains of generalized weakness, ask the health care provider to order a basic metabolic panel.
Spironolactone (Aldactone) Teaching
- Effective teaching is indicated by the patient stating they will drink apple juice instead of orange juice for breakfast.
Hyponatremia Room Assignment
- Assign the patient to a room near the nurse's station.
Tracheostomy Arterial Blood Gas Interpretation: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L
- Indicates respiratory alkalosis.
Rapid, Deep Respirations in DKA
- Administer the prescribed normal saline bolus and insulin.
Malnutrition and Low Serum Protein
- Expect edema as a clinical manifestation.
3% NaCl Solution
- Monitor lung sounds while the patient is receiving this infusion for correction of hyponatremia.
Protein Supplements for Malnourished Older Residents
- Decreased peripheral edema indicates improvement.
Arterial Blood Gas Interpretation: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L and lethargy
- Indicates metabolic acidosis.
Low Serum Potassium and Diuretics
- Alert the health care provider immediately that the patient is on oral digoxin (Lanoxin) 0.25 mg daily.
High Calcium Level (12.1 mg/dL)
- Encourage fluid intake up to 4000 mL every day.
Low Phosphate Diet
- Instruct UAP to remove milk carton.
Findings to Report to Provider
- Priority is a gradually decreasing level of consciousness (LOC).
Assessing New Heart Failure Patient First
- Assess mental status first.
Unresponsive Hemodialysis Patient
- Notify the patient's health care provider first.
Post Colectomy Patient with Anxiety and Respiratory Alkalosis
- Give the patient the PRN IV morphine sulfate 4 mg.
LPN/LVN Delegation
- An experienced LPN/LVN can monitor the IV sites for redness, swelling, or tenderness.
Low Serum Calcium (7.0 mEq/L)
- Report laryngeal stridor to the health care provider as most important.
Post Thyroidectomy Patient with Tingling
- Assess for the presence of Chvostek's sign immediately.
Emergency Department Lab Value
- A serum calcium of 18 mg/dL will require the most immediate action.
3% Saline Rapid Response Needed (crackels in lungs)
- Crackles audible throughout both lung fields requires the most rapid response.
Low Serum Calcium (Chronic Malnutrition)
- Monitor ionized calcium level next.
Frequent, Watery Stools
- Check the patient's blood pressure first.
Acute Chest Pain and Dyspnea Post IV Insertion
- Auscultate the patient's breath sounds first.
Post shift report - assess what patient first
- Assess patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes.
Laparoscopic Cholecystectomy
- Surgery will involve multiple small incisions.
Reaction to Rubber Gloves
- Ask additional questions to assess for a possible latex allergy.
Patient Taking Ginkgo Daily
- Inform the surgeon, since the procedure may have to be rescheduled.
Emancipated Minor
- Witness the permit after consent is obtained by the surgeon.
Coping with Fear of Postoperative Pain
- Explain the pain management plan, including the use of a pain rating scale.
Patient ate before surgery
- Notify the anesthesia care provider of when and what the patient last ate.
Insulin Adjustment Before Surgery
- Have her get instructions from her surgeon or HCP on any insulin adjustments.
Preoperative Considerations for Older Adults
- Recognize that sensory deficits may be present.
- Provide warm blankets to prevent hypothermia.
Semirestricted Area Attire
- Surgical attire and head cover are required.
Scrub Nurse Activities
- Preparing the instrument table.
- Passing instruments to the surgeon and assistants.
- Maintaining accurate counts of sponges, needles, and instruments.
Patient Safety
- Ensure universal protocol is followed.
- The patient's allergies are conveyed to the surgical team.
Primary Responsibility of the Nurse
- Developing an individualized plan of nursing care for the patient.
Injury during surgery
- Incorrect musculoskeletal alignment is most likely to occur.
Priority interventions in the post anesthesia care unit (PACU)
- Assess for airway patency and quality of respirations and obtain vital signs.
Potential Vomiting Immediately Post-Op
- Position patient in lateral recovery position to prevent aspiration.
Immediate Attention Post operative after clinical unit admission
- O2 saturation of 85% requires the most immediate attention.
Low Urine output
- Evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.
Phase II discharge
- No respiratory depression should be evident.
- Written discharge instructions have been understood.
- Opioid pain medication has been given 45 minutes ago.
Elective Hysterectomy Fear
- The most appropriate response is, "Tell me more about what happened to your mother."
Concerns over surgery outpatient
- The information most concerning is, the patient is planning to drive home alone after surgery.
Allergies, which action should the nurse take?
- The most important action for the nurse to take is to, alert the surgery center about a possible latex allergy.
Therapeutic Abortion Assessment?
- Value-belief is the most important assessment.
St. John's Wort side effects post anesthesia
- Longer time to recover from anesthesia.
Post anesthesia care unit (PACU) from previous smoker.
- The most important action at is time is to, Auscultate for adventitious breath sounds.
Post operative medication discussion
- Discuss the herb and supplement use with the patient's health care provider.
Nurse witnesses patient signing consent?
- Notify the surgeon that the informed consent process is not complete.
Abdominal surgery teaching (Open Cholecystectomy)
- Deep breathing and coughing techniques teaching.
Administer Midazolam action?
- Offer a Urinal or bed pan and position the patient in bed to promote voiding.
Pre OP teaching for older man action?
- Provide additional time for the patient to understand preoperative instructions and carry out procedures.
insulin administration action?
- Obtain a blood glucose measurement before any insulin administration.
CBC results what action to take?
- Send the patient to the holding area when the operating room calls.
Patient says refuses to take wedding ring off action?
- Suggest that the patient give the ring to a family member to keep.
Pt complains about dry mouth because of atropine action
- Tell the patient dry mouth is an expected side effect.
Health hx communicate to healthcare provider says what?
- I had a heart valve replacement last year
Interview patients communicate says
- The patient's father died after receiving general anesthesia for abdominal surgery
Comunicate before surger pt takes ginko.
- The patient takes garlic capsules daily but did not take any on the surgical day.
Preop patient - betablocker and diuretic
- Serum potassium 3.2 Meq/L
Asleep with Mask
- A drug may be given to you through your IV line first. I will check with the anesthesia care provider.
Manual reducation of shoulder
- Starting a 20-gauge IV in the patient's unaffected arm.
Patient Recieved ketamine reaction action taking
- Provide a quiet environment in the postanesthesia care unit.
Reaction to surgery/fever what nurse action/priority
- Alert the anesthesia care provider of the family member's reaction to surgery
Neuromuscular Blocking assessment finding to report
- Weak chest wall movement
Surgical team during a spinal fushion action/ rapid intervention
- Walking the hallway outside an operating room without the hair covered
delegate the RN first assist (RNFA)
- Make surgical incision and suture incisions as needed
Perioperative plan patient action:
- Pass sterile instruments and supplies to the surgeon
General anesthetic: nurse notes raised wheals action
- Notify acp immediately
Surgical time out procedure?
- Have the patient state name and date of birth.
- Verify the patient identification band number.
- Ask the patient name of surgical procedure
- confirm hospital identification
Post anesthesia care unit? PACU action?
- Continue the take vital signals every 15mins
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
