Podcast
Questions and Answers
Following a blood transfusion, a patient exhibits fever, chills, hypotension, and dark red urine. Which type of transfusion reaction is MOST likely occurring, and why?
Following a blood transfusion, a patient exhibits fever, chills, hypotension, and dark red urine. Which type of transfusion reaction is MOST likely occurring, and why?
- Hemolytic transfusion reaction due to incompatible blood products, resulting in red blood cell destruction. (correct)
- Allergic transfusion reaction due to allergens in the blood product, causing histamine release.
- Febrile non-hemolytic reaction due to WBC incompatibility, leading to cytokine release.
- Transfusion-related acute lung injury (TRALI) due to donor plasma reacting with lung tissue, causing edema.
A patient with chronic kidney disease (CKD) presents with confusion and abdominal pain. Lab results show elevated BUN and creatinine, metabolic acidosis, and hyperkalemia. Which assessment is MOST critical to perform FIRST?
A patient with chronic kidney disease (CKD) presents with confusion and abdominal pain. Lab results show elevated BUN and creatinine, metabolic acidosis, and hyperkalemia. Which assessment is MOST critical to perform FIRST?
- Perform a detailed neurological exam to rule out uremic encephalopathy.
- Evaluate for EKG changes indicative of hyperkalemia-induced cardiac arrhythmias. (correct)
- Assess for Costovertebral Angle (CVA) tenderness to evaluate for pyelonephritis.
- Evaluate urine output and fluid balance to determine the severity of kidney dysfunction.
A patient is scheduled for an intravenous pyelogram (IVP). Which pre-procedure finding would be of GREATEST concern and warrant immediate notification of the physician?
A patient is scheduled for an intravenous pyelogram (IVP). Which pre-procedure finding would be of GREATEST concern and warrant immediate notification of the physician?
- The patient reports feeling anxious about the procedure.
- The patient has a history of mild seasonal allergies.
- The patient took their regular dose of metformin this morning.
- The patient's creatinine level is 3.0 mg/dL. (correct)
A kidney transplant recipient reports fever, hypertension, and pain at the transplant site. Which intervention MOST directly addresses the potential cause of these symptoms?
A kidney transplant recipient reports fever, hypertension, and pain at the transplant site. Which intervention MOST directly addresses the potential cause of these symptoms?
A patient undergoing hemodialysis suddenly develops a severe headache, confusion, and nausea. Which action is MOST appropriate for the nurse to take FIRST?
A patient undergoing hemodialysis suddenly develops a severe headache, confusion, and nausea. Which action is MOST appropriate for the nurse to take FIRST?
A pregnant patient with preeclampsia is receiving magnesium sulfate. The nurse observes a respiratory rate of 8 breaths per minute, absent deep tendon reflexes, and decreased level of consciousness. What is the MOST appropriate initial nursing intervention?
A pregnant patient with preeclampsia is receiving magnesium sulfate. The nurse observes a respiratory rate of 8 breaths per minute, absent deep tendon reflexes, and decreased level of consciousness. What is the MOST appropriate initial nursing intervention?
A patient presents to the emergency department with a positive pregnancy test, severe unilateral abdominal pain, and shoulder pain. Which intervention should the nurse anticipate as MOST likely to be initiated?
A patient presents to the emergency department with a positive pregnancy test, severe unilateral abdominal pain, and shoulder pain. Which intervention should the nurse anticipate as MOST likely to be initiated?
A patient with a history of hypertension and atrial fibrillation presents with sudden onset of left-sided weakness, slurred speech, and visual disturbances. Which diagnostic test is MOST crucial to perform FIRST to determine the MOST appropriate course of treatment?
A patient with a history of hypertension and atrial fibrillation presents with sudden onset of left-sided weakness, slurred speech, and visual disturbances. Which diagnostic test is MOST crucial to perform FIRST to determine the MOST appropriate course of treatment?
A patient is actively seizing. After ensuring the patient's safety, which medication should the nurse prepare to administer FIRST?
A patient is actively seizing. After ensuring the patient's safety, which medication should the nurse prepare to administer FIRST?
A patient is being evaluated for possible appendicitis. The nurse elicits pain in the right lower quadrant (RLQ) when palpating the left lower quadrant (LLQ). This finding is known as what?
A patient is being evaluated for possible appendicitis. The nurse elicits pain in the right lower quadrant (RLQ) when palpating the left lower quadrant (LLQ). This finding is known as what?
A patient with acute pancreatitis is experiencing severe abdominal pain, nausea, and vomiting. Which intervention is MOST important to implement INITIALLY?
A patient with acute pancreatitis is experiencing severe abdominal pain, nausea, and vomiting. Which intervention is MOST important to implement INITIALLY?
A patient with cirrhosis develops ascites. Which dietary modification is MOST important for the nurse to teach the patient?
A patient with cirrhosis develops ascites. Which dietary modification is MOST important for the nurse to teach the patient?
Post-operative teaching to a client who is recovering from a laparoscopic cholecystectomy should include which statement about resumption of activities?
Post-operative teaching to a client who is recovering from a laparoscopic cholecystectomy should include which statement about resumption of activities?
A client with peptic ulcer disease reports sudden, severe abdominal pain and a rigid abdomen. What complication should the nurse suspect?
A client with peptic ulcer disease reports sudden, severe abdominal pain and a rigid abdomen. What complication should the nurse suspect?
A post-operative patient reports abdominal distention and absence of bowel sounds four days after surgery. Which condition is MOST likely causing these symptoms?
A post-operative patient reports abdominal distention and absence of bowel sounds four days after surgery. Which condition is MOST likely causing these symptoms?
An infant presents with projectile vomiting, visible peristaltic waves in the abdomen, and an olive-shaped mass palpable in the right upper quadrant. Which condition is MOST likely?
An infant presents with projectile vomiting, visible peristaltic waves in the abdomen, and an olive-shaped mass palpable in the right upper quadrant. Which condition is MOST likely?
A client with gastritis is provided dietary counseling. Which statement indicates a NEED for further education?
A client with gastritis is provided dietary counseling. Which statement indicates a NEED for further education?
A patient is admitted with hematemesis and melena. Which assessment finding would BEST differentiate between an upper and lower gastrointestinal (GI) bleed?
A patient is admitted with hematemesis and melena. Which assessment finding would BEST differentiate between an upper and lower gastrointestinal (GI) bleed?
Following a thyroidectomy, a patient reports tingling around the mouth and muscle twitching. Which laboratory value should the nurse assess FIRST?
Following a thyroidectomy, a patient reports tingling around the mouth and muscle twitching. Which laboratory value should the nurse assess FIRST?
A patient with type 1 diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which intervention is MOST critical to initiate FIRST?
A patient with type 1 diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which intervention is MOST critical to initiate FIRST?
Which post-surgical positioning intervention is CONTRAINDICATED?
Which post-surgical positioning intervention is CONTRAINDICATED?
The physician requests a baseline set of laboratory values prior to surgery. Of the following list, which value should the nurse report immediately?
The physician requests a baseline set of laboratory values prior to surgery. Of the following list, which value should the nurse report immediately?
A client's EKG shows a prolonged PR interval. Which of the following physiological processes is MOST likely affected?
A client's EKG shows a prolonged PR interval. Which of the following physiological processes is MOST likely affected?
A patient's EKG displays flattened T waves and prominent U waves. Which electrolyte imbalance is the MOST likely cause?
A patient's EKG displays flattened T waves and prominent U waves. Which electrolyte imbalance is the MOST likely cause?
Following an ST-elevation myocardial infarction (STEMI), a patient's troponin level peaks at 30 ng/mL (normal <0.04 ng/mL). What does this level indicate about the myocardial tissue?
Following an ST-elevation myocardial infarction (STEMI), a patient's troponin level peaks at 30 ng/mL (normal <0.04 ng/mL). What does this level indicate about the myocardial tissue?
A patient with metabolic alkalosis has an arterial blood gas (ABG) result showing elevated bicarbonate levels. Which underlying condition is MOST likely contributing to this imbalance?
A patient with metabolic alkalosis has an arterial blood gas (ABG) result showing elevated bicarbonate levels. Which underlying condition is MOST likely contributing to this imbalance?
The GFR result is best for which improved function lab?
The GFR result is best for which improved function lab?
Labs show decreased calcium and which lab would be expected for a patient with pancreatitis?
Labs show decreased calcium and which lab would be expected for a patient with pancreatitis?
The nurse is teaching about cirrohosis which is irreversible with what tissue infiltration?
The nurse is teaching about cirrohosis which is irreversible with what tissue infiltration?
A client has a positive Chvostek's sign that indicates which condition?
A client has a positive Chvostek's sign that indicates which condition?
Following a severe trauma, the clients labs come back revealing the disease Sickle Cell. What is the greatest risk factor?
Following a severe trauma, the clients labs come back revealing the disease Sickle Cell. What is the greatest risk factor?
The client is found to have Murphy’s Sign. What condition has occurred?
The client is found to have Murphy’s Sign. What condition has occurred?
The client is admited to the hospital and is ordered to have a laxative after a specified time. What is he being tested for?
The client is admited to the hospital and is ordered to have a laxative after a specified time. What is he being tested for?
Which complication is indicated by sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock?
Which complication is indicated by sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock?
The bowel folds back upon itself. What condition has happened?
The bowel folds back upon itself. What condition has happened?
What is the nurse's best action to take in order to test for Chvostek's Sign?
What is the nurse's best action to take in order to test for Chvostek's Sign?
During an EKG interpretation, an elevated ST segment is observed. What is the MOST critical action for the nurse to take?
During an EKG interpretation, an elevated ST segment is observed. What is the MOST critical action for the nurse to take?
A patient experiences a blood transfusion reaction characterized by fever, chills, and flank pain. Which action should the nurse take to address the cause of the reaction?
A patient experiences a blood transfusion reaction characterized by fever, chills, and flank pain. Which action should the nurse take to address the cause of the reaction?
A nurse is caring for a client in metabolic alkalosis who is also hypokalemic. Which EKG change would warrant immediate notification of the healthcare provider?
A nurse is caring for a client in metabolic alkalosis who is also hypokalemic. Which EKG change would warrant immediate notification of the healthcare provider?
A client is experiencing metabolic acidosis due to kidney failure. Which EKG change typically associated with this condition requires the most continuous monitoring?
A client is experiencing metabolic acidosis due to kidney failure. Which EKG change typically associated with this condition requires the most continuous monitoring?
A patient is scheduled for an intravenous pyelogram (IVP). Which assessment finding represents the highest risk and warrants immediate intervention?
A patient is scheduled for an intravenous pyelogram (IVP). Which assessment finding represents the highest risk and warrants immediate intervention?
Following a kidney transplant, a patient develops a fever, hypertension, and experiences tenderness at the transplant site. Which intervention would directly address the underlying cause of these findings?
Following a kidney transplant, a patient develops a fever, hypertension, and experiences tenderness at the transplant site. Which intervention would directly address the underlying cause of these findings?
A client undergoing hemodialysis becomes restless, confused, and complains of a severe headache. What is the priority nursing intervention?
A client undergoing hemodialysis becomes restless, confused, and complains of a severe headache. What is the priority nursing intervention?
A pregnant patient with severe preeclampsia is receiving magnesium sulfate. The nurse assesses absent deep tendon reflexes and a respiratory rate of 9 breaths/min. Which action takes priority?
A pregnant patient with severe preeclampsia is receiving magnesium sulfate. The nurse assesses absent deep tendon reflexes and a respiratory rate of 9 breaths/min. Which action takes priority?
A client presents with suspected ectopic pregnancy. Which assessment finding would require the nurse to prepare the client for immediate surgical intervention?
A client presents with suspected ectopic pregnancy. Which assessment finding would require the nurse to prepare the client for immediate surgical intervention?
A client with a history of atrial fibrillation presents with sudden-onset aphasia and right-sided weakness. Which intervention would have the greatest impact on improving long-term neurological outcomes?
A client with a history of atrial fibrillation presents with sudden-onset aphasia and right-sided weakness. Which intervention would have the greatest impact on improving long-term neurological outcomes?
A client is actively seizing. After ensuring patient safety, what is the nurse's most important action?
A client is actively seizing. After ensuring patient safety, what is the nurse's most important action?
A client being evaluated for appendicitis reports right lower quadrant (RLQ) pain. Which finding would most strongly suggest perforation?
A client being evaluated for appendicitis reports right lower quadrant (RLQ) pain. Which finding would most strongly suggest perforation?
A client with acute pancreatitis is experiencing severe abdominal pain. Considering the underlying pathophysiology, which intervention addresses the primary cause of this pain?
A client with acute pancreatitis is experiencing severe abdominal pain. Considering the underlying pathophysiology, which intervention addresses the primary cause of this pain?
A client with cirrhosis develops ascites. Which intervention best supports fluid volume management and the underlying cause of this complication?
A client with cirrhosis develops ascites. Which intervention best supports fluid volume management and the underlying cause of this complication?
Following a laparoscopic cholecystectomy, which statement indicates the client correctly understands activity restrictions during their recovery?
Following a laparoscopic cholecystectomy, which statement indicates the client correctly understands activity restrictions during their recovery?
A client with peptic ulcer disease reports sudden, severe abdominal pain. What assessment finding provides the strongest indication of a perforation?
A client with peptic ulcer disease reports sudden, severe abdominal pain. What assessment finding provides the strongest indication of a perforation?
A post-operative patient reports abdominal distention and absence of bowel sounds on day four. What underlying process is MOST likely causing these symptoms?
A post-operative patient reports abdominal distention and absence of bowel sounds on day four. What underlying process is MOST likely causing these symptoms?
An infant presents with projectile vomiting, visible peristaltic waves, and a palpable olive-shaped mass in the upper abdomen. Which intervention would have the greatest impact on preventing metabolic complications?
An infant presents with projectile vomiting, visible peristaltic waves, and a palpable olive-shaped mass in the upper abdomen. Which intervention would have the greatest impact on preventing metabolic complications?
A client with gastritis is provided with dietary teaching. Which food choice would be considered the MOST appropriate?
A client with gastritis is provided with dietary teaching. Which food choice would be considered the MOST appropriate?
A client who underwent a thyroidectomy is now 12 hours post-op. Which assessment requires the most immediate intervention?
A client who underwent a thyroidectomy is now 12 hours post-op. Which assessment requires the most immediate intervention?
A patient with type 1 diabetes mellitus presents with altered mental status, fruity breath, and rapid, deep respirations. Besides administering insulin, which intervention is most critical to correct the underlying cause of these symptoms?
A patient with type 1 diabetes mellitus presents with altered mental status, fruity breath, and rapid, deep respirations. Besides administering insulin, which intervention is most critical to correct the underlying cause of these symptoms?
Which action poses a contraindication to client safety and post-surgical recovery?
Which action poses a contraindication to client safety and post-surgical recovery?
A nurse is reviewing pre-operative lab results. Which result poses the greatest risk for complications during surgery?
A nurse is reviewing pre-operative lab results. Which result poses the greatest risk for complications during surgery?
A client's EKG shows a prolonged PR interval. Which intervention best addresses the underlying conduction defect causing this EKG change?
A client's EKG shows a prolonged PR interval. Which intervention best addresses the underlying conduction defect causing this EKG change?
A nurse is caring for a client showing flattened T waves and prominent U waves. What is the most appropriate action for the nurse to take, keeping in mind the EKG changes?
A nurse is caring for a client showing flattened T waves and prominent U waves. What is the most appropriate action for the nurse to take, keeping in mind the EKG changes?
Following an ST-elevation myocardial infarction (STEMI), a patient's troponin level peaks at 30 ng/mL (normal <0.04 ng/mL). What does this specifically indicate about the myocardial tissue?
Following an ST-elevation myocardial infarction (STEMI), a patient's troponin level peaks at 30 ng/mL (normal <0.04 ng/mL). What does this specifically indicate about the myocardial tissue?
A patient with metabolic alkalosis has an arterial blood gas (ABG) result showing elevated bicarbonate levels. Which underlying pathophysiological process is MOST likely contributing to this imbalance?
A patient with metabolic alkalosis has an arterial blood gas (ABG) result showing elevated bicarbonate levels. Which underlying pathophysiological process is MOST likely contributing to this imbalance?
A client has been diagnosed with Hirschsprung's disease. Which sign or symptom would most clearly differentiate this condition from other causes of constipation?
A client has been diagnosed with Hirschsprung's disease. Which sign or symptom would most clearly differentiate this condition from other causes of constipation?
What is the appropriate nursing intervention when testing for Chvostek's sign?
What is the appropriate nursing intervention when testing for Chvostek's sign?
A client recently diagnosed with cirrhosis needs education on managing ascites at home. Which statement indicates a need for further teaching?
A client recently diagnosed with cirrhosis needs education on managing ascites at home. Which statement indicates a need for further teaching?
A client presents with severe abdominal pain, vomiting, and 'red currant jelly' stools. What is the INITIAL intervention?
A client presents with severe abdominal pain, vomiting, and 'red currant jelly' stools. What is the INITIAL intervention?
During an assessment of a client with suspected appendicitis, the nurse elicits pain upon palpation of the left lower quadrant. This is related to further assessment of:
During an assessment of a client with suspected appendicitis, the nurse elicits pain upon palpation of the left lower quadrant. This is related to further assessment of:
What is the primary reason for prescribing stool softeners (e.g., docusate sodium) to a post-operative patient?
What is the primary reason for prescribing stool softeners (e.g., docusate sodium) to a post-operative patient?
A client with a history of chronic gastritis asks about dietary choices. Which response by the nurse would be MOST helpful?
A client with a history of chronic gastritis asks about dietary choices. Which response by the nurse would be MOST helpful?
A nurse is providing discharge teaching to a patient being discharged after an episode of acute pancreatitis. What is the most important dietary instruction?
A nurse is providing discharge teaching to a patient being discharged after an episode of acute pancreatitis. What is the most important dietary instruction?
Following a thyroidectomy, a client reports increasing anxiety, muscle cramps, and tingling in their fingers. What lab result would best explain this?
Following a thyroidectomy, a client reports increasing anxiety, muscle cramps, and tingling in their fingers. What lab result would best explain this?
A client in DKA is receiving insulin. Which assessment finding would prompt the nurse to decrease the insulin infusion rate?
A client in DKA is receiving insulin. Which assessment finding would prompt the nurse to decrease the insulin infusion rate?
Which teaching point is most important when educating a client with diabetes about 'sick day' management?
Which teaching point is most important when educating a client with diabetes about 'sick day' management?
A client with metabolic alkalosis and hypokalemia exhibits flattened T waves and prominent U waves on an EKG. Which assessment finding would MOST warrant immediate notification of the healthcare provider?
A client with metabolic alkalosis and hypokalemia exhibits flattened T waves and prominent U waves on an EKG. Which assessment finding would MOST warrant immediate notification of the healthcare provider?
A patient with kidney failure presents with confusion and abdominal pain. Lab results show elevated BUN and creatinine, metabolic acidosis, and hyperkalemia. Which EKG change typically associated with this condition requires the MOST continuous monitoring?
A patient with kidney failure presents with confusion and abdominal pain. Lab results show elevated BUN and creatinine, metabolic acidosis, and hyperkalemia. Which EKG change typically associated with this condition requires the MOST continuous monitoring?
A patient is scheduled for an intravenous pyelogram (IVP). After reviewing the patient's chart, which finding represents the HIGHEST risk and warrants immediate intervention?
A patient is scheduled for an intravenous pyelogram (IVP). After reviewing the patient's chart, which finding represents the HIGHEST risk and warrants immediate intervention?
A nurse is caring for a client who underwent a thyroidectomy 12 hours ago. Which assessment requires the most immediate intervention?
A nurse is caring for a client who underwent a thyroidectomy 12 hours ago. Which assessment requires the most immediate intervention?
Flashcards
EKG P-wave
EKG P-wave
Firing from SA node, representing atrial depolarization on an EKG.
EKG QRS complex
EKG QRS complex
Ventricular depolarization; also includes atrial repolarization which is masked.
EKG T-wave
EKG T-wave
Ventricular repolarization on an EKG.
EKG U-wave
EKG U-wave
May indicate electrolyte imbalance (Na, K, Ca).
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PR interval
PR interval
Time for atrial depolarization, AV node delay. Normal range is 0.12-0.20 seconds.
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QT interval
QT interval
Total time for ventricular depolarization and repolarization.
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Troponin
Troponin
Cardiac enzyme released when there's a mismatch between oxygen demand and supply, indicating myocardial tissue damage.
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EKG in Acidosis/Hyperkalemia
EKG in Acidosis/Hyperkalemia
Characterized by peaked T-waves and widened QRS complex, commonly related to kidney failure.
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EKG in Alkalosis/Hypokalemia
EKG in Alkalosis/Hypokalemia
Characterized by flattened T-waves and presence of U-waves.
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Febrile Transfusion Reaction
Febrile Transfusion Reaction
Fever, hypotension/hypertension, chills, anxiety, tachypnea 1-6 hours post transfusion.
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Hemolytic Transfusion Reaction
Hemolytic Transfusion Reaction
Fever, chills, hypotension, hemolysis, renal damage, dark urine, flank pain, typically within 24 hours post-transfusion.
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Allergic Transfusion Reaction
Allergic Transfusion Reaction
Hives, itching, possible anaphylaxis; occurs seconds to minutes after transfusion.
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TRALI
TRALI
Acute respiratory distress syndrome, pulmonary edema; may occur hours to days after transfusion.
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TACO
TACO
Acute pulmonary edema slowing transfusion required; may occur hours after transfusion.
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Normal BUN level
Normal BUN level
Normal range: 10-20 mg/dL.
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Normal Creatinine level
Normal Creatinine level
Normal range: 0.5-1.3 mg/dL.
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Normal Potassium level
Normal Potassium level
Normal range: 3.5-5.0 mEq/L.
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CVA Tenderness
CVA Tenderness
Tenderness indicates kidney inflammation or infection, such as pyelonephritis.
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Hematuria
Hematuria
Blood in urine
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Proteinuria
Proteinuria
Protein in urine
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Prerenal AKI
Prerenal AKI
Reduced blood flow to the kidneys, directly affecting GFR.
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Intrarenal AKI
Intrarenal AKI
Direct damage to renal tissue.
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Postrenal AKI
Postrenal AKI
Obstruction in the urinary tract.
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GFR
GFR
Best lab to test overall filtration function of kidney
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Creatinine
Creatinine
Best lab to test for kidney damage.
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Azotemia
Azotemia
Increased levels of waste products in the blood.
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EKG: Acidosis/Hyperkalemia
EKG: Acidosis/Hyperkalemia
Typically related to kidney failure, peaked T-waves and widened QRS complex.
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Pyelogram
Pyelogram
X-ray of the urinary tract used to diagnose kidney stones, cysts, UTI, tumors, blockages, enlarged prostate.
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Pyelogram Contraindications
Pyelogram Contraindications
Pregnancy, kidney failure, allergy to dye (iodine).
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Kidney Transplant Rejection
Kidney Transplant Rejection
Fever, hypertension, pain at the transplant site, decreased urine output.
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Disequilibrium Syndrome
Disequilibrium Syndrome
Rapid solute removal leads to cerebral edema. Symptoms: headache, confusion, seizures.
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Hypotension during Hemodialysis
Hypotension during Hemodialysis
Rapid fluid depletion. Slow dialysis exchange rate.
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Magnesium Sulfate
Magnesium Sulfate
Prevents seizures (eclampsia) and promotes vasodilation to lower blood pressure.
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Hypermagnesemia Symptoms
Hypermagnesemia Symptoms
Flaccid paralysis, decreased respiratory rate, hypotension, bradycardia.
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BURP acronym
BURP acronym
Blood pressure increase, urine output decrease, reflexes absent
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Hallmark Signs of Preeclampsia
Hallmark Signs of Preeclampsia
Hypertension, proteinuria, headache, visual changes, possible seizures, edema.
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Ectopic Pregnancy
Ectopic Pregnancy
Fertilized egg implants outside the uterus.
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Ectopic Pregnancy Symptoms
Ectopic Pregnancy Symptoms
Unilateral abdominal pain, vaginal bleeding, lightheadedness, shoulder pain.
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Ectopic Pregnancy Treatment
Ectopic Pregnancy Treatment
Methotrexate administration, surgical intervention.
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Hemorrhagic Stroke Symptoms
Hemorrhagic Stroke Symptoms
Weakness or numbness, slurred speech, confusion, visual disturbances, severe headache.
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Ischemic Stroke Symptoms
Ischemic Stroke Symptoms
Weakness or numbness, slurred speech, confusion, visual disturbances.
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Seizure Precautions
Seizure Precautions
Bed and environmental safety, padded rails, oxygen for client
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Seizure Interventions
Seizure Interventions
Administer medications (benzodiazepines, AEDs), maintain safety, monitor vitals.
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Appendicitis Symptoms
Appendicitis Symptoms
Abdominal pain (RLQ), nausea/vomiting, fever, McBurney’s point tenderness.
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Murphy's Sign
Murphy's Sign
Positive when pushing in RLQ relieves pain, increases with release of pressure.
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McBurney’s Point
McBurney’s Point
RLQ point where appendix is located.
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Pancreatitis Labs
Pancreatitis Labs
Elevated amylase and lipase.
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Ascites
Ascites
Fluid retention and shifting due to low albumin levels.
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Cirrhosis
Cirrhosis
Silent, gradual, irreversible damage to the liver.
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- EKG represents the electrical activity of the heart.
EKG Components
- P wave indicates firing from the SA node, signifying atrial depolarization.
- QRS complex represents ventricular depolarization, and atrial repolarization occurs during this phase.
- T wave shows ventricular repolarization.
- U wave indicates Purkinje fibers; its presence can suggest electrolyte imbalances like sodium, potassium, or calcium issues.
EKG Intervals
- PR interval should be between 0.12-0.20 seconds.
- QT interval represents the time it takes for the ventricles to depolarize and repolarize.
Electrolyte Imbalances & EKG
- Acidosis and hyperkalemia lead to peaked T-waves and widened QRS complexes.
- Alkalosis and hypokalemia can cause flattened T-waves plus U waves.
Myocardial Infarction (MI) Labs
- Troponin is a cardiac enzyme released when there is a mismatch between oxygen demand and supply in the cardiac muscle.
- Elevated troponin levels indicate myocardial tissue damage.
Acid-Base Imbalances & EKG
- Elevated T waves and widened QRS complexes are indicated in acidosis
- Depressed or flattened T waves and U waves are indicated in alkalosis
Blood Transfusion Reactions
- Fever, hypotension or hypertension, chills, anxiety, and tachypnea occurs w/in 1-6 hours after Febrile (Fever) non-hemolytic transfusion reaction.
Febrile Transfusion Reaction Interventions
- Leukocyte-reduced red blood cells should be given in the future.
Hemolytic Transfusion Reaction
- Fever, chills, hypotension, hemolysis, renal damage, dark red or brown urine, and flank pain. Usually occurs within 24 hours after transfusion.
Allergic Transfusion Reaction
- Hives, itching, possible anaphylaxis if severe; occurs seconds to minutes after initiation of blood
Transfusion related acute lung injury (TRALI)
- Acute respiratory distress syndrome, pulmonary edema; may occur hours to days after transfusion
Transfusion associated circulatory overload (TACO)
- Acute pulmonary edema and you have to slow the transfusion; may occur hours after transfusion
Kidney Failure Assessment Findings
- Costovertebral Angle (CVA) Tenderness may indicate kidney inflammation or infection.
- Other signs include hematuria, proteinuria, and dark urine.
- BUN normal: 10-20 mg/dL
- Serum Creatinine normal: 0.5 – 1.3 mg/dL and is related to gender and age
- Hemoglobin normal: 12-18 g/dL related to gender
- Potassium normal: 3.5-5.0 mEq/L
Kidney Failure Pathophysiology
- Prerenal involves reduced blood flow, intrarenal involves direct kidney tissue damage, and postrenal involves obstruction.
- Three phases are initial insult, maintenance, and recovery.
Kidney Labs
- GFR (glomerular filtration rate) is the best lab to test function of filtration.
- Creatinine is the best lab to test for damage.
- AKI results in azotemia, elevated creatinine, fluid retention, SOB, N/V, oliguria, electrolyte imbalances, and low GFR.
Manifestations of Kidney Dysfunction
- Abdominal pain (flank) and confusion
- Metabolic acidosis is common in kidney failure.
Pyelogram
- An X-ray of the urinary tract used to diagnose kidney stones, cysts, UTIs, tumors, blockages, and enlarged prostate.
- Fast before, take laxatives, confirm not pregnant, and remove metal objects
- IVP injects dye into a vein, while retrograde pyelogram introduces dye via a catheter.
- IVP should not be performed on patients with decreased renal function because contrast media can be nephrotoxic.
- Retrograde pyelogram may cause pain from distention of pelvis and discomfort from the cystoscope.
Pyelogram Contraindications
- Pregnancy, kidney failure, allergy to dye (iodine)
Pyelogram Client Education
- Warn patient that contrast injection may cause a feeling of being warm and flushed.
- Force fluids to avoid renal problems with contrast.
- Explain burning on urination, pink tinged urine, and urinary frequency are all expected.
Post Kidney Transplant Rejection
- Fever, hypertension, pain, and decreased urine output
Hemodialysis Complications
- Disequilibrium Syndrome: Rapid removal of solutes leads to cerebral edema, more common in new patients or those with long delays between treatments.
Disequilibrium Syndrome S/S include:
- Headache, confusion, seizures, N/V, muscle cramps, hypertension, bradycardia, loss of consciousness
Disequilibrium Syndrome Intervention
- Stop or slow dialysis, administer hypertonic saline or mannitol.
- Hypotension: Rapid fluid depletion. Slow dialysis exchange rate.
Magnesium Sulfate
- Magnesium sulfate is administered to prevent seizures (eclampsia) and promote vasodilation to lower blood pressure.
- Normal Magnesium lab values are 1.3-2.1 mEq/L
- Preeclampsia therapeutic levels are 4.8-8.4 mEq/L
- Hypermagnesemia leads to muscle flaccid paralysis, decreased respiratory rate, hypotension, bradycardia, AV Block, lethargy.
Magnesium Sulfate: Assessments
- Regularly assess blood pressure, signs, and symptoms (such as headache, vision changes, epigastric pain)
- Monitor heart rate, oxygenation, lung sounds, reflexes, and edema.
- Assess for hyperreflexia and clonus.
- Frequent monitoring of intake and output (I&O).
Magnesium Sulfate: Concerns
- Watch the BURP acronym to avoid magnesium toxicity
- Blood pressure decrease <90 systolic
- Urine output decrease <30mL/hr - REPORT URINE OUTPUT
- Respiratory depression
- Patellar Reflex Absent - decreased reflexes may be seen both upper and lower extremities
- Hallmark sign of preeclampsia: >140/90 mmHg
- Proteinuria: Indicates renal dysfunction and decreased glomerular filtration rate (GFR).
- Neurological Findings- Headache, visual changes, possible seizures
- Pitting Edema: Edema seen in extremities, hands, face.
Ectopic Pregnancy: Identification
- Fertilized egg implants outside of the uterus, commonly in the fallopian tube.
Ectopic Pregnancy: Assessment Findings
- Positive pregnancy test, unilateral abdominal pain, vaginal bleeding, lightheadedness, shoulder pain, and unstable vital signs.
Ectopic Pregnancy: Treatment/Complications
- Managed with medication (methotrexate) or surgery (laparoscopy).
Stroke Risk Factors
- Modifiable: Hypertension, atherosclerosis, diabetes, smoking, high cholesterol, atrial fibrillation, heart disease, obesity.
- Non-Modifiable: Family history, age, gender, ethnicity, sickle cell disease, amyloid accumulation.
Hemorrhagic Stroke Symptoms
- Sudden severe headache, nausea and vomiting, altered consciousness, weakness or numbness, seizures, visual disturbances, difficulty speaking or slurred speech.
Ischemic Stroke Symptoms
- Weakness or numbness, difficulty speaking or slurred speech, confusion, visual disturbances, severe headache, trouble with coordination and balance, dizziness or loss of consciousness.
Seizure Interventions & Nursing Actions
- Bed Safety: Use a firm mattress on the bed to reduce the risk of injury during a fall.
- Keep bed away from objects
- Padded Side Rails: If side rails are used on the bed, they should be padded to prevent injury during a seizure.
- Administer benzos
- Clearing the Environment: Remove any sharp or potentially dangerous objects from the immediate environment.
- Soft Head Protection: Wear soft head protection (helmets) to reduce the risk of head injury during a fall.
- Maintain airway (A,B,Cs), provide oxygen therapy, establish IV access, monitor EEG (ECG), monitor vital signs including pulse oximetry and evaluate ABGs. Administer benzo (Diazepam or Lorazepam)
- During : continually assess the client's airway during a seizure, remove objects that can cause injury to the client during a seizure, and the client should be positioned side-lying or turn the client’s head to the side to prevent aspiration of secretions or vomit. Remove tight clothing from the neck to protect from injury, document the length of the seizure. Maintain IV Patency while the client is admitted to ensure access if medications are required for prevention of seizures. Do not: Restrain the client, place anything in the client’s mouth, lay the client on their back, over stimulate (rest the brain)
Appendicitis Symptoms
- Abdominal pain that starts near the umbilicus and travels to the right lower quadrant.
- Nausea/Vomiting and loss of appetite
- Fever Positive Murphy’s Sign and RLQ pain on palpation of McBurney’s Point.
Appendicitis Perforation Indication
- A sudden decrease in abdominal pain should indicate that the appendix might be ruptured. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen. The abdomen becomes progressively distended and temperature will elevate.
Appendicitis Assessments/Palpation Points
- Rovsing's sign is positive when tenderness occurs in the right lower quadrant.
- Positive Murphy’s Sign and RLQ pain on palpation of McBurney’s Point.
Pancreatitis Labs
- Elevated pancreatic enzymes, such as amylase and lipase, in the blood.
- Elevated WBCs would be expected. Decreased calcium and magnesium levels would be expected.
Pancreatitis Diet
- With a history of pancreatitis and or diagnosed with cholecystitis you would educate the client to avoid fatty foods. Alcohol Consumption: Excessive alcohol intake can lead to pancreatitis
- Pancreatitis Lab: Increased Amylase
Ascites & Cirrhosis
- Both of these are related to liver disease. Fluid retention and shifting due to low albumin levels. Educate the client to decrease fluid intake, decrease sodium and fat intake.
- Portal hypertension leads to the accumulation of fluid in the abdominal cavity, known as ascites. This occurs because high pressure forces fluid out of the bloodstream and into the abdominal space.
Gallbladder
- Removal of the gallbladder: traditional (large abdominal incision) or laparoscopic (small incisions) requires proper positioning after surgery to encourage lung expansion and support the wound (semi-fowlers). For laparoscopic the nurse should also encourage ambulation as soon as fully away to encourage the absorption of the carbon dioxide that was used during the surgery. This will minimize discomfort from trapped CO2. Lift no more than 2.3 kg (5 lb)and following surgery. Offer foods low in fat to prevent nausea and vomiting.
- Avoid fatty foods
Gastric Ulcer Perforation Indications
- Sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock.
Paralytic Ileus
- Caused by surgery, peritonitis, inflammatory response, electrolyte imbalance, or spinal fractures.
Pyloric Stenosis
- Identified in the first few weeks of life due to projectile vomiting and failure to thrive. Visible gastric peristaltic waves and a distended abdomen. May cause Metabolic alkalosis. Olive-shaped mass palpable right of the umbilicus
Intussusception
- More common in boys and most often seen in 6 months to 2 years of age. Severe colicky abdominal pain, “Red Current Jelly” stools. Vomiting, and palpable right upper quadrant mass that is sausage shaped.
Hirschsprung's Disease
- A congenital condition that affects the large intestine (colon) and causes difficulty with passing stool due to a lack of nerve cells in the colon. Results in chronic constipation and can be managed with Tx.
Gastritis Teaching
- Avoid drinking alcohol and NSAIDS to avoid increasing manifestations, drink milk, and increase exercise.
Upper vs Lower GI Bleeding
- Upper: Hematemesis (coffee ground) or bloody stool that appears as tarry/dark.
- Lower: Bright red stools
Thyroid Surgery Complications
- Damage the parathyroid glands. Observe for changes in calcium levels (hypocalcemia). Manifestations of hypocalcemia include numbness and tingling. Check for Chvostek’s Sign and prioritize ABCs
DKA symptoms
- Hyperglycemia, dehydration, ketones in the urine, and fruity breath.
Post Surgical Client Positioning
- Positioning is vital for respiratory function and circulation. If responsive, elevate to semi-Fowler’s position. And if unconscious, the lateral position should be maintained to reduce aspiration risk. Avoid placing a pillow under the knees, as these may impair venous return and may increase the risk of DVT development.
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