A patient presents with liver injury due to history of Tylenol misuse. On arrival the patient is
unconscious. After giving him 3 liters of IV fluids, the
... [Show More] nurse did an assessment. The findings
were bilateral 2+ pedal edema, BP 160/90, HR 115.
What would be the priority assessment the nurse should do next? Assess lung sounds
2.After intervention and stopping fluids and giving a small dose of Lasix, the patient became a
little responsive. ABG labs results came back, the results are as follows: pH 7.28, PaCO2 38,
PAO2 89, HCO3 17.
Is there a sign of acid base imbalance in these values? Yes
What type of acid base imbalance would this be? Metabolic Acidosis
3. A COPD patient is admitted with hypoxemia due to V/Q mismatch. The nurse is anticipating
the delivery system that will be used to provide oxygen. What type of oxygen flow would you
provide for this patient?
low levels of oxygen either via nasal cannula or using a face mask at 24% to 32% oxygen.
4.A trauma patient who has acute heart failure has not gotten out of bed and has not being
using his incentive spirometry became very restless. Vital signs reveals signs of decrease
cardiac output (low BP, bradycardic with thready pulse). A chest X-ray reveals pneumonia.
What would be the priority intervention for this patient?
intubate
5.What medication prescribed for this patient would you want to clarify?
Azithromycin (due to pt’s heart condition)
6.The patient is found to have fluids in the lungs due to bronchiectasis and requires postural
drainage 3X daily.
What would be some essential teaching essential teaching necessary for this patient about
postural drainage? Three hours after meals to allow food to digest- to prevent aspiration, use of
pillows to position client, give bronchodilator (albuterol) before procedure, percuss over a towel
(or a pillow case) to ensure it does not feel uncomfortable
7. A patient presents to the ED with complaints of the heart feeling fluttering. The MD orders for
the patient to be placed on telemetry.
Looking at the strip, how would you calculate the HR?
Count up the QRS complex and multiply by 10 (for 6 second strips)
8. the patient is diagnosed with atrial flutter. What are the clinical manifestations the patient
would present with?
It is associated with CAD, hypertension, mitral valve disorders, pulmonary embolism, chronic
lung disease, cor pulmonale, cardiomyopathy, hyperthyroidism, and the use of drugs such as
digoxin, quinidine, and epinephrine (page 765)
9. Where on the body should the electrodes be placed?
Upper leads (white & black) on clavicle line, lower leads (green & red) right below rib cage, and
brown lead on the right of sternum [Show Less]