Early signs of cerebral hypoxia
Restlessness and irritability
Necessary for Blood Product infusions
18-19 gauge needle with filter tubing
NS only run
... [Show More] with blood within 30 minutes of hanging
Check vitals before infusing, at 15 minutes, 30 minutes, then every hour, and directly after
Checking blood before infusing
2 RNs
Check order (expiration date, clots, color, air bubbles, leaks) patient, product, previous transfusion Hx
Premedicate with Benadryl for previous rxn
What does the PR interval represent
Time required for the impulse to travel from atria through the AV node
Isotonic solutions
D5W NS
Lactated ringers
Tracheostomy
Keep Kelly clamp and obturator at the bedside
To assess CVA for hemorrhagic or ischemic
CT scan first
Heart conditions related to thrombus formation
A-fib and A-flutter
Aphasia, agraphia, slow, cautious, anxious, memory ok
Left hemisphere lesion
Cannot recognize faces, loss of depth perception, impulsive behavior, poor judgement, constant smile, loss of tonal hearing
Right hemisphere lesion
Most important indicator of increased ICP
Change in LOC
Spinal shock
Complete loss of all reflexes
If the U wave is most prominent what condition
hypokalemia
Burns
First degree- epidermis {superficial}
Second degree- epidermis and dermis {deep partial}
Third degree- epidermis, dermis, and subQ {full thickness}
Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes telemetry pattern shows second degree heart block with Ventricular rate of 50. Action
Hold scheduled dose and notify HCP of telemetry pattern
Nurse is reviewing client ECG and determines PR interval prolonged. Indicates
Increased conduction time from the SA node to the AV junction
When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on right side only. Action
Reposition the depth of the ET tube
Nurse called to a train derailment likely caused by terrorist bomb. Triage in order
Middle-aged man wandering around Woman sitting on ground with blanket Crying child held by another passenger Mother and father just arrived on scene
Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35. Which needs immediate communication to HCP
Drowsiness and diff in arousing
Assess a 78 year old with L sided HF. Symptoms
Dyspnea, cough, fatigue
Caring for a burn patient with serum potassium of 4. Question which medication
Potassium
Patient admitted with deep 2nd degree burns of thighs, chest and arms covering 40% BSA. Fluid shift after burn so nurse expects
Decreased cardiac output
Patient bedridden for 2 wks with following lab values: pH 7.37, PO2 90, PCO2 40, HCO3 25, hypoalbuminemia and hypocalcemia. Priority action
Turn patient side to side q2h
Which age group should nurse assess first
40 year old with sickle cell crisis
There has been a major disaster. Triage nurse should give which patient priority
Cut over eye
Move which patient to medical surgical unit
Patient with ABNL liver levels
One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do
Take patient to ICU and arrange for respiratory patient to stay in PACU [Show Less]
