exam 3 pt3Patient returns from CT with contrast and develops tongue swelling and difficulty breathing. What medication is anticipated first? Epinephrine 0.3 mg IM Which nursing action is included when caring for a patient with balloon tamponade for esopha

Patient returns from CT with contrast and develops tongue swelling and difficulty breathing. What medication is anticipated first?

Epinephrine 0.3 mg IM

Which nursing action is included when caring for a patient with balloon tamponade for esophageal varices?

Keep scissors at bedside

A balloon tamponade tube partially dislodges and patient develops respiratory distress. What is the priority action?

Cut the tube with scissors

Pulseless unresponsive patient with chaotic ECG rhythm should be identified as what?

Ventricular fibrillation

Burn patient sodium 152 and potassium 2.8 after emergency phase. What caused this imbalance?

Excessive fluid replacement without potassium supplementation

How should the nurse evaluate improvement in hepatic encephalopathy?

Have patient extend arms and dorsiflex wrists to assess asterixis

Carpal spasms during blood pressure measurement in pancreatitis patient indicates need to check what lab?

Calcium level

Medication expected for bleeding esophageal varices?

Vasopressin

A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the neck and chest. While planning the client’s care, the nurse should be aware that initially, the client is at the greatest risk for which of the following?

Airway obstruction

Burn patient calculation using Parkland formula determines what?

Total fluid replacement over first 24 hours

Signs of cardiogenic shock?

Tachycardia, hypotension, low urine output, cool moist skin

Goal when administering vasoactive drugs during shock?

Maintain MAP greater than 65 mmHg

Best diet for severe burn patient?

High calorie, high protein

Burn patient urine output 20 mL/hr after fluids. What should nurse do?

Notify physician

Infection prevention in burn patients includes what?

Aseptic technique, assess need for central lines, topical antibacterial ointments

Pancreatitis patient NPO with NG suction improving when what occurs?

Abdominal pain decreases

Intervention for pancreatitis pain rated 8/10?

Administer analgesics around the clock

Pancreatitis patient with ascites requires monitoring for what?

Hypovolemic shock

The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply)

Ascites, malnutrition, hypoglycemia, DIC

How is asterixis assessed?

Have patient extend arms and dorsiflex wrists

Rule of nines burn calculation involving half arm, whole leg, and perineum equals what?

28%

The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse’s teaching? (SATA)

Hepatitis B is preventable with a vaccine series.

Patients with blood transfusion or solid organ donation prior to 1992 are at higher risk for developing hepatitis.

You should get tested for hepatitis if you inject drugs, even if it was just once or many years ago.

Patient with acute pancreatitis develops hypocalcemia signs such as what?

Tetany and carpal spasms

Primary cause of acute pancreatitis?

Premature activation of pancreatic enzymes

Patient with ascites and liver disease requires monitoring for what complication?

Hypovolemic shock

ECG interpretation identifying ventricular tachycardia requires what first action if patient unstable?

Check for pulse

DKA patient potassium 2.6 requires which priority intervention?

Potassium replacement

Client returning from Bangladesh with hepatitis symptoms likely has which type?

Hepatitis E

Cancer patient with sodium 120 and decreased urine output likely has?

SIADH

Management priority in pancreatitis with severe ascites?

Monitor blood pressure for hypovolemia

First intervention when ECG alarm indicates unstable rhythm?

Check for pulse

A patient is admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate?

Over-the-counter medication use

First treatment for HHS?

Rapid IV fluid rehydration

Hypotensive patient with symptomatic bradycardia should receive what intervention?

Transcutaneous pacing

Potassium decreases during insulin therapy because what occurs?

Insulin shifts potassium into cells

Unconscious diabetic with glucose 25 mg/dL should receive what medication?

D50W

A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism?

Premature activation of inactive digestive enzymes, resulting in autodigestion.

Expected lab finding in SIADH?

Low serum sodium

TPN should be administered through what type of line?

Central venous catheter

Effect of antidiuretic hormone (ADH)?

Kidneys reabsorb water

Treatment for nephrogenic diabetes insipidus?

Thiazide diuretics

Insulin infusion calculation 1500 units in 500 mL means 50 mL contains how many units?

150 units

Medications used to manage cirrhosis include?

Diuretics, lactulose, beta blockers

ECG showing PVC every other beat is called what?

Bigeminy

Signs of thyroid storm?

Hypertension and heat intolerance

Hypoglycemic patient exercising should do what first?

Consume 15 g carbohydrates

Small cell carcinoma patient with weight gain and decreased urine output likely has?

SIADH

Expected findings in DKA?

Kussmaul respirations and metabolic acidosis

Patient with severe burn requiring nutrition should receive what type of diet?

High calorie high protein

Shock therapy goal when giving vasopressors?

Maintain adequate organ perfusion