lOMoARcPSD|26582732
Hesi Advanced Clinical Concepts Adult Health Ii 2025-2026 • All Vasopressors/Vasodilator Drugs Are Potent And
Dangerous And Require Weaning On And Off. Do Not
Change Infusion Rates Simultaneously.
• Ards Is An Unexpected, Catastrophic Pulmonary • A Client Is Brought Into The Hospital Suffering Shock
Complication Occurring In A Person With No Previous Symptoms As A Result Of A Bee Sting. What Is The First
Pulmonary Problems. The Mortality Rate Is High (50%) Priority? Maintaining An Open Airway (The Allergic Reaction
Damages The Lining Of The Airways Causing Edema). Also,
• In Ards, A Common Laboratory Finding Is Lowered Po2. Keep The Client Warm Without Constricting Clothing; Keep
However, These Clients Are Not Very Responsive To High Legs Elevated (Not Trendelenburg Because The Weight Of
Concentrations Of Oxygen. The Lower Organs Restricts Breathing).
• Think About The Physiology Of The Lungs By Remembering • Epinephrine: 1:1000, 0.2 To 0.5ml Subq For Mild
Peep: Positive End Expiratory Pressure Is The Instillation
And Maintenance Of Small Amounts Of Air Into The Alveolar • Epinephrine: 1:10,000, Or 5ml Iv For Severe
Sacs To Prevent Them From Collapsing Each Time The
Client Exhales. The Amount Of Pressure Can Be Set With • Volume Expanding Fluids Are Usually Given To Clients In
The Ventilator And Is Usually Around 5 To 10 Cm Of Water. Shock. However, If The Shock Is Cardiogenic, Pulmonary
Edema May Result.
• Suction Only When Secretions Are Present.
• Drugs Of Choice For Shock
• Before Drawing Arterial Blood Gases From The Radial Artery, - Digitalis Preparations: Increase The Contractility Of The
Perform The Allen Test To Assess Collateral Circulation. Heart Muscle
Make The Client’s Hand Blanch By Obliterating Both The - Vasoconstrictors (Levophed, Dopamine): Generalized
Radial And Ulnar Pulses. Then Release The Pressure Over Vasonconstriction To Provide More Available Blood To The
The Ulnar Artery Only. If Flow Through The Ulnar Artery Is Heart To Help Maintain Cardiac Output.
Good, Flushing Will Be Seen Immediately. The Allen Test Is
Then Positive, And The Radial Artery Can Be Used For • A Common Volume-Expanding Substance Is Plasma And
Puncture. If The Allen Test Is Negative, Repeat On The Possibly Whole Blood.
Other Arm. If This Test Is Also Negative, Seek Another Site
For Arterial Puncture. The Allen Test Ensures Collateral • You Are Caring For A Woman Who Was In Severe
Circulation To The Hand If Thrombosis Of The Radial Artery Automobile Accident Several Days Ago. She Has Several
Should Follow The Puncture. Fractures And Internal Injuries. The Exploratory Laparotomy
Was Successful In Controlling The Bleeding. However,
• If The Client Does Not Have O2 To His/Her Brain, The Rest Today You Find That This Client Is Bleeding From Her
Of The Injuries Do Not Matter Because Death Will Occur. Incision, Short Of Breath, Has A Weak Thready Pulse, Has
However, They Must Be Removed From Any Source Of Cold And Clammy Skin, And Hematuria.
Imminent Danger, Such As A Fire. - What Do You Think Is Wrong With The Client, And What
Would You Expect To Do About It?
• Pc)2 >45 Or Po2 <60 On 50% O2 Signifies Respiratory - These Are Typical Signs And Symptoms Of Dic Crisis.
Failure. Expect To Administer Iv Heparin To Block The Formation Of
Thrombin ( Coumadin Does Not Do This). However, The
• A Child In Severe Distress Should Be On 100% O2. Client Described Is Already Past The Coagulation Phase And
Into The Hemorrhagic Phase. Her Management Would Be
• Early Signs Of Shock Are Agitation And Restlessness Administration Of Clotting Factors Along With Palliative
Resulting From Cerebral Hypoxia. Treatment Of The Symptoms As They Arise. (Her Prognosis
Is Poor).
• If Cardiogenic Shock Exists With The Presence Of
Pulmonary Edema, I.E., From Pump Failure, Position Client Nclex-Rn Questions On Cpr Often Deal With Prioritization Of
To Reduce Venous Return (High Fowler’s With Legs Down) Actions. Question: What Actions Are Required For Each Of
In Order To Decrease Venous Return Further To The Left The Following Situations?
Ventricle. - A 24-Year Old Motorcycle Accident Vistim With A Ruptured
Artery If The Leg Is Pulseless And Apneic.
• Severe Shock Leads To Widespread Cellular Injury And - A 36-Year Old First Time Pregnant Woman Who Arrests
Impairs The Integrity Of The Capillary Membranes. Fluid And During Labor.
Osmotic Proteins Seep Into The Extra Vascular Spaces, - A 17-Year Old With No Pulse Or Respirations Who Is
Further Reducing Cardiac Output. A Vicious Cycle Of Trapped In An Overturned Car, Which Is Starting To Catch
Decreased Perfusion To All Cellular Level Activities Ensues. Fire.
All Organs Are Damaged, And If Perfusion Problems Exist, - A 40-Year Old Businessman Who Arrests Two Days After A
The Damage Can Be Permanent. Cervical Laminectomy.
1
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When To Seek Emergency Medical Service (Ems) • Fluid Volume Deficit: Dehydration
- The American Heart Association Recommends That Those - Elevated Bun: The Bun Measures The Amount Of Urea
With Known Angina Pectoris Seek Emergency Medical Care Nitrogen In The Blood. Urea Is Formed In The Liver As The
If Chest Pain Is Not Relieved By Three Nitroglycerin Tablets End Product Of Protein Metabolism. The Bun Is Directly
5 Minutes Apart Over A 150minute Period. Related To The Metabolic Function Of The Liver And The
- A Person With Previously Unrecognized Coronary Disease Excretory Function Of The Kidneys.
Experiencing Chest Pain Persisting For 2 Minutes Or Longer - Creatinine, As With Bun, Is Excreted Entirely By The Kidneys
Should Seek Emergency Medical Treatment. And Is Therefore Directly Proportional To Renal Excretory
• It Is Important For The Nurse To Stay Current With The Function. However, Unlike Bun, The Creatinine Level Is
American Heart Association’s Guidelines For Basic Life Affected Very Little By Dehydration, Malnutrition, Or Hepatic
Support (Bls) By Being Certified Every Two Years As Function. The Daily Production Of Creatinine Depends On
Required. Muscle Mass, Which Fluctuates Very Little. Therefore, It Is A
Better Test Of Renal Function Than Is The Bun. Creatinine
• If One Rescuer Is Performing Cpr, 1 15:2 Ratio Of Is Generally Used In Conjunction With The Bun Test And
Compression To Ventilations Is Performed For 4 Cycles, They Normally Are In A 1:20 Ratio.
Then Reassess For Breathing And Pulse. If Two Rescuers - Serum Osmolality Measures The Concentration Of Particles
Are Performing Cpr, A 15:2 Ratio Is Now Recommended For In A Solution. It Refers To The Fact That The Same Amount
Compressions To Ventilations. Perform For 15 Cycles With Of Solute Is Present, But The Amount Of Solvent (Fluid) Is
A 100/Min Compression Rate. When Trading Off, Start With Decreased. Therefore, The Blood Can Be Considered “More
Compressions. Concentrated.”
- Urine Osmolality And Specific Gravity Increase.
• Initiate Cpr With Bls Guidelines Immediately, Then Move On
To Advanced Cardiac Life Support (Acls) Guidelines. • Check The Iv Tubing Container To Determine The Drip
Factor Because Drip Factors Vary. The Most Common Drip
• When Significant Arterial Acidosis Is Noted, Try To Reduce Factors Are 10, 12, 15, And 60 Drops Per Milliliter. A
Pco2 By Increasing Ventilation, Which Will Correct Arterial, Microdrip Is 60 Drops Per Milliliter.
Venous, And Tissue Acidosis. Bicarbonate May Exacerbate
Acidosis B Producing Co2. Thus, The Acls Guidelines Have • Flushing A Saline Lock Requires Approximately 1 ½ Times
Recommended Bicarbonate Not Be Used Unless The Amount Of Fluid That The Tubing Will Hold In Order To
Hyperkalemia And/Or Preexisting Acidosis Is Documented. Efficiently Flush The Tubing. Remember To Use Sterile
Technique To Prevent Complications Such As Infiltration,
• Infants/Prematures May Have Problems With The Following Emboli And Infection.
That Can Predispose To Arrest: Beware Of The “H’s” –
Hypoxia, Hypoglycemia, Hypothermia, Increased H+ • A Ph Of Less Than 6.8 Or More Than 7.8 Is Not Compatible
(Metabolic And/Or Respiratory Acidosis), Hypercoagulability With Life.
(If Polycythemia Exists).
• The Acronym Rome Can Help You Remember: Respiratory,
• Changes Is Osmolarity Cause Shifts In Fluid. The Osmolarity Opposite, Metabolic, Equal.
Of The Extracellular Fluid (Ecf) Is Almost Entriely Due To
Sodium. The Osmolarity Of Intracellular Fluid (Icf) Is Related • Review The Order Of Blood Flow To The Heart:
To Many Particles, With Potassium Being The Primary - Unoxygenated Blood Flows From The Superior And Inferior
Electrolyte. The Pressures In The Ecf And The Icf Are Vena Cava Into The Right Atrium, Then To The Right
Almost Identical. If Either Ecf Or Icf Change In Ventricle. It Flows Out Of The Heart Through The Pulmonary
Concentration, Fluid Shifts From The Area Of Lesser Artery, To The Lungs For Oxygenation. The Pulmonary Vein
Concentration To The Area Of Greater Concentration. Delivers Oxygenated Blood Back To The Left Atrium, Then
To The Left Ventricle (Largest, Strongest Chamber) And Out
• Dextrose 10% Is A Hypertonic Solution And Should Be The Aorta.
Administered Iv. - Review The Three Structures That Control The One-Way
Flow Of Blood Through The Heart:
• Normal Saline Is An Isotonic Solution And Is Used For 1. Valves Atrioventricular Valves Tricuspid (Right Side)
Irrigations, Such As Bladder Irrigations Or Iv Flush Lines With Mitral (Left Side)
Intermittent Iv Medication. Semilunar Valves Pulmonary (In Pulmonary Artery)
Aortic (In Aorta)
• Use Only Isotonic (Neutral) Solutions In Irrigations, Infusions, 2. Cordae Tendinae
Etc., Unless The Specific Aim Is To Shift Fluid Into 3. Papillary Muscles
Intracellular Or Extracellular Spaces.
• Since The T Waves Represents Repolarization Of The
• Potassium Imbalances Are Potentially Life-Threatening, Must Ventricle, This Is A Critical Time In The Heartbeat. This
Be Corrected Immediately. A Low Magnesium Often Action Represents A Resting And Regrouping Stage So That
Accompanies A Low K+, Especially With The Use Of The Next Heartbeat Can Occur. If Defibrillation Occurs
Diuretics. During This Phase, The Heart Can Be Thrust Into A Life-
Threatening Dysrhythmia.
2
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• Observe The Client For Tolerance Of The Current Rhythm. Of Distress, Assess To Determine If The Leads Are Attached
This Information Is The Most Important Data The Nurse Can Properly.
Collect On The Client With An Arrythmia.
• Marking The Operative Site Is Required For Procedures
• Remember To Monitor The Client As Well As The Machine! Involving Right/Left Distinctions, Multiple Structures (Fingers,
If The Ekg Monitor Shows A Severe Dysrhythmia, But The Toes), Or Levels (Spinal Procedures). Site Marking Should
Client Is Sitting Up Quietly Watching A Tv Without Any Sign Be Done With The Involvement Of The Client.
Wound Dehiscence Is Separation Of The Wound - Interpersonal Skills
Edges And Is More Likely To Occur With Vertical - Physical Care: Altering Positions, Touch, Hot And Cold
Incisions. It Usually Occurs After The Early Applications.
Postoperative Period, When The Client’s Own
Granulation Tissue Is “Taking Over” The Wound, After • Narcotic Analgesics Are Prepared For Pain Relief Because
Absorption Of The Sutures Has Begun. Evisceration They Bind To The Various Opiate Receptor Sites In The Cns.
Of The Wound Is Protrusion Of Intestinal Contents (In Morphine Is Often The Preferred Narcotic (Remember: It
An Abdominal Wound) And Is More Likely In Clients Causes Respiratory Depression).
Who Are Older, Diabetic, Obese, Or Malnourished And
Have Prolonged Paralytic Ileus. • Other Agonists Are Meperidine And Methadone. Narcotic
Antagonists Block The Attachment Of Narcotics To The
Nclex-Rn Items Will Focus On The Nurse’s Role In Receptors, Such As Narcan (Naloxone). Once Narcan Has
Terms Of The Entire Perioperative Process. Sample: Been Given, Additional Narcotics Cannot Be Given Until The
A 43-Year Old Mother Of 2 Teenage Daughters Enters Narcan Effects Have Passed.
The Hospital To Have Her Gallbladder Removed In A
Same-Day Surgery Using A Scope Instead Of An • Do Not Take Away The Coping Style Used In A Crisis State…
Incision. What Nursing Needs Will Dominate Each Denial. It Is A Useful And Needed Tool At The Initial Stage
Phase Of Her Short Hospital Stay? For Some. Support, Do Not Challenge, Unless It
Preparation Phase: Education About Postoperative Care, Hinders/Blocks Treatment – Endangering The Patient.
Npo, Assist With Meeting Family Needs.
Operative Phase: Assessment, Management Of The Medical –Surgical Nursing
Operative Suite.
Post-Anesthesia Phase: Pain Management, Post- Respiratory System
Anesthesia Precautions.
Post-Operative Phase: Prevent And Assess For Fever Can Cause Dehydration From Excessive Fluid
Complications, Pain Management, Dietary Restrictions, • Loss In Diaphoresis. Increased Temperature Also
Increases Metabolism And The Demand For Oxygen.
Activity.
Hiv Clients With Tuberculosis Require Respiratory High Risk For Pneumonia:
Isolation. Tuberculosis Is The Only Real Risk To Non- Any Person, Who Has Altered Level Of
•
Pregnant Caregivers That Is Not Related To A Break Consciousness, Has Depressed Or Absent Gag
- Reflex And Cough Reflexes, Is Susceptible To
In Universal Precautions (I.E., Needle Sticks, Etc.).
Aspirating Oropharyngeal Secretions. ( Alcoholics,
Standard Precautions: Anesthesized Individuals, Those With Brain Injury,
Wash Hands, Even If Gloves Have Been Worn To Drug Overdose, Or Stroke Victims).
Give Care Wear Gloves (Latex) For Touching Blood When Feeding, Raise The Head Of The Bed And
- Position The Client On Side – Not On Back.
Or Body Fluids, Or Any Non-Intact Body Surface.
Wear Gowns During Any Procedure That Might Generate
Splashes (Changing Clients With Diarrhea). Bronchial Breath Sounds Are Heard Over Areas Of
Use Masks And Eye Protection During Activity Which Density Or Consolidation. Sound Waves Are Easily
Might Disperse Droplets (Suctioning). Transmitted Over Consolidated Tissue.
Do Not Recap Needles, Dispose Of In Puncture-Resistant
Containers. • Hydration – Enables Liquification Of Mucous Trapped
Use Mouth Piece For Resuscitation Efforts. In The Bronchioles And Alveoli, Facilitating
Refrain From Giving Care If You Have Open Skin Lesions. Expectoration. Essential For The Client Experiencing
Fever. Important Because 300 To 400 Ml Of Fluid Are
Caregivers Who Are Pregnant May Choose Not To Care Lost Daily By The Lungs Through Evaporation.
For A Client With Cytomegalovirus (Cmv).
• Irritability And Restlessness Are Early Signs Of
Pediatric Hiv Is Often Evidenced By Lymphoid Interstitial Cerebral Hypoxia – The Client Is Not Getting Enough
Pneumonitis. Oxygen To The Brain.
The Focus Of Nclex-Rn Questions Is Likely To Be Pneumonia Preventatives:
• Elderly: Flu Shots; Pneumonia Immunizations;
Assessment Of Early Signs Of The Disease And -
Management Of Complications Associated With Hiv. Avoiding Sources Of Infection And Indoor Pollutants
(Dust, Smoke, And Aerosols); Do Not Smoke.
For Narcotic Induced Respiratory Depression, Immunosuppressed And Debilitated Persons: Infection
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Administer Naloxone 0.1mg To 0.4mg Iv Every 2-3
Minutes As Needed, Until 1.0mg Is Achieved.
-
Use Non-Invasive Methods For Pain Management When Avoidance, Sensible Nutrition, Adequate Intake,
Possible: Balance Of Rest And Activity.
Relaxation Techniques - Comatose And Immobile Persons: Elevate Head Of
Bed To Feed; Turn Frequently.
- Distraction
- Imagery
- Biofeedback
• Compensation Occurs Over Time In Clients With Chronic • Pink Puffer: Barrel Chest Is Indicative Of Emphysema And Is
Lung Disease, And Arterial Blood Gases (Abgs) Are Altered. Caused By Use Of Accessory Muscles To Breathe, Which
It Is Imperative That Baseline Data Are Obtained On The Causes The Person To Work Harder To Breathe, But The
Client. Amount Of O2 Taken In In Adequate To Oxygenate The
Tissues.
• Productive Cough And Comfort Can Be Facilitated By
Semifowler’s Or High Fowler’s Positions, Which Lessen • Blue Bloater: Insufficient Oxygenation Occurs With Chronic
Pressure On The Diaphragm From Abdominal Organs. Bronchitis And Leads To Generalized Cyanosis And Often
Gastric Distention Becomes A Priority In These Clients Rightsided Heart Failure.
Because It Elevates The Diaphragm And Inhibits Lung • Cells Of The Body Depend On Oxygen To Carry Out Their
Expansion. Functions. Inadequate Arterial Oxygenation Is Manifested By
Cyanosis And Slow Capillary Refill (<3 Seconds). A Chronic
Sign Is Clubbing Of The Fingernails, And A Late Sign Is
Clubbing Of The Fingers.
4
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Hesi Advanced Clinical Concepts Adult Health Ii 2025-2026 • All Vasopressors/Vasodilator Drugs Are Potent And
Dangerous And Require Weaning On And Off. Do Not
Change Infusion Rates Simultaneously.
• Ards Is An Unexpected, Catastrophic Pulmonary • A Client Is Brought Into The Hospital Suffering Shock
Complication Occurring In A Person With No Previous Symptoms As A Result Of A Bee Sting. What Is The First
Pulmonary Problems. The Mortality Rate Is High (50%) Priority? Maintaining An Open Airway (The Allergic Reaction
Damages The Lining Of The Airways Causing Edema). Also,
• In Ards, A Common Laboratory Finding Is Lowered Po2. Keep The Client Warm Without Constricting Clothing; Keep
However, These Clients Are Not Very Responsive To High Legs Elevated (Not Trendelenburg Because The Weight Of
Concentrations Of Oxygen. The Lower Organs Restricts Breathing).
• Think About The Physiology Of The Lungs By Remembering • Epinephrine: 1:1000, 0.2 To 0.5ml Subq For Mild
Peep: Positive End Expiratory Pressure Is The Instillation
And Maintenance Of Small Amounts Of Air Into The Alveolar • Epinephrine: 1:10,000, Or 5ml Iv For Severe
Sacs To Prevent Them From Collapsing Each Time The
Client Exhales. The Amount Of Pressure Can Be Set With • Volume Expanding Fluids Are Usually Given To Clients In
The Ventilator And Is Usually Around 5 To 10 Cm Of Water. Shock. However, If The Shock Is Cardiogenic, Pulmonary
Edema May Result.
• Suction Only When Secretions Are Present.
• Drugs Of Choice For Shock
• Before Drawing Arterial Blood Gases From The Radial Artery, - Digitalis Preparations: Increase The Contractility Of The
Perform The Allen Test To Assess Collateral Circulation. Heart Muscle
Make The Client’s Hand Blanch By Obliterating Both The - Vasoconstrictors (Levophed, Dopamine): Generalized
Radial And Ulnar Pulses. Then Release The Pressure Over Vasonconstriction To Provide More Available Blood To The
The Ulnar Artery Only. If Flow Through The Ulnar Artery Is Heart To Help Maintain Cardiac Output.
Good, Flushing Will Be Seen Immediately. The Allen Test Is
Then Positive, And The Radial Artery Can Be Used For • A Common Volume-Expanding Substance Is Plasma And
Puncture. If The Allen Test Is Negative, Repeat On The Possibly Whole Blood.
Other Arm. If This Test Is Also Negative, Seek Another Site
For Arterial Puncture. The Allen Test Ensures Collateral • You Are Caring For A Woman Who Was In Severe
Circulation To The Hand If Thrombosis Of The Radial Artery Automobile Accident Several Days Ago. She Has Several
Should Follow The Puncture. Fractures And Internal Injuries. The Exploratory Laparotomy
Was Successful In Controlling The Bleeding. However,
• If The Client Does Not Have O2 To His/Her Brain, The Rest Today You Find That This Client Is Bleeding From Her
Of The Injuries Do Not Matter Because Death Will Occur. Incision, Short Of Breath, Has A Weak Thready Pulse, Has
However, They Must Be Removed From Any Source Of Cold And Clammy Skin, And Hematuria.
Imminent Danger, Such As A Fire. - What Do You Think Is Wrong With The Client, And What
Would You Expect To Do About It?
• Pc)2 >45 Or Po2 <60 On 50% O2 Signifies Respiratory - These Are Typical Signs And Symptoms Of Dic Crisis.
Failure. Expect To Administer Iv Heparin To Block The Formation Of
Thrombin ( Coumadin Does Not Do This). However, The
• A Child In Severe Distress Should Be On 100% O2. Client Described Is Already Past The Coagulation Phase And
Into The Hemorrhagic Phase. Her Management Would Be
• Early Signs Of Shock Are Agitation And Restlessness Administration Of Clotting Factors Along With Palliative
Resulting From Cerebral Hypoxia. Treatment Of The Symptoms As They Arise. (Her Prognosis
Is Poor).
• If Cardiogenic Shock Exists With The Presence Of
Pulmonary Edema, I.E., From Pump Failure, Position Client Nclex-Rn Questions On Cpr Often Deal With Prioritization Of
To Reduce Venous Return (High Fowler’s With Legs Down) Actions. Question: What Actions Are Required For Each Of
In Order To Decrease Venous Return Further To The Left The Following Situations?
Ventricle. - A 24-Year Old Motorcycle Accident Vistim With A Ruptured
Artery If The Leg Is Pulseless And Apneic.
• Severe Shock Leads To Widespread Cellular Injury And - A 36-Year Old First Time Pregnant Woman Who Arrests
Impairs The Integrity Of The Capillary Membranes. Fluid And During Labor.
Osmotic Proteins Seep Into The Extra Vascular Spaces, - A 17-Year Old With No Pulse Or Respirations Who Is
Further Reducing Cardiac Output. A Vicious Cycle Of Trapped In An Overturned Car, Which Is Starting To Catch
Decreased Perfusion To All Cellular Level Activities Ensues. Fire.
All Organs Are Damaged, And If Perfusion Problems Exist, - A 40-Year Old Businessman Who Arrests Two Days After A
The Damage Can Be Permanent. Cervical Laminectomy.
1
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, lOMoARcPSD|26582732
When To Seek Emergency Medical Service (Ems) • Fluid Volume Deficit: Dehydration
- The American Heart Association Recommends That Those - Elevated Bun: The Bun Measures The Amount Of Urea
With Known Angina Pectoris Seek Emergency Medical Care Nitrogen In The Blood. Urea Is Formed In The Liver As The
If Chest Pain Is Not Relieved By Three Nitroglycerin Tablets End Product Of Protein Metabolism. The Bun Is Directly
5 Minutes Apart Over A 150minute Period. Related To The Metabolic Function Of The Liver And The
- A Person With Previously Unrecognized Coronary Disease Excretory Function Of The Kidneys.
Experiencing Chest Pain Persisting For 2 Minutes Or Longer - Creatinine, As With Bun, Is Excreted Entirely By The Kidneys
Should Seek Emergency Medical Treatment. And Is Therefore Directly Proportional To Renal Excretory
• It Is Important For The Nurse To Stay Current With The Function. However, Unlike Bun, The Creatinine Level Is
American Heart Association’s Guidelines For Basic Life Affected Very Little By Dehydration, Malnutrition, Or Hepatic
Support (Bls) By Being Certified Every Two Years As Function. The Daily Production Of Creatinine Depends On
Required. Muscle Mass, Which Fluctuates Very Little. Therefore, It Is A
Better Test Of Renal Function Than Is The Bun. Creatinine
• If One Rescuer Is Performing Cpr, 1 15:2 Ratio Of Is Generally Used In Conjunction With The Bun Test And
Compression To Ventilations Is Performed For 4 Cycles, They Normally Are In A 1:20 Ratio.
Then Reassess For Breathing And Pulse. If Two Rescuers - Serum Osmolality Measures The Concentration Of Particles
Are Performing Cpr, A 15:2 Ratio Is Now Recommended For In A Solution. It Refers To The Fact That The Same Amount
Compressions To Ventilations. Perform For 15 Cycles With Of Solute Is Present, But The Amount Of Solvent (Fluid) Is
A 100/Min Compression Rate. When Trading Off, Start With Decreased. Therefore, The Blood Can Be Considered “More
Compressions. Concentrated.”
- Urine Osmolality And Specific Gravity Increase.
• Initiate Cpr With Bls Guidelines Immediately, Then Move On
To Advanced Cardiac Life Support (Acls) Guidelines. • Check The Iv Tubing Container To Determine The Drip
Factor Because Drip Factors Vary. The Most Common Drip
• When Significant Arterial Acidosis Is Noted, Try To Reduce Factors Are 10, 12, 15, And 60 Drops Per Milliliter. A
Pco2 By Increasing Ventilation, Which Will Correct Arterial, Microdrip Is 60 Drops Per Milliliter.
Venous, And Tissue Acidosis. Bicarbonate May Exacerbate
Acidosis B Producing Co2. Thus, The Acls Guidelines Have • Flushing A Saline Lock Requires Approximately 1 ½ Times
Recommended Bicarbonate Not Be Used Unless The Amount Of Fluid That The Tubing Will Hold In Order To
Hyperkalemia And/Or Preexisting Acidosis Is Documented. Efficiently Flush The Tubing. Remember To Use Sterile
Technique To Prevent Complications Such As Infiltration,
• Infants/Prematures May Have Problems With The Following Emboli And Infection.
That Can Predispose To Arrest: Beware Of The “H’s” –
Hypoxia, Hypoglycemia, Hypothermia, Increased H+ • A Ph Of Less Than 6.8 Or More Than 7.8 Is Not Compatible
(Metabolic And/Or Respiratory Acidosis), Hypercoagulability With Life.
(If Polycythemia Exists).
• The Acronym Rome Can Help You Remember: Respiratory,
• Changes Is Osmolarity Cause Shifts In Fluid. The Osmolarity Opposite, Metabolic, Equal.
Of The Extracellular Fluid (Ecf) Is Almost Entriely Due To
Sodium. The Osmolarity Of Intracellular Fluid (Icf) Is Related • Review The Order Of Blood Flow To The Heart:
To Many Particles, With Potassium Being The Primary - Unoxygenated Blood Flows From The Superior And Inferior
Electrolyte. The Pressures In The Ecf And The Icf Are Vena Cava Into The Right Atrium, Then To The Right
Almost Identical. If Either Ecf Or Icf Change In Ventricle. It Flows Out Of The Heart Through The Pulmonary
Concentration, Fluid Shifts From The Area Of Lesser Artery, To The Lungs For Oxygenation. The Pulmonary Vein
Concentration To The Area Of Greater Concentration. Delivers Oxygenated Blood Back To The Left Atrium, Then
To The Left Ventricle (Largest, Strongest Chamber) And Out
• Dextrose 10% Is A Hypertonic Solution And Should Be The Aorta.
Administered Iv. - Review The Three Structures That Control The One-Way
Flow Of Blood Through The Heart:
• Normal Saline Is An Isotonic Solution And Is Used For 1. Valves Atrioventricular Valves Tricuspid (Right Side)
Irrigations, Such As Bladder Irrigations Or Iv Flush Lines With Mitral (Left Side)
Intermittent Iv Medication. Semilunar Valves Pulmonary (In Pulmonary Artery)
Aortic (In Aorta)
• Use Only Isotonic (Neutral) Solutions In Irrigations, Infusions, 2. Cordae Tendinae
Etc., Unless The Specific Aim Is To Shift Fluid Into 3. Papillary Muscles
Intracellular Or Extracellular Spaces.
• Since The T Waves Represents Repolarization Of The
• Potassium Imbalances Are Potentially Life-Threatening, Must Ventricle, This Is A Critical Time In The Heartbeat. This
Be Corrected Immediately. A Low Magnesium Often Action Represents A Resting And Regrouping Stage So That
Accompanies A Low K+, Especially With The Use Of The Next Heartbeat Can Occur. If Defibrillation Occurs
Diuretics. During This Phase, The Heart Can Be Thrust Into A Life-
Threatening Dysrhythmia.
2
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, lOMoARcPSD|26582732
• Observe The Client For Tolerance Of The Current Rhythm. Of Distress, Assess To Determine If The Leads Are Attached
This Information Is The Most Important Data The Nurse Can Properly.
Collect On The Client With An Arrythmia.
• Marking The Operative Site Is Required For Procedures
• Remember To Monitor The Client As Well As The Machine! Involving Right/Left Distinctions, Multiple Structures (Fingers,
If The Ekg Monitor Shows A Severe Dysrhythmia, But The Toes), Or Levels (Spinal Procedures). Site Marking Should
Client Is Sitting Up Quietly Watching A Tv Without Any Sign Be Done With The Involvement Of The Client.
Wound Dehiscence Is Separation Of The Wound - Interpersonal Skills
Edges And Is More Likely To Occur With Vertical - Physical Care: Altering Positions, Touch, Hot And Cold
Incisions. It Usually Occurs After The Early Applications.
Postoperative Period, When The Client’s Own
Granulation Tissue Is “Taking Over” The Wound, After • Narcotic Analgesics Are Prepared For Pain Relief Because
Absorption Of The Sutures Has Begun. Evisceration They Bind To The Various Opiate Receptor Sites In The Cns.
Of The Wound Is Protrusion Of Intestinal Contents (In Morphine Is Often The Preferred Narcotic (Remember: It
An Abdominal Wound) And Is More Likely In Clients Causes Respiratory Depression).
Who Are Older, Diabetic, Obese, Or Malnourished And
Have Prolonged Paralytic Ileus. • Other Agonists Are Meperidine And Methadone. Narcotic
Antagonists Block The Attachment Of Narcotics To The
Nclex-Rn Items Will Focus On The Nurse’s Role In Receptors, Such As Narcan (Naloxone). Once Narcan Has
Terms Of The Entire Perioperative Process. Sample: Been Given, Additional Narcotics Cannot Be Given Until The
A 43-Year Old Mother Of 2 Teenage Daughters Enters Narcan Effects Have Passed.
The Hospital To Have Her Gallbladder Removed In A
Same-Day Surgery Using A Scope Instead Of An • Do Not Take Away The Coping Style Used In A Crisis State…
Incision. What Nursing Needs Will Dominate Each Denial. It Is A Useful And Needed Tool At The Initial Stage
Phase Of Her Short Hospital Stay? For Some. Support, Do Not Challenge, Unless It
Preparation Phase: Education About Postoperative Care, Hinders/Blocks Treatment – Endangering The Patient.
Npo, Assist With Meeting Family Needs.
Operative Phase: Assessment, Management Of The Medical –Surgical Nursing
Operative Suite.
Post-Anesthesia Phase: Pain Management, Post- Respiratory System
Anesthesia Precautions.
Post-Operative Phase: Prevent And Assess For Fever Can Cause Dehydration From Excessive Fluid
Complications, Pain Management, Dietary Restrictions, • Loss In Diaphoresis. Increased Temperature Also
Increases Metabolism And The Demand For Oxygen.
Activity.
Hiv Clients With Tuberculosis Require Respiratory High Risk For Pneumonia:
Isolation. Tuberculosis Is The Only Real Risk To Non- Any Person, Who Has Altered Level Of
•
Pregnant Caregivers That Is Not Related To A Break Consciousness, Has Depressed Or Absent Gag
- Reflex And Cough Reflexes, Is Susceptible To
In Universal Precautions (I.E., Needle Sticks, Etc.).
Aspirating Oropharyngeal Secretions. ( Alcoholics,
Standard Precautions: Anesthesized Individuals, Those With Brain Injury,
Wash Hands, Even If Gloves Have Been Worn To Drug Overdose, Or Stroke Victims).
Give Care Wear Gloves (Latex) For Touching Blood When Feeding, Raise The Head Of The Bed And
- Position The Client On Side – Not On Back.
Or Body Fluids, Or Any Non-Intact Body Surface.
Wear Gowns During Any Procedure That Might Generate
Splashes (Changing Clients With Diarrhea). Bronchial Breath Sounds Are Heard Over Areas Of
Use Masks And Eye Protection During Activity Which Density Or Consolidation. Sound Waves Are Easily
Might Disperse Droplets (Suctioning). Transmitted Over Consolidated Tissue.
Do Not Recap Needles, Dispose Of In Puncture-Resistant
Containers. • Hydration – Enables Liquification Of Mucous Trapped
Use Mouth Piece For Resuscitation Efforts. In The Bronchioles And Alveoli, Facilitating
Refrain From Giving Care If You Have Open Skin Lesions. Expectoration. Essential For The Client Experiencing
Fever. Important Because 300 To 400 Ml Of Fluid Are
Caregivers Who Are Pregnant May Choose Not To Care Lost Daily By The Lungs Through Evaporation.
For A Client With Cytomegalovirus (Cmv).
• Irritability And Restlessness Are Early Signs Of
Pediatric Hiv Is Often Evidenced By Lymphoid Interstitial Cerebral Hypoxia – The Client Is Not Getting Enough
Pneumonitis. Oxygen To The Brain.
The Focus Of Nclex-Rn Questions Is Likely To Be Pneumonia Preventatives:
• Elderly: Flu Shots; Pneumonia Immunizations;
Assessment Of Early Signs Of The Disease And -
Management Of Complications Associated With Hiv. Avoiding Sources Of Infection And Indoor Pollutants
(Dust, Smoke, And Aerosols); Do Not Smoke.
For Narcotic Induced Respiratory Depression, Immunosuppressed And Debilitated Persons: Infection
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Administer Naloxone 0.1mg To 0.4mg Iv Every 2-3
Minutes As Needed, Until 1.0mg Is Achieved.
-
Use Non-Invasive Methods For Pain Management When Avoidance, Sensible Nutrition, Adequate Intake,
Possible: Balance Of Rest And Activity.
Relaxation Techniques - Comatose And Immobile Persons: Elevate Head Of
Bed To Feed; Turn Frequently.
- Distraction
- Imagery
- Biofeedback
• Compensation Occurs Over Time In Clients With Chronic • Pink Puffer: Barrel Chest Is Indicative Of Emphysema And Is
Lung Disease, And Arterial Blood Gases (Abgs) Are Altered. Caused By Use Of Accessory Muscles To Breathe, Which
It Is Imperative That Baseline Data Are Obtained On The Causes The Person To Work Harder To Breathe, But The
Client. Amount Of O2 Taken In In Adequate To Oxygenate The
Tissues.
• Productive Cough And Comfort Can Be Facilitated By
Semifowler’s Or High Fowler’s Positions, Which Lessen • Blue Bloater: Insufficient Oxygenation Occurs With Chronic
Pressure On The Diaphragm From Abdominal Organs. Bronchitis And Leads To Generalized Cyanosis And Often
Gastric Distention Becomes A Priority In These Clients Rightsided Heart Failure.
Because It Elevates The Diaphragm And Inhibits Lung • Cells Of The Body Depend On Oxygen To Carry Out Their
Expansion. Functions. Inadequate Arterial Oxygenation Is Manifested By
Cyanosis And Slow Capillary Refill (<3 Seconds). A Chronic
Sign Is Clubbing Of The Fingernails, And A Late Sign Is
Clubbing Of The Fingers.
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