Which nursing diagnosis is a priority in the client with anaphylactic shock
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ineffective breathing pattern
The nurse is caring for a post-operative patient who was given pain medication
before leaving the recovery room. Upon transfer to the ward, the patient is still
,experiencing pain and requests more pain medication. Of the following actions, which
is the first for the nurse to take?
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Notify the practitioner that the patient is still experiencing pain
chest tube insertion
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to remove air in space: placed anteriorly through the 2nd intercostal space
to remove fluid and blood: placed posteriorly through the 8th or 9th
intercostal space
focal seizure
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- localized seizure often affecting one limb
- no LOC
- lasts less than one (1) minute
- may involve motor, sensory, or autonomic manifestations
You are assisting a physician with insertion of a chest tube for pneumothorax. With this
procedure, you will expect which of the following (Select all that apply):
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, Apply an occlusive dressing over the insertion setting
Analgesics will be administered before the procedure
Non-Established Tracheostomy Stoma
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Stoma that has had an initial uncomplicated tracheostomy tube change
(usually done at 7-10 days post op, but is not yet 14 days old)
treatment active seizures
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• Seizures need to be monitored for frequency and length: TIME THEM!
Monitor times of phases/ ask pt, what posture,
sitting/walking/vocalizations/speech/ incontinent/bowel/lose
consciousness, motor weakness
• Controlled (cessation): STOP THEM! Assess for changes to mental status,
restlessness, drowsiness, lethargy, BP, HR temp, hemodynamic, cardiac
stability, pH lactic acid, iv fluids, vasoactive meds, electrolyte imbalance
• Maintain Oxygenation- ABGs, Sat monitoring, hemodynamically stable, 02
sat 92%
• Free from injury- place pt. on side lying procedure, padding side rails,
rails up, don't restrain, loosen restrictive clothing
The following nursing diagnosis relates to pneumothorax. Please fill in the blanks:
related to the pressure in the pleural space
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, Impaired gas exchange: positive
Cervical Nerves (C1-C8)
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head and neck, diaphragm, deltoids, biceps, wrist extenders, triceps, hand
What is the most common cause of aortic aneurysm?
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Atherosclerosis
why can chest tubes be clamped ?
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• Chest tubes may be clamped to assess whether a chest is ready to be
removed order
• Chest tubes may be clamped for < a minute
• To change drainage unit
• To locate an air leak
• To assess bubbling & fluctuation of the unclamped chest tube
Thoracic Nerves (T1-T12)
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ineffective breathing pattern
The nurse is caring for a post-operative patient who was given pain medication
before leaving the recovery room. Upon transfer to the ward, the patient is still
,experiencing pain and requests more pain medication. Of the following actions, which
is the first for the nurse to take?
Give this one a try later!
Notify the practitioner that the patient is still experiencing pain
chest tube insertion
Give this one a try later!
to remove air in space: placed anteriorly through the 2nd intercostal space
to remove fluid and blood: placed posteriorly through the 8th or 9th
intercostal space
focal seizure
Give this one a try later!
- localized seizure often affecting one limb
- no LOC
- lasts less than one (1) minute
- may involve motor, sensory, or autonomic manifestations
You are assisting a physician with insertion of a chest tube for pneumothorax. With this
procedure, you will expect which of the following (Select all that apply):
Give this one a try later!
, Apply an occlusive dressing over the insertion setting
Analgesics will be administered before the procedure
Non-Established Tracheostomy Stoma
Give this one a try later!
Stoma that has had an initial uncomplicated tracheostomy tube change
(usually done at 7-10 days post op, but is not yet 14 days old)
treatment active seizures
Give this one a try later!
• Seizures need to be monitored for frequency and length: TIME THEM!
Monitor times of phases/ ask pt, what posture,
sitting/walking/vocalizations/speech/ incontinent/bowel/lose
consciousness, motor weakness
• Controlled (cessation): STOP THEM! Assess for changes to mental status,
restlessness, drowsiness, lethargy, BP, HR temp, hemodynamic, cardiac
stability, pH lactic acid, iv fluids, vasoactive meds, electrolyte imbalance
• Maintain Oxygenation- ABGs, Sat monitoring, hemodynamically stable, 02
sat 92%
• Free from injury- place pt. on side lying procedure, padding side rails,
rails up, don't restrain, loosen restrictive clothing
The following nursing diagnosis relates to pneumothorax. Please fill in the blanks:
related to the pressure in the pleural space
Give this one a try later!
, Impaired gas exchange: positive
Cervical Nerves (C1-C8)
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head and neck, diaphragm, deltoids, biceps, wrist extenders, triceps, hand
What is the most common cause of aortic aneurysm?
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Atherosclerosis
why can chest tubes be clamped ?
Give this one a try later!
• Chest tubes may be clamped to assess whether a chest is ready to be
removed order
• Chest tubes may be clamped for < a minute
• To change drainage unit
• To locate an air leak
• To assess bubbling & fluctuation of the unclamped chest tube
Thoracic Nerves (T1-T12)
