Critical Care Hesi

long history of smoking; sob; ABG pH7.25, PCO2 50, HCO3 24 respiratory acidosis (if CO2 is high it will always be resp. acidosis) "heart is pounding outside of her chest" client is in SVT; intervention coach client in relaxation and deep breathing insulin protocol; pt. insulin is infused at 5 units/hr and her current glucose reading is 165. what to do? increase drip by 1 unit/hr calculate; 1,500,000 IU in 500 mL of 0.9% NS 33 DKA math question 1000 mL NS with 30 mEq of sodium older client comes in with CAP and SpO2 89%. what is priority intervention? assist client with turning, coughing, and deep breathing pt. received ETT 7 days ago and is currently on 50% O2. Pt is currently anxious and hyperventilating. what is the priority intervention? auscultate lungs client has not been taking cortisone for either 2 weeks or 2 months and husband bring her into ED; not feeling well. SIADH. what to do? initiate fall precautions (SIADH causes seizures) UAP assisting nurse in situation where pt is having SVT and nurse has to prepare for cardioversion. what task for UAP bring resuscitation cart to the bedside pt has cardioversion due to uncontrolled a fib. what vital shows that the cardioversion was successful? normal sinus rhythm with HR 84 pt. has ortho surgery and 12 hrs after surgery is anxious with SOB; intervention position client on the left side pt. receiving dopamine. monitor for what monitor urinary output during insertion of swan gans, what should nurse do monitor for dysrhythmias which vital signs are contraindicative of ICP? PaCO2 of 55 (normal PaCO2 should be between 35-45; when increased it will cause more ICP) SIADH with normal lab values associated with this hyperkalemia and hyponatremia pt. glasgow coma scale of 14. what should the nurse do document the findings when caring for a client on a ventilator which finding shows the airway is open? bilateral breath sounds can be auscultated pt. is in the ICU after a colon resection. vitals are HR 135, temp 103, BP 88/65, urine output 10 mL/hr. intervention? give a 500 mL IV bolus challenge (another question similar with low BP and same answer) client with syncopal episodes due to 3rd degree block. receives transcutaneous pacemaker; several fails increase the sensitivity which of these drugs are the strongest for most effective vasodilators lidocaine mcg to mg; 4mcg/kg and client weighs 165 lbs 3.5 mL/hr female falls down a flight of stairs and is having trouble walking and bearing weight. prescription for hydrocodone for pain and an xray. intervention have the client take a urine pregnancy test pt. with chest tube has the tube dislodged from pleural space; intervention place an occlusive dressing with take on 3 sides postop client admitted to ED with intra-arterial cannula; heparin infusing at 2 units per mL. what finding indicates the heparin has achieved therapeutic use the IA remain patent pt. arrives to the ED with pain. description should prompt nurse to suspect an MI produces chest heaviness with left arm pain what equipment should always be made available at the bedside for a pt. with a chest tube occlusive dressing things should be done if an ET tube is in place chest xray chest rises and falls bilaterally auscultate breath sounds pt. comes in with severe hypotension. what medication should you expect a prescription for? amiodaron female has been asystole for 20 minutes and there has been no change in the client's condition; intubated; what should the nurse do talk to the family members in a private area about desire to continue life support 47 year old female that comes in and thinks they have indigestion due to vigorous workout. which problem has highest priority? decreased cardiac output EKG strip prepare the client for pericardiocentesis treated for MI that occurred less than 6 hrs ago; MD suspects 100% occlusion; what does the EKG show sinus bradycardia Q waves and ST elevation QRS lengthening list of vitals and patient will come in 2 hours after being in pain; what does nurse suspect the patient to have acute pancreatitis client has pneumothorax and has chest tube with NO fluctuation in the water seal assess lung sounds male falls 20 feet and the nurse observes it; client has no pulse begin CPR 120 per 1 min older woman pt. that feels very weak and is having a hard time breathing; leaning over while the nurse is doing assessment and cant keep head up; intervention keep the client in high fowlers client on a ventilator; intervention done so that the pt. doesn't develop VAP oral hygiene pt. getting an ET tube; MD has sedated the pt and the pt has soft restraints; intervention test to see if the pt is aggressive once the sedation has weened down trying to place an IV in pt that is confused and anxious; intervention notify MD for a restraint so that the pt. can get the IV they need what do you do prior to drawing from an arterial line allens test vitals related to acute pancreatitis; what should you monitor for cushings triad pt. diagnosed with acute pancreatitis admitted to ICU with temp 102, HR 138, RR 32, BP80/40. what to report to HCP hemorrhagic discoloration at the umbilicus pt comes in who was in a fire and the smoke was in her face; pt states they can not breathe; priority auscultate broncus (trach) pt is on ventilator and the vent is malfunctioning; intervention bag the pt. manually pt. is turning and the best tube falls out; what should the nurse tell the pt. to do? exhale forcefully and cough rapidly on admission client is septic due to a ruptured appendix; vitals of temp 39.8 , WBC 18,000, BP 68/42. what class of meds is needed vasoconstrictor list of lab values; normal sodium, elevated WBC, BNP 800 BNP 800 vent high alarm is going off; reason check for kink in tubing pt with basilar skull fracture has blood leaking from their nose and ears; intervention gently dab blood from ear with gauze and observe for Halo diclofenac; what to monitor with this med monitor BP septic shock drug used anti infective blood transfusion; blood must be hung within 30 min of arriving on the unit, obtain a baseline vital signs reasons for using only non-narcotics ask full explanation from interpreters cardiac tamponade notify MD to prepare pericardia video question regarding ampule wrap gauze pad around the neck 25 mEq/10mEq x 5mL 12.5 mL MRSA collect place cont school aged child hearing MI decrease smoking IV pump alarm clamp the IV tubing inhaler use spacer to use for this med dry nose water soluble lubricant infant phototherapy reposition every 2 hrs headache 142/89 admin lisinopril provide PRN acetaminophen ciprofloxine give with applesauce parkinsons disease worry about physical mobility 34 weeks gestation problem hematocrit 28% spinal cord injury never move the head or pt sickle cell anemia fluids, daily drinks U-wave ST 12 leads P level warfarin and diet in food avoid food rich in vitamin K 200 mg/250mg x 2mL 1.6 mL sequential compression device on both legs 1 day post op if pt is crying and confused encourage the family to stay with the patient positive fern test 37 weeks gestation, primigravida tied sheet around the client sitting in a chair mother of child with cerebral palsy brain damage with CP is not progressive class b felonies acute renal failure monitor PT cardiac activity blood urea blood urea nitrogen 35 poor feed and vomitting venticulcaperitoneal VP pacemaker permanent pacemaker inpatient acute care unit bowel obstruction volvulus low fiber diet turkey