2024/2025
Acute abdomen and its complication
nursing assessment related to topic - ANSWERSHistory:type of pain, nature and onset of pain, location,
quality (sharp, dull, crampy) changes in bowel habits, Hx of trauma, gynecological Hx, anorexia, malaise,
tachycardia, hypertension, fever, nausea/vomiting, inspect- look, listen, feel abdomen
Acute abdomen and its complication
priority nursing interventions and rationale - ANSWERSGive pain meds, keep patient quiet, assess for
trauma, treat trauma if indicated
Acute abdomen and it complication
data to report to physician - ANSWERSPain: level, location, quality, duration, onset, time, change, bowel
habits, blood pressure, temperature, respiratory status, pulse, N/V, last menstrual period, trauma
findings if indicated
Acute abdomen and its complication
orders anticipated physician - ANSWERSPain meds, NPO, labs, IV fluids, NG suction, antiemetics,
narcotics and or analgesics, surgical consultation
Acute abdomen and its complication
misc. info (labs and meds) - ANSWERSCBC, urinalysis, pyuria, hematuria, glucosuria, ketones, serum
lipase, serum HCG, serum electrolytes and glucose, gonorrhea & chlamydia, if over 40 EKG, KUB, chest x-
ray, abdominal CT, guaiac
CHF and its complication
nursing assessment findings and related to topic - ANSWERSAuscultate lung fields & heart sounds, blood
pressure, temperature, pulse, history, recent weight gain, activity limits, sleep pattern, edema
, CHF and its complication
priority nursing interventions with rationale - ANSWERSO2, raise head of board, IV access, cardiac
monitor, pulse oximetry, antiembolism stockings
CHF and its complication
data to report to physician - ANSWERSBP, respiratory status, pulse, recent weight gain, activity limits,
sleep pattern, current medications, edema
CHF and its complication
orders anticipated from physician - ANSWERSO2, ECG, chest x-ray, ABG's, cardiac monitor, diuretics,
potassium, labs- electrolytes, BUN & creatinine, BNP, cardiac enzymes, echocardiography
CHF and its complication
misc. info ( labs and meds) - ANSWERSLabs: respiratory alkalosis, increased creatinine if severe, changes
in pulmonary artery wedge pressure, meds: diuretics, digoxin to improve contractility, ACE inhibitor to
decrease afterload, Beta blockers, vasodilators to decrease preload, afterload, and systemic resistance
Diabetic Ketoacidosis and its complication
nursing assesment - ANSWERSdehydration,hypotension, hyper tension, tachypnea, N/V, abdominal pain
& tenderness, LOC, cardiac changes, history
DKA and its complication
intervention with rationale - ANSWERSmonitor I&O's, replace fluid as ordered, monitor glucoses,
monitor cardiac monitor, NPO, provide reassurrance bed rest
DKA and its complication
data to report to physicain - ANSWERSBlood sugar, LOC, cardiac changes, respiratory status, pain level,
location, etc, BP, temp, pulse, N/V
DKA and its complication
orders to anticipate from physician - ANSWERSLabs: serum glucose, electrolyte, BUN, urinalysis, CBC,
ketones, serum osmolarity, ABG's, CT- head if mental status altered, intubation if comatose, IV NS