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A nurse is admitting a client who sustained a C3 spinal cord
injury. Which of the following findings should the nurse
recognize as the priority of care?
1. Heart rate 52/min.
2. Respiratory 10/min (CORRECT)
3. Temperature 36 C (98.8 F)
4. Blood pressure 88/54 mm Hg - Correct Answers
✅Instructor: "I would like to point out with BP! When the
blood pressure is below 100 systolic you want to think in the
back of your mind -this client could be in shock. The majority
of client are 100 or grater. There are some elderly who can
have less than 100 that is their normal.
What is conceptual learning in nursing? (ati) - Correct
Answers ✅Conceptual learning encourages students to
build upon current knowledge and familiar experiences, relate
these experiences to learning new material, and integrate
new learning into clinical practice.
A nurse is assisting in developing the plan of care for an older
adult client who is to receive a unit of packed red blood cells
(RBCs). Which of the following actions should the nurse
recommend? - Correct Answers ✅✅ Verify the information
on the packed RBCs with another nurse
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The nurse should verify the information on the label of the
packed RBCs with another nurse. She should also verify the
information on the label with the provider's order, the blood
administration form from the blood bank, and with the client
armband and blood bracelet.
✅ Infuse the packed RBCs over 4 hr The nurse should
administer packed RBCs slowly to allow the older adult
client's body time to adjust to the increased fluid volume. The
blood should be infused over 4 hr .Allow the packed RBCs to
warm at room temperature for 1 hr before starting the
transfusion.
✅ The nurse should start the blood within 30 min after
arriving on the unit, to decrease the risk of bacterial growth.
A nurse is contributing to the plan of care for a client who has
pernicious anemia. Which of the following interventions
should the nurse recommend? - Correct Answers ✅Initiate
weekly injections of vitamin B12.
The nurse should recommend that weekly injections of
vitamin B12 be initiated for a client who has pernicious
anemia, and then decrease to monthly. Pernicious anemia is
caused by a lack of intrinsic factor needed to absorb vitamin
B12 from the gastrointestinal tract.
No metformin while pregnant! - Correct Answers ✅If mom
was on metformin, she will be off of metformin because
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metformin does not go into baby. Baby would come out super
high!
So she she starts on insulin sliding scale before meals and
bedtime. But her baby is going to have some issues. First off,
she goes hypo and hyperglycemic. Baby has more anomalies,
meaning might have limb problem, might have an organ
problem, more miscarriages, more fetal death.
Ex: macrosomia. A 120 - pound mom delivers an 11-pound
baby. That is not atypical for diabetic, cause that baby had a
lot richer source of sugar going on.
Cardiac Disease in Pregnancy - Correct Answers ✅Women
who have cardiac issues can still have a baby. The baby is
IUGR (intrauterine growth restriction). It's a tiny baby. Mod
doesn't circulate well, so why would we think baby would
circulate well? He may come out at 4 pounds and be full-
term. Mother has to take medicines, but they'll be modified.
Propranolol will not hurt the baby. Heparin will not hurt the
baby (No Warfarin!) . And Digoxin will not hurt the baby.
These are things that'll help mom maintain her cardiac
problems. She might even take prophylactic penicillin to
make sure she doesn't have difficulties. She is high-risk
automatically if she lives with cardiac diseases. Remember,
this is one of those acute-over-chronic things. During the
delivery, the acutes thing is the delivery. She lives with the
chronicity of having a heart problem.
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In the second stage of labor, please know that's the pushing
stage. So she has to have her head up. She can't breathe.
Think of what lithotomy position is - the woman down with
the legs and hip up, ready fo the baby to be caught by the
doctor. Well, guess what? This might be when the lady gets to
sit up like this, and the doctor's on a little chair down there,
or the midwife, because she can't breathe if you put her in
lithotomy. HOB is head of bed - up !
A nurse arrives at a work site explosion. Which of the
following clients should be triaged first? - Correct Answers
✅1. A client who has a closed fracture reporting "a pain level
of 3",
2. A client who has fixed pupils and agonal respirations.
3. A client who has burns to face with respiratory stridor.
4. A client who has type 2 diabetes mellitus who is
disoriented
Rationale : In an explosion you see hot vapor that is breathed
in: there are burns on inside of throat
Use-SURVIVAL POTENTIAL: Possible to have respiratory burns
as well
#2 has who has fixed pupils and agonal respirations
(2gasps /min).=brain injury, will have black tag #4 will be
yellow tag, they will be next to help (30min-2hour); #1 will be
green tag (will help to evacuate).