Nurse admits patient to med surg unit. Resp rate
of 38. Patient using chest muscles to breathe,
pulse ox of 87 on room air, pink frothy sputum. Patient has SOB, edema in legs and face and
What intervention would you implement first? - has the following labs: BUN-95 (high), Creatinine
ANSWER -O2 at 2 Liters/Min of 9.2, Potassium of 6.0 (high). What are you
going to do - ANSWER -Give Kexolate,
prepare the patient a central line for dialysis.
Caring for pt. who is intubated and receiving Cardiac monitoring.
mechanical ventilation. What action by the nurse
would decrease the patient's incidence of
developing ventilator associated pneumonia? - Working with a UAP, what task can be
ANSWER -Put head of bed at 30-45 delegated? - ANSWER -Instill non-
degrees. prescription eye drops in patient's eyes.
The nurse is administering acetylcysteine (muca- Nurse is caring for patient who had total knee
mist) as nebulizer treatment to patient. Which replacement yesterday. Patient up in chair stating
should the nurse have available for adverse he feels good. Pain is 3/10. Resp. 16, pulse is 75,
effect on the patient? - ANSWER -Suction bp is 110/78. Pulse ox 88 reading is after
equipment incentive spirometer. What actions would you
take at this time? - ANSWER -Move pulse
ox to another finger on the other hand and
Patient coming in with SOB and resp. rate of 32. recheck.
ABG results PH 7.3 (acid), Co2-50 Bicarb-28,
PO2-70
Resp. Acidosis, what orders do you anticipate Vancomycin - ANSWER -Nephrotoxic
carrying out? - ANSWER -Apply O2 and (meaning it can really damage the kidney's) and
give med-neb treatment. Ototoxic (temp. hearing loss) Can be given IV,
orally, or via enema. pharmacy is usually
involved with this medication.
You have 4 patients in a long term care facility.
Which would you check first? - ANSWER -
COPD patient with resp rate of 30, O2 of 87 and Lomotil - ANSWER -mix of 2 different drugs
on 3 Liters of O2 complaining of dyspnea. (atropine-can dry up fluids or for bradycardia &
diphenoxylate can raise the BP/HR and lower the
urinary output). Monitor BP and HR. Monitor
Caring for newly intubated patient getting urinary output.
mechanical ventilation. Pt.'s wife was not at
hosp. when this occurred. Wife appears angry
and states "What have you all done to him?" Caring for patient with hx of diarrhea. Weight
What would be your response as a nurse? - loss, bloating, run labs on them. Which to report
ANSWER -Explain to the patient why the potassium-5.1 WBC 10.8 Sodium 146 Hgb-9.1. ?
patient had to be intubated, continue to update - ANSWER -HgB
patient's wife on condition and plan of care, I'm
sorry that you walked in on him like that, I
understand this must have been very frightening. Patient with dx of colorectal cx. Colostomy
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