PBDS Assessment| QUESTIONS WITH COMPLETE SOLUTIONS
Hypokalemia Assessment Correct Answer: Pain, LOC changes, BP/HR/RR- rate, depth, rhythm,
Breath sounds, monitor BMP, BUN/creatinine, stat EKG, I/O, AC/HS poor muscle strength/tone, slow reflexes, cardiac dysrhythmias, fatigue/weakness IV access, tele, bedrest, EKG
Hypokalemia interventions/anticipated orders Correct Answer: K+ IV infusion, K+ rich diet, HOLD diuretics/digoxin, STAT EKG for critical levels, treat underlying cause- antiemetics for N/V, antidiarrheal for diarrhea, monitor insulin levels in diabetics
Hypokalemia symptoms to report Correct Answer: MD STAT FOR CRITICAL VALUE Declining vital signs or change in breath sounds, critical lab values, abnormal EKG reports, LOC
changes
Pneumonia Assessment Correct Answer: Skin Assessment: fever, chills/rigors, sweats
Cough with or without sputum
Chest pain/pain assessment Dyspnea: use of accessory muscles/SOB Breath sounds- note crackles BP/HR/RR/SP02/T - monitor for fever or declining resp status O2, suction, IV access, HOB>30, IS, position changes, cough/deep breathe, cluster care, AAT-
encourage ambulation, vaccinations, smoking cessation
Pneumonia interventions/orders Correct Answer: ABGs, CXR, sputum culture, CBC
RT-breathing tx
Expectorants, bronchodilators, antipyretics, IV fluids, antibiotics
Pneumonia symptoms to report Correct Answer: LOC changes, declining respiratory status, abnormal VS or lab work, WBC count/T, test results
Hypoxia assessment Correct Answer: Breath sounds use of accessory muscles, BP/HR/RR/SPO2, LOC changes, pain, assess for JVD or tracheal deviation, monitor for resp distress, skin color, capillary refill, edema, patient positioning, nasal flarring MET, IV access, HOB >30, O2, decrease stimuli, tele, EKG, bedrest, possible mechanical ventilation, seizure precautions
Hypoxia interventions/orders Correct Answer: O2 monitor, ABGs, stat labs (CBC, BMP), pulmonary function tests, O2 STAT, treat underlying cause (blood culture, remove foreign body), possible bronchoscopy, smoking/narcotic education
Pulmonary Consult / RT @ bedside
Hypoxic symptoms to report Correct Answer: MD STAT
Hypokalemia Assessment Correct Answer: Pain, LOC changes, BP/HR/RR- rate, depth, rhythm,
Breath sounds, monitor BMP, BUN/creatinine, stat EKG, I/O, AC/HS poor muscle strength/tone, slow reflexes, cardiac dysrhythmias, fatigue/weakness IV access, tele, bedrest, EKG
Hypokalemia interventions/anticipated orders Correct Answer: K+ IV infusion, K+ rich diet, HOLD diuretics/digoxin, STAT EKG for critical levels, treat underlying cause- antiemetics for N/V, antidiarrheal for diarrhea, monitor insulin levels in diabetics
Hypokalemia symptoms to report Correct Answer: MD STAT FOR CRITICAL VALUE Declining vital signs or change in breath sounds, critical lab values, abnormal EKG reports, LOC
changes
Pneumonia Assessment Correct Answer: Skin Assessment: fever, chills/rigors, sweats
Cough with or without sputum
Chest pain/pain assessment Dyspnea: use of accessory muscles/SOB Breath sounds- note crackles BP/HR/RR/SP02/T - monitor for fever or declining resp status O2, suction, IV access, HOB>30, IS, position changes, cough/deep breathe, cluster care, AAT-
encourage ambulation, vaccinations, smoking cessation
Pneumonia interventions/orders Correct Answer: ABGs, CXR, sputum culture, CBC
RT-breathing tx
Expectorants, bronchodilators, antipyretics, IV fluids, antibiotics
Pneumonia symptoms to report Correct Answer: LOC changes, declining respiratory status, abnormal VS or lab work, WBC count/T, test results
Hypoxia assessment Correct Answer: Breath sounds use of accessory muscles, BP/HR/RR/SPO2, LOC changes, pain, assess for JVD or tracheal deviation, monitor for resp distress, skin color, capillary refill, edema, patient positioning, nasal flarring MET, IV access, HOB >30, O2, decrease stimuli, tele, EKG, bedrest, possible mechanical ventilation, seizure precautions
Hypoxia interventions/orders Correct Answer: O2 monitor, ABGs, stat labs (CBC, BMP), pulmonary function tests, O2 STAT, treat underlying cause (blood culture, remove foreign body), possible bronchoscopy, smoking/narcotic education
Pulmonary Consult / RT @ bedside
Hypoxic symptoms to report Correct Answer: MD STAT
