Nurse Amy

The nurse caring for a patient with Addison disease suspects adrenal crisis when the patient exhibits: A. Hypertension and abdominal pain B. Confusion and tachycardia C. Bradycardia and nausea D. Widening pulse pressure and shortness of breath B. Confusion and tachycardia In drawing up a teaching plan for a patient with Addison disease, the nurse will include: A. discontinuing hormonal replacement therapy if the patient becomes nauseated or has diarrhea. B. Decreasing medication if the p...

. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response ANS: C Immunoglobulin E (IgE) ...

B ~ Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation. A client is in shock and the nur...

Nursing Plan for the patient with chronic bronchitis and emphysema Lowest FiO2 possible to prevent CO2 retention Monitor for signs and symptoms of fluid overload Maintain PaO2 between 55 and 60 Baseline ABGs Teach purse-lip breathing and diaphragmatic breathing Teach Tripod position Administer bronchodilators and anti-inflammatory agents Normal Blood gas pH in adults? Children? Adults - 7.35-7.45 Children - 7.36-7.44 Normal PCO2 blood gas 35-45 mmHg; same in adults and children Norm...

Nursing Plan for the patient with chronic bronchitis and emphysema Lowest FiO2 possible to prevent CO2 retention Monitor for signs and symptoms of fluid overload Maintain PaO2 between 55 and 60 Baseline ABGs Teach purse-lip breathing and diaphragmatic breathing Teach Tripod position Administer bronchodilators and anti-inflammatory agents Normal Blood gas pH in adults? Children? Adults - 7.35-7.45 Children - 7.36-7.44 Normal PCO2 blood gas 35-45 mmHg; same in adults and children Norm...

Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case The patient is hospitalized with pneumonia. Which dia...

"Pink puffers", barrell chest, pursed lip breathers, distant quiet breath sounds, wheezes, pulmonary blebs on radiograph- air trappings can explode next to each other and cause pneumothorax. Asthma assessment: Dyspnea, wheezing, chest tightness, assess precipitating factors, medication history. Compensation with COPD: ABG's are altered. As COPD worsens, the amount of O2 in blood decreased- hypoxemia, and the amount of CO2 in the blood increased-hypercapnia. This caused chronic respi...

A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap). ANS: D For an adult with ...

A male patient is brought into the emergency department with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority? A. Guard locked access doors. B. Maintain patient safety from revenge. C. Maintain personal and work place safety. D. Attain open patient airway and breathi...

Leg injury of surgery injury or surgery that blocks the flow of blood through a vein can increase pressure Excess weight or weight gain The added weight of pregnancy or obesity can increase pressure in the veins of the legs and damage the veins and valves Standing or sitting for too long Prolonged periods without walking can decrease the movement of blood out of the legs and lead to increased pressure in the veins and pooling of blood -- thats because the muscles in the legs play an i...

Peritonsillar abcess "Quinsy" Collection of purulent exudate between the tonsillar capsule and surrounding tissues. LIFE THREATENING. inability to open mouth. medical emergency Laryngitis inflammation of the larynx. voice abuse, hoarseness, severe cough, Obstructive sleep apnea (OSA) recurrent episodes of upper airway obstruction; cessation of breathing during sleep. s/s: waking abruptly with loud snore; cessation longer than 10 secs Epistaxis Nosebleed; caused by tiny vessels in th...

Put them on a non-rebreather mask at 15L What would you do if your patient is breathing 6x per minute and pulse ox is 60%? - use a bag valve mask - prepare to intubate Low-flow oxygen delivery systems Does not provide enough flow to meet total oxygen and air volume - nasal cannula - simple face mask - partial/non rebreather mask Nasal cannula - 1-6 liters - 24-44% - assess patency of nostrils - most people cannot handle a nasal cannula, so they use a simple face mask Simple facemas...

Disease state characterized by progressively increased airflow obstruction that is NOT reversible Onset of symptoms is slow Includes diseases that cause airflow obstruction (emphysema - destruction of alveoli, Chronic Bronchitis - inflammation of conducting air tubules) Must be coughing daily for at least 3 months Decreased breath sounds on exhalation *Common feature in all COPD (whether emphysema, chronic bronchitis) = airflow obstruction Pathophyisology of COPD Airflow limitation is p...

Establish a communication mechanism w/the client Keep airway clear by coughing and suctioning When examining a client with emphysema, what physical findings is the nurse likely to see? Barrel chest cough (dry or productive) decreased breath sounds dyspnea crackles in lung fields What is the most common risk factor associated with lung cancer? smoking Describe the preoperative nursing care for a client undergoing a laryngectomy. -Involve family and client in teaching on tracheostomy eq...

An older female client recently moved to an assisted living facility. The family explains to the registered nurse (RN) that the client is unmanageable and always confused, disoriented and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond? A. Explain that she is in a new home called an assisted living community B. Question the client about her perception of where she might be now. C. Distract the client with a scenario that she is on an outing with he...

A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose of benztropine mesylate (Cogentin) PRN. B.Determine if the client has increased photosensitivity. C.Provide comfort measures for sore muscles. D.Assess the client for visual and auditory hallucinations. A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and mask...

A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse "Please let me go I must leave because the secret police are after me." which is best for the nurse to make? A. No one is after you. You are safe here B. You will feel better after you have rested C. I know you must feel lonely and frightened D. Come with me to your room and I will sit with you Come with me to your room and I will sit with you A...

Tachycardia. Increased blood pressure. Rapid resolution of wheezing. Correct Improved pulse oximetry values. Correct Reduce fever airway inflammation. Beta 2 receptor agonist agents should provide immediate return of airflow and resolve wheezing and improve oxygenation. A client prescribed atenolol has a blood pressure of 120/68 mmHg, displaying a sinus bradycardia with a rate of 58 beats/minute, and a P-R interval of 0.24. Which action should the nurse take? Lower the head of the bed...

Congenital heart disease is the most common associated defect in children with Down syndrome. Trisomy 13 my have seemed possible since Down syndrome is a trisomal chromosomal abnormality o chromosome 21. Fragile x-chromosome is a sex-linked abnormality also causing mental retardation. Pyloric stenosis is not associated with Down syndrome. When assessing a child with asthma, the nurse should expect intercostal retractions during A. inspiration B. coughing C. apneic episodes D. expirati...

After talking with the healthcare provider, a male client continues to have questions about the results of a prostatic surface antigen (PSA) screening test and asks the nurse how the PSA levels become elevated. The nurse should explain which pathophysiological mechanism? A. As the prostate gland enlarges, its cells contribute more PSA in the circulating blood. B. The PSA levels normally rise and fall, so multiple testings over time are necessary. C. Low PSA levels indicate that the prosta...