Nurse Amy

. 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...

Maintain a dry occlusive dressing, keep tubing tight and taped, monitor clinical status, encourage deep breathing, monitor drainage and mark fluid level. What do you do when a chest tube disconnects from water suction? place tube in a sterile water container to reactivate seal and tell the HCP. What do you do when a chest tube comes out of the patient? Apply occlusive dressing, taped on only 3 sides, and tell the HCP STAT. What instructions should be given to a client after radiation ther...

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 ...

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...