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Patient Review Asses

Patient Review Assessment Performance

QuestionAnswer
Which of the following assessment findings are consistent with volume depletion with dehydration? - Capillary refill time greater than 3 seconds - Sinus tachycardia - Weak peripheral pulses (+1) - Dry skin with poor turgor - BP 80/45 - Oliguria
Anticipating fluid replacement for Mrs. Wilson, which IV solution do you prepare? Isotonic saline
Assessing for signs of fluid overload is important. Which of the following assessment findings could occur as signs of fluid volume overload? - S3 heart sound (ventricular gallop) on cardiac auscultation - Fine crackles auscultated at lung bases - Decreased oxygen saturation by pulse oximeter (SpO2)
Which of the following characterizes fluid shift when serum osmolality is elevated? Water moves from the intracellular fluid (ICF) to the extracellular fluid (ECF)
Fluid replacement and insulin will be important treatments for Mrs. Wilson. Insulin will be administered IV. Which type of insulin should you have available for IV use? - Regular insulin
You observe a focal seizure that starts in Mrs. Wilson's right hand. Which of the following characterizes a focal seizure? Spasmodic movement confined to a specific body part
Which of the following actions on your part is indicated in response to the order for Dilantin (phenytoin sodium)? Question the order for Dilantin (phenytoin sodium)
Nursing interventions designed to prevent injury from seizures include: - removing potentially injurious objects away Mrs. Wilson's immediate area -keeping suction equipment available - padding of Mrs. Wilson's side rails
You know that Mrs. Wilson is being intubated to: preserve her airway
Mrs. Wilson's low values for cardiac output and cardiac index are probably due to inadequate: - preload
Mrs. Wilson's daughter asks about her mother's prognosis. Although the physician is better prepared to discuss this with her, you are aware that: hyperglycemic hyperosmolar state (HHS) is life-threatening, with a significant mortality rate
Nursing care of Mrs. Wilson must address numerous problems. These include: - Deficient Fluid Volume - Risk for Aspiration
Ongoing assessment of Mrs. Wilson is important. Which of the following evaluation criteria would indicate a positive, successful outcome to fluid resuscitation? - Urine output of 100 mL per hour - Right atrial pressure (RAP) of 6 mm Hg (earlier reading 1 mm Hg) - Cardiac output (CO) of 5 L/minute (earlier reading 3 L/minute) - Serum osmolality of 300 mOsm/kg H2O (earlier value 365 mOsm/kg H2O)
Interventions aimed at identifying/preventing deep vein thrombosis (DVT) include: - graduated compression stockings - passive range of motion exercises to the extremities - frequent assessment of the lower extremities for warmth, tenderness, and swelling - frequent assessment of peripheral pulses
At 3 PM, Mrs. Wilson's cardiac monitor alarm sounds. Her ECG waveform indicates: ventricular fibrilation
The definitive treatment required for a successful outcome at this time is: defibrillation
A defibrillator is in the ICU but not readily available at Mrs. Wilson's bedside. What should you do? Begin cardiopulmonary resuscitation (CPR) but defibrillate Mrs. Wilson as soon as the defibrillator arrives at the bedside
Mrs. Wilson's daughter is present when she "codes." As a patient/family advocate you: encourage the code team to allow her to stay in the room
Created by: Brandi Sizemore
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