line manager = charge nurse, supervisor
“mistakenly or accidentally”
“incident report completed” reports then become part of the pt’s chart. instead write “physician noted”
don not write “I” when charting. instead write ” this”
skin: dark bronze
urine: dark color
hemoglobin: 9 g/ dl (low)
RBC: 2.75 million (low)
-decreased in osmolarity
-decrease in body weight and edema
nurse should wear gloves, mask, and eye protection during suctioning. apply a mask to face for transport
•First, cortisol and ACTH levels are drawn at baseline. Next, the nurse administers synthetic ACTH, I.V. Finally, cortisol and ACTH levels should be drawn at 30 minutes and 60 minutes after ACTH administration.
•ACTH stimulation test is used to assess the adrenal glands response to stress. This is used to help diagnose or exclude Addison’s diease and adrenal insufficiency.
-reduces BP and HR
-reduces anxiety and fear
2. ease the child to the floor
3. clear the area of potentially harmful objects and pad the head
4. roll the child to the side
1. Active TB
2. Had contact with Mycobacterium tuberculosis
A positive PPD test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists.
2. Monitor the client’s blood pressure
4. Keep the client NPO.
Because hypotension is a complication of peritoneal dialysis, the nurse records intake and output, monitors VS, and observes the client’s behavior.
It can develop into ventricular fibrillation at any time.
Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Client’s frequently experience a feeling of impending death. Ventricular tachycardia is treated with antidysrhythmic medications or magnesium sulfate, cardioversion (client awake), or defibrillation (loss of consciousness), Ventricular tachycardia can deteriorate into ventricular defibrillation at any time.
B: Diabetic nephropathy
C: Autonomic neuropathy
D: Somatic neuropathy
can cause inability to urinate
Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.
relief of chest pain is a priority in myocardial infarction. Pain increases cardiac workload and may lead to shock. Morphine sulfate is the drug of choice.
-hyperventilate the client
-administer stool softener
DO NOT elevate the head with 2 pillows and DO NOT keep the client well hydrated
nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance
it guides the physician in determining fluid management for the client.
infants under GENERAL anasthesia have decreased or absent reflexes.
1. Temperature 97.6°F (36.5°C).
2. Apical pulse 140 bpm.
3. Respirations 18/min.
4. BP 80/50
magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min
STOMATITIS- irritation of the mucous membrane
DYSGEUSIA- diminished taste
1. canned peaches 2. white rice
3.black beans 4. whole grain bread
5. tomato juice
WHOLE GRAIN BREAD
blood clots that commonly drain from the bladder after TURP can block the drainage system. Irrigating the catheter will flush out the clots and allow urine and irrigating fluid to drain.
“I WILL KEEP A RECORD OF MY CHILD’S TEMPERATURE UNTIL SHE HAS NO FEVER”
A. The client lost 2 pounds
B. The client’s K level is 4meq/L
C. The client’s urine output was 1500 cc in five hours
D. The client is to receive another dose of Lasix at 10pm
bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one its purposes, removing air from the bubble space. continuous bubbling during inspiration and expiration indicates that an air leak exists. if this occurs, it must be corrected.
1. Furosemide (Lasix) 20 mg IV every 12 hours.
2. 2 g/day sodium diet
3. Normal saline at 125 ml/hour IV.
4. Oxygen at 2 L per nasal cannula
because the patient may have excess fluid volume, may be on fluid volume restriction; weigh daily and measure I and O
appropriate order; loop diuretic that promotes the excretion of excess water; decreases blood volume and pressure in the left ventricle
1. Clamp off the lumen and label it as “clotted off.”
3. Aspirate blood from the lumen to restore patency.
4. Secure the lumen with a Luer-Lock cap and notify the physician.
streptokinase may be used to dissolve clot; if unsuccessful, lumen is labeled as clotted off
(1) should be reported to the physician to see if patency can be re-established before it is labeled as clotted off
(2) force should never be used to irrigate the catheter
(3) blood should not be aspirated from the catheter
A. Report weight and appetite changes.
B. Wear sunglasses to prevent cataracts.
C. Schedule to take the flu vaccine
D. Take medication 30 mins before eating
Polycythemia vera is a bone marrow disease that leads to an abnormal increase in the number of blood cells. The red blood cells are mostly affected.
A child with myelomeningocele
B child with coxa plana
C child with rheumatic fever
D child with epispadias
This is due to all the surgeries and dressing changes that will occur.
1. A client with a new tracheotomy with a small amount of serosanguineous drainage on the dressing.
2. A client who is responsive with a moderate amount of clear fluid draining from the NG tube.
3. A client with a chest tube and dark red drainage in the collection chamber.
4. A client who is unresponsive to verbal stimuli with the oral airway out of place.
Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles
1.Sensation of palpitations
2.Causative factors, such as caffeine
3.Precipitating factors, such as infection
4.Blood pressure and oxygen saturation
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.