NSG 430 Exam 4
SATA: Risk Factors for Bacterial Infection
Select all that apply.• Diabetes Mellitus • Atopic dermatitis • Moisture • Obesity • Skin neoplasms All options are correct — All listed conditions compromise skin integrity or immunity, increasing infection risk.
SATA: Treatment for Lower Extremity Cellulitis — What Orders Do You
Expect?• Vancomycin 1000 mL • Elevate the extremity • Heat packs Vancomycin 1000 mL (antibiotic therapy) Elevate the extremity (reduces edema, promotes healing) Heat packs are not recommended — warmth can worsen inflammation or spread infection.
Multiple Organ Dysfunction Syndrome (MODS) from Cardiogenic Shock Which data indicates MODS?
- The patient‘s serum creatinine level is elevated.
- The patient reports intermittent chest pressure.
- The patient‘s extremities are cool and pulses are weak.
- The patient has bilateral crackles throughout lung fields.
- The patient‘s serum creatinine level is elevated.
This indicates renal dysfunction, a sign of MODS.
INR/PT Levels Doubled — What Do You Give? 1 / 4
Fresh frozen plasma Replenishes clotting factors rapidly when INR is dangerously high.
Post-Heart Surgery Pericarditis with Pain on Deep Breathing — Best PRN Med?
- Fentanyl 1 mg IV
- IV morphine sulfate 4 mg
- Oral ibuprofen (Motrin) 600 mg
- Oral acetaminophen (Tylenol) 650 mg
- Oral ibuprofen (Motrin) 600 mg
NSAIDs are first-line for pericarditis pain.
Chest Pain Suggestive of Myocardial Infarction (MI)?
- Pain increases with deep breathing
- Pain has lasted longer than 30 minutes
- Pain relieved with nitroglycerin
- Pain is reproducible on movement
- Pain has lasted longer than 30 minutes
Prolonged, unrelieved chest pain suggests MI.
Balloon Tamponade for Esophageal Varices — Priority Nursing Action?
- Instruct to cough every hour
- Monitor for shortness of breath
- Verify balloon position every 4 hours
- Deflate balloon if nauseated
- Monitor for shortness of breath — Could indicate balloon displacement or airway
obstruction.
Car Accident Patient on Warfarin — What to Report?Report regular warfarin use — Risk of intracranial bleeding after trauma.
Mechanical Valve Replacement — Discharge Teaching? 2 / 4
Need for long-term anticoagulation and regular INR/PT monitoring
Pyelonephritis — Which Symptom to Report First?
- Flank tenderness
- Blood pressure 82/60 mm Hg
- Cloudy, foul urine
- Temp 100.1°F
- BP 82/60 mm Hg — Suggests septic shock, priority concern.
Decorticate Posturing — What Do You Question?Consent for lumbar puncture — Sign of increased ICP; LP is contraindicated.
Acute Pancreatitis with Polyuria, Thirst, and Blurred Vision — First Action?Check blood glucose — May indicate hyperglycemia or DKA.
Early Signs of Hypoxemia in Anemia?Restlessness
Teaching During Physical Exam at Age 50?Colonoscopy — Screening for colorectal cancer.
TIPS Procedure — Indicates It Was Effective?Fewer episodes of bleeding varices
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SIADH — Expected Lab Finding?
- Weight gain
- Dyspnea
- Urine specific gravity 1.025
- Serum sodium 115 mEq/L
- Serum sodium 115 mEq/L — Severe hyponatremia is hallmark.
Evaluating Kidney Recovery from AKI — Most Useful Info?
- Urine output
- Creatinine
- GFR
- BUN
- Glomerular filtration rate (GFR) — Best indicator of kidney function.
Risk Factor for Gastritis?Use of NSAIDs
A1C Measures?Glucose control over the past 90 days
Fluid Resuscitation Effective for Burns?Measure hourly urine output
Septic Shock — After 2L NS, BP 82/40, CVP 10 — What Medication?Norepinephrine
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