Critical Care HESI 2

Early signs of cerebral hypoxia Restlessness and irritability Necessary for Blood Product infusions 18-19 gauge needle with filter tubing NS only run with blood within 30 minutes of hanging Check vitals before infusing, at 15 minutes, 30 minutes, then every hour, and directly after Checking blood before infusing 2 RNs Check order (expiration date, clots, color, air bubbles, leaks) patient, product, previous transfusion Hx Premedicate with Benadryl for previous rxn What does the PR interval represent Time required for the impulse to travel from atria through the AV node Isotonic solutions D5W NS Lactated ringers Tracheostomy Keep Kelly clamp and obturator at the bedside To assess CVA for hemorrhagic or ischemic CT scan first Heart conditions related to thrombus formation A-fib and A-flutter Aphasia, agraphia, slow, cautious, anxious, memory ok Left hemisphere lesion Cannot recognize faces, loss of depth perception, impulsive behavior, poor judgement, constant smile, loss of tonal hearing Right hemisphere lesion Most important indicator of increased ICP Change in LOC Spinal shock Complete loss of all reflexes If the U wave is most prominent what condition hypokalemia Burns First degree- epidermis {superficial} Second degree- epidermis and dermis {deep partial} Third degree- epidermis, dermis, and subQ {full thickness} Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes telemetry pattern shows second degree heart block with Ventricular rate of 50. Action Hold scheduled dose and notify HCP of telemetry pattern Nurse is reviewing client ECG and determines PR interval prolonged. Indicates Increased conduction time from the SA node to the AV junction When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on right side only. Action Reposition the depth of the ET tube ..........