A 38 year old female client was admitted 3 days ago with severe
abdominal pain, fever, and nausea. She was diagnosed with a
small bowel obstruction and received general anesthesia
yesterday during an exploratory laparotomy to remove
adhesions. According to admission documents, the client has a
29 pack-year smoking history as well as chronic obstructive
pulmonary disease, for which she takes fluticasone and
albuterol; endometriosis, for which she takes ibuprofen and oral
contraceptives; and a BMI of 36. The client lives alone and
works at a telecommunication call center. The shift report
indicated that the patient had a difficult recovery after surgery
and has been on bedrest since admission. Initial shift assessment
findings are listed below. Which findings call for immediate
follow up by the nurse?
-Dry unproductive cough
-Abdominal incision approximated/healing
-Right lower extremity edema
-Left leg cooler than rig Correct Answers -Right lower
extremity edema
-Left leg cooler than right leg
-Reports pain in right calf
anaphylactic shock Correct Answers -A severe reaction that
occurs when an allergen is introduced to the bloodstream of an
allergic individual. -Characterized by bronchoconstriction,
labored breathing, widespread vasodilation, circulatory shock,
and sometimes sudden death.
-airway closes/overproduction of histamines
, -give EPI or intubate, provide
fluids/antihistamines/steroids/vasopressor therapy
Anaphylactic Shock is commonly treated with... Correct
Answers -infusion of fluids
-antihistamines
-steroids
cardiogenic shock Correct Answers A state in which not
enough oxygen is delivered to the tissues of the body, caused by
low output of blood from the heart. It can be a severe
complication of a large acute myocardial infarction, as well as
other conditions.
-heart is unable to produce efficient cardiac output, treat with
meds to
improve contractility, preload/afterload reducers
Cardiogenic shock is best described as . . Correct Answers
extreme heart failure
Case #1
Mr. Antonio is a 27 year old male landscaper is brought to the
ED after collapsing on the job at a local country club. The
weather has been very hot. He is slightly confused, but is able to
tell you he feels dizzy and weak and doesn't understand it
because he had such a good time dancing at the club last night.
He has poor skin turgor and dry mucus membranes. Correct
Answers -Recognize clues: collapsed, slightly confused, able to
say he feels dizzy/weak, poor skin turgor, dry mucous
membranes