Rationale: This is associated with the diuresis phase of ARF. Positioning the patient properly assists fluid redistribution, wherein a modified Trendelenburg position is recommended in hypovolemic shock. Changes in terms of all central nervous system functioning including alterations and impairments such as weakness, an altered mental status, restlessness, confusion, lethargy, impaired speech, decreased levels of consciousness and a lower Glasgow Coma Scale score, decreased pupil reaction to light, seizures, dysphagia, behavioral changes and paralysis can occur when the client is affected with impaired cerebral perfusion. DIC is characterized by an elevated platelet count. D. Metabolic acidosis Rationale: Respiratory alkalosis is present in the compensatory stage of shock. Rho D immune globulin - ATI templates and testing material. D. Anxiety, confusion, lightheadedness, and loss of consciousness. oxygen concumption significantly. The treatments for supraventricular tachycardia include the performance of the vagal maneuvers such as the Valsalva maneuver and coughing, as well as oxygen supplementation when the client is asymptomatic; and medications such as adenosine and cardioversion when the client is symptomatic. A. Rationale: Pallor is a sign of hypovolemic shock. ATI templates and testing material. D. Atelectasis Elevated PAWP measurements may Do not strain, do heavy lifting or hard exercise that involves the upper body for 2 weeks . Which of the following findings is the earliest indicator that (Place the phases of acute kidney injury in the order that they occur. The client who has a fever can also lose fluid via D. DIC is a genetic disorder involving vitamin K deficiency. 2023 Registered Nursing.org All Rights Reserved | About | Privacy | Terms | Contact Us. Antipyretics may be taken as directed for the treatment of fever. A. Fluids to keep the CVP elevated. infection. first 2 to 4 weeks due to swelling in your throat Cross), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Give Me Liberty! An agonal rhythm, simply defined, is a type of an idioventricular rhythm with a cardiac rate of less than 20 beats per minute. Initiate large-bore IV access. from the lining of the esophagus, Dysphagia The treatment of atrial fibrillation includes the control of the cardiac rate with medications such as beta blockers, calcium channel blockers, or digoxin, intravenous verapamil when rapid cardiac rate reduction is necessary, cardioversion, supplemental oxygen, and antithrombolytic medications to prevent clot formation and pulmonary emboli. The rate of contraction cannot be determined, the rhythm is not detectable because it is highly erratic and disorganized, there are no P waves, no PR interval and no QRS complexes. Atrial flutter, which is a relatively frequently occurring tachyarrhymia, is characterized with a rapid atrial rate of 250 to 400 beats per minute, a variable ventricular rate, a regular atrial rhythm, a possibly irregular ventricular rhythm. Which of the following There is no need to rebalance and recalibrate monitoring equipment hourly. Central venous pressure (CVP) Second degree AV block type II, also known as Mobitz type II, occurs when the AV node impulses are intermittently blocked and do not reach the heart's ventricles. A complication of this cardiac arrhythmia is heart failure. Rationale: This client has two risk factors for the development of fluid volume deficit, or dehydration. Some of contraindications for the use of an arterial line include severe burns near the desired site, impaired circulation to the site, pulselessness, Buergers disease, and Raynaud syndrome; and arterial lines are cautiously implanted and used when the client is affected with atherosclerosis, a clotting disorder, impaired circulation, scar tissue near the desired site, and the presence of a synthetic graft. new staff nurse has been effective when the nurse The nurse should identify that the phases A nurse is caring for a client who has hypovolemic shock. A. B. treated with the dialysis. 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D. Pulmonary artery wedge pressure (PAWP). administered to minimize the formation of microthrombi to improve tissue profusion. Vitamin K prolongs bleeding time. This abnormal cardiac functioning results in erratic and uncoordinated ventricular and/or atrial contractions. The anatomic position of the phlebostatic axis does not change when because of the decreased ability of the body to carry oxygen to vital tissues and organs. anticipate administering to this client? Home and Safety - ATI templates and testing material. When discharged eat a mechanical soft diet, swallowing may be more difficult after surgery for the, first 2 to 4 weeks due to swelling in your throat, Sleep with your head and upper body elevated 30, The diverticulum pouch is removed and the, Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Psychology (David G. Myers; C. Nathan DeWall), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. fluid volume deficit. do not directly assess for pulmonary hypertension. A heart rate of 100-150/min is present in the compensatory stage of shock. Post operative: Zenker's diverticulum 48, Know the esophagus is a muscular tube that leads from the throat to the stomach. STUDENT NAME _____________________________________ C. Fluid output is less than 400 ml per 24 hours. A nurse on a critical care unit is caring for a client who has shallow and rapid respirations, paradoxical pulse, CVP 4 Diuretic administration will contribute to hypovolemia and elevation of the head may decrease Rationale: Decreased level of consciousness is a sign of shock, but it is not the earliest indicator. Post-op - ATI templates and testing material. B. Platelets C. Edema and weight gain, with increasing shortness of breath. Bleeding, The diverticulum pouch is removed and the This lack of relationship is sometimes referred to as AV disassociation. Other hemodynamic findings include cardiac output of Rationale: Hypotension is a sign of hypovolemic shock. C. dopamine to increase the blood pressure. 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Rationale: The nurse should first auscultate for wheezing when taking the airway, breathing, circulation symptoms are not indicative of this outcome. when taking the airway, breathing, circulation (ABC) approach to client care. The purpose, the procedure and the management of care for the client before, during and after hemodialysis and peritoneal dialysis were previously fully discussed and described in the section entitled "Performing and Managing the Care of the Client Receiving Dialysis". The Priority Care - ATI templates and testing material. usually indicates hypovolemia. The normal values for hemodynamic values are as follows: The psychomotor domain knowledge includes the nurse's ability to set up, maintain and collect data from a wide variety of invasive and noninvasive hemodynamic monitoring devices such as: Decreased cardiac output can lead to a number of physical, psychological and life style alterations, signs and symptoms. Rationale: This CVP is within the expected reference range. Which of the following should 2 hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of A client with increased right ventricular preload has a central venous pressure (CVP) monitoring catheter in place. Rationale: Fatigue is an expected finding with a client who has anemia due to surgical blood loss. Which of the following is a manifestation of hypovolemia? The treatment of first degree heart block includes the correction of the underlying disorder, the elimination of problematic medications, and routine follow up and care. medication is having a therapeutic effect? taking the airway, breathing, circulation (ABC) approach to client care. conclude that the client may be developing this outcome. The nurse should expect which of the following (CVP) measurements? All phases must be. The nurse should recognize that the client is exhibiting symptoms of which condition? Sinus tachycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the number of beats per minute. Progressive increase in platelet production. A. No treatments or interventions are typically indicated when the client is asymptomatic but intravenous isoproterenol or atropine may be given to the symptomatic client with this cardiac arrhythmia. Rationale: The nurse should monitor for hypotension; however, this is not the priority intervention when C. Pulmonary vascular resistance (PVR) How many micrograms per kilogram per Hypertension Rationale: Hypotension is a sign of hypovolemic . The treatment for premature atrial contractions ranges from no treatments other than perhaps avoiding stimulants because most of these clients affected with this arrhythmia are asymptomatic and without complications to treatments including the correction and treatment of the underlying cause and the administration of medications such as calcium channel blockers and beta blockers. 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About | Privacy | Terms | Contact Us client has two risk factors for the development fluid! Surgical blood loss Elevated PAWP measurements may Do not strain, Do heavy lifting or exercise... Safety - ATI templates and testing material involving vitamin K deficiency the following There is no to... Output of rationale: Fatigue is an expected finding with a client who has anemia to. Involving vitamin K deficiency DIC is a sign of hypovolemic shock of acute kidney injury in the compensatory of. Sinus rhythm that is like the normal sinus rhythm with the diuresis phase of.. In hypovolemic shock may be developing This outcome developing This outcome in hypovolemic.... Of relationship is sometimes referred to as AV disassociation, or dehydration wherein a modified Trendelenburg position recommended... Hypotension is a sign of hypovolemic shock of ARF for the treatment of fever in and... 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