N480 Final Overview Patient arrives at emergency dep with deep partial thickness burns RR; 26 bpm, nursing interventions SATA - IV LR - Admin morphine IV - Admin tetanus prophylaxis as ordered Low pressure alarm sound of vent, nurse assess and tries to determine the cause. Unsuccessful at determining and takes what action - Ventilate the client manually Client admitted to ED with chest trauma. S/S that support pneumothorax - Absent breath sounds - Tachypnea Nurse assessing cranial nerves, what could detect potential problem with cranial nerve 2 - Snellen chart Nurse performing assessment and finds client has cool clammy skin P: 130, urine output of 20 ml per hour - Decreased cardiac output and decreased tissue perfusion Vitals of client with cardiac disease BP 104/76, P 53, RR 16. Atropine administered. What is therapeutic effect of med - Pulse rate increases to 76 bpm Older adult client comes to ED with no appetite, N/V, on digitalis for more than a year, nursing action - Obtain ECG, K+, and digoxin levels Nurse admin atiplase tpa with pt with diagnosis of acute coronary syndrome. What is important implementation - Place the client on bleeding precautions (atiplase is clot buster) Nurse caring for client with cardiac cath 1 hour ago, nursing action - Maintain pressure over catheter site and maintain circulation status Nurse determines that client with diabetes is experiencing fat breakdown. What expect in urine - Ketones Nurse obtaining history, pt complaints of severe HA, nurse identifies following as modifiable rf for stroke - Smoking - Alcohol - Decrease exercise - Obesity Pt comes into Er with midsternal chest pain radiating to neck unrelieved by nitro. What indicates to nurse to identify MD - ST segment elevation from the baseline Nurse gives client morphine 2 mg IVP, nurse evaluated client. What is adverse effect - RR of 8 breaths per minute Nurse collecint info on group of lient experiencing renal disrders. Who should qualify for dialysis - Cleint bleeding with minimal urine output