Nursing Care and Patient Monitoring Worksheet

The ICU is monitoring a patient who has a traumatic brain injury for signs of increased ICP. Which would indicate an EARLY sign of deterioration in the patient's neurological status?

• Narrowed Pulse Pressure and Seizures

• Tachycardia and II Pulse Pressure

• Bradycardia and Systolic Hypertension

• Systolic hypotension and fever

The nurse is caring for a patient with an open AAA repair who is 4 hours post op. Which action by the tech would require the nurse to intervene?

• Offering the patient sips of water

• Taking the patient's vital signs

• Answering the patient's room phone located on the nightstand

• Preparing to help the patient to the bathroom

Which of the following nursing interventions are appropriate in the immediate post op care of a patient with an endovascular graft repair of an AAA?

• Check pedal pulses

• Coughing and Deep breathing

• Splinting the incision

• Keeping the HOB in High Fowler's position

Which of the following signs would cause the nurse to suspect a critically ill patient is developing DIC?

• Fever

• Nosebleed

• High BP

• Tachycardia

6. Dosage calc - ________

• 60

• 30

• 120

• 15

The nurse is reviewing the HCP's orders for a patient with DIC. Which of the following orders should the nurse question?

• Administer Vitamin K IM

• Initiate a Heparin infusion according to Heparin protocols

• Vital signs and neuro check every 30 minutes

• Place a pressure-reducing mattress on the bed

Tags

NGSS.HS-LS1-3

The nurse is caring for a client who has tetraplegia. When the nurse elevates the HOB to 30 degrees, the patient complains of dizziness and becomes hypotensive. What should the nurse do?

• Wait for the client to adjust to the change

• Call the HCP immediately

• Lower the HOB

• Raise the foot of the bed

The nurse is reviewing the diagnostic tests of a client admitted with a thoracic aneurysm. The client asks the nurse, "How does the doctor know that this is an aneurysm?" The nurse knows that which of the following test results best confirms the diagnosis?

• A PA and Lateral Chest X-RAY

• CTA

• Serial High BP Readings

• High LDL and Triglycerides

The charge nurse is observing a new RN providing discharge teaching for a client with hypertension who is being prescribed Analapril. Which of the following comments by the new RN would prompt the charge nurse to intervene?

• Make an appt with the dietician to learn about the low-sodium diet

• Check your BP with a home BP monitor regularly

• You need to move slowly when moving from lying to standing

• You will need to increase your diet high in Potassium foods

The nurse on the cardiac unit is caring for a patient on telemetry who is recovering from a MI and has a history of glaucoma. The patient's heart rate is 44. The nurse assesses the BP, which is 98/60, and the patient is complaining of dizziness and fatigue. The nurse notifies the provider and anticipates which of the following management strategies?

• Defibrillation (for cardiac arrest)

• Synchronized cardioversion (if hr is 150 bpm, so not this one)

• Temporary transcutaneous pacing (The initial treatment of choice is an IV bolus of atropine, although it is not effective in second-degree AV block, type II, or third-degree AV block. If the patient does not respond to atropine, has advanced AV block, or has had an acute MI, temporary transcutaneous pacing may be started.)

• IV Bolus of Atropine (can’t give this because it’s contraindicated to glaucoma)