Complex Care Flashcards

A client with chronic kidney disease (CKD) stage 4 has a serum potassium of 6.2 mEq/L. Which dietary instruction is the priority?

Answer: Avoid high-potassium foods such as bananas and potatoes

Hyperkalemia in CKD is life-threatening and requires immediate dietary restriction of high-potassium foods to prevent cardiac dysrhythmias.

A nurse is caring for a client on mechanical ventilation with a PEEP of 10 cmH2O. The client's blood pressure drops suddenly to 80/50 mmHg. What is the most likely cause?

Answer: Decreased venous return from high PEEP

High PEEP increases intrathoracic pressure, reducing venous return to the heart and causing decreased cardiac output and hypotension.

A client with a traumatic brain injury (TBI) has a GCS score of 8 and demonstrates Cushing's triad. Which set of vital signs is consistent with Cushing's triad?

Answer: HR 48, BP 180/100, RR 8 irregular

Cushing's triad indicates increased intracranial pressure and presents with bradycardia, hypertension (widened pulse pressure), and irregular respirations.

A client receiving total parenteral nutrition (TPN) develops fever, chills, and glucose of 22 mmol/L. The most appropriate initial nursing action is to:

Answer: Change the TPN bag and tubing and notify the physician

Fever and chills with TPN suggest catheter-related bloodstream infection; changing the bag and tubing and notifying the physician addresses both the potential contamination source and escalates care.

A client with acute respiratory distress syndrome (ARDS) is being ventilated with a tidal volume of 6 mL/kg ideal body weight. What is the rationale for this low tidal volume strategy?

Answer: To prevent ventilator-induced lung injury and volutrauma

Lung-protective ventilation with low tidal volumes in ARDS prevents overdistension of alveoli (volutrauma) and reduces ventilator-induced lung injury.

A client with septic shock is receiving norepinephrine. The nurse notes the infusion site is cool, pale, and mottled. What is the immediate action?

Answer: Stop the infusion and notify the physician immediately

Norepinephrine extravasation can cause severe tissue necrosis; stopping the infusion and notifying the physician immediately is required to prevent serious tissue damage.

A nurse is caring for a postoperative client who develops sudden onset chest pain, dyspnea, and SpO2 of 88%. The nurse notes the client had a total hip replacement 3 days ago. What condition is most suspected?

Answer: Pulmonary embolism

Sudden onset chest pain, dyspnea, and hypoxia in a post-orthopedic surgery client are classic signs of pulmonary embolism due to venous thromboembolism risk.