Adult Health Nursing Flashcards

Which assessment finding indicates compartment syndrome in a patient with a lower leg cast?

Answer: Severe pain unrelieved by analgesics, pallor, pulselessness, paresthesia, paralysis

Compartment syndrome is identified by the 6 P's: Pain (unrelieved), Pressure (increased), Pallor, Pulselessness, Paresthesia, and Paralysis. It is a surgical emergency requiring immediate fasciotomy. Casts must be split and bivalved promptly.

A patient with chronic obstructive pulmonary disease (COPD) is in respiratory failure. Which ABG result indicates the need for mechanical ventilation?

Answer: PaO2 of 45 mmHg, PaCO2 of 70 mmHg, pH of 7.20 despite maximal oxygen therapy

Severe hypoxemia (PaO2 70 mmHg), and respiratory acidosis (pH <7.25) despite maximal conservative therapy indicate impending respiratory failure requiring mechanical ventilation support.

A patient with a burn covering 36% of total body surface area (TBSA) is being resuscitated using the Parkland formula. What does the formula calculate?

Answer: 4 mL × weight (kg) × %TBSA burned of Lactated Ringer's in the first 24 hours

The Parkland (Baxter) formula: 4 mL × kg × %TBSA = total Lactated Ringer's for first 24 hours. Half is given in the first 8 hours from time of burn (not admission), and the remainder over the next 16 hours.

Which complication is the nurse most concerned about in a patient with a spinal cord injury at C4?

Answer: Respiratory failure requiring ventilatory support

Injury at C4 affects the phrenic nerve (C3–C5), which innervates the diaphragm. Patients with lesions at or above C4 are at high risk for respiratory failure and typically require mechanical ventilation. This is the immediate life threat.

A patient is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding is expected?

Answer: Hyponatremia, concentrated urine, and euvolemia or mild fluid excess

SIADH involves excessive ADH causing water retention and dilutional hyponatremia. Urine is concentrated (high urine osmolality/sodium) despite low serum sodium. The patient is euvolemic or slightly hypervolemic, not dehydrated.

A patient on warfarin therapy has an INR of 8.5 and is actively bleeding. What is the antidote?

Answer: Vitamin K IV and fresh frozen plasma (FFP)

For life-threatening bleeding with supratherapeutic INR, warfarin must be reversed immediately. Vitamin K reverses warfarin's mechanism (blocking vitamin K-dependent clotting factors); FFP provides immediate clotting factors. 4-factor PCC is preferred over FFP when available.