Random Facts based on Kaplan
1. Evisceration- cover the open area with sterile gauze soaked in normal saline, position supine to reduce pressure
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2. Central Line changes- If air embolism is suspected, lower the head of the bed, position on left side (left lateral) the air will rise to the right atrium and prevent it from reaching cerebral circulation.
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3. Whenever TPN solution is not available or if the doctor discontinued it, place no less than 10% dextrose solution to prevent hypoglycemia. Also TPN tubing must be changed EVERY 24 hours, decreases risk of infection from micro
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4. You cannot give aspirin to pregnant women or during a sickle cell crisis
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5. For unconscious clients, turn every two hours to maintain pulonary function, this reduces pooling of respiratory secretions
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6. T-Tube drains bile from cholecystectomy (greenish-brown), document the drainage, should be 500-1000 daily
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7. Prep for IV Pyelogram- client cannot be taking "metformin" glucophage, Contrast dye can lead to lactic acidosis
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8. Following Lumbar Puncture- client will remain supine, flat for 8 hours to prevent spinal headache
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9. Mantoux Skin Test for HIV- Induration is 5 mmHg
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10. Postpartum, if uterus is boggy and to the left of midline, encourage mom to urinate or offer bed pan. A full bladder can prevent the uterus from contracting and lead to bleeding.
Signs and Symptoms Segment
a. Bulimia- ulcerated mucous membranes from excessive vomiting
b. Autonomic Dysreflexia- severe pounding headache, profuse sweating, nasal congestion
c. Intestinal Obstruction- distended abdomen, complaints of pain
d. Gastric Ulcer- experience pain 30 min-1 hour after meal
e. Previa=painless bleeding
f. Abruptio=absolutely painful bleeding (medical emergency)
Examples of Clients to see FIRST
1. Client with forceful bleed from head- indicates arterial bleed, could go into shock
2. Client expectorating pink tinged mucous- pulmonary edema
3. Client receiving blood begins to vomit- hemolytic reaction
4. Client with burns to the face- airway compromise
5. Client with a crush injury to the chest with RR of 10- ABC's
6. Client with swollen lips after an ant bite- could be anaphylactic reaction
7. Client admitted with status asthmaticus- life threatening
8. Child with croup and RR rate of 35
9. Client who delivered by C-Section 1 hour ago with 3 soaked pads- active bleed
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