An external ventricular drain (EVD) is placed to evacuate the blood. Over two days the patient remains stable. The current treatment order is to remove the drain and plan for a transition to a step-down unit. The patient has the EVD removed and is transferred to the step-down unit. She continues to have some residual cognitive deficits but is ambulatory with a walker.Before discharge, the nurse teaches the family about actions that can increase intracranial pressure. Which of the following explanations should the nurse provide as to why the patient should avoid the Valsalva maneuver?

 A 36-year-old male brought to the Emergency Department by EMS following a motor vehicle accident. He was an unrestrained\ passenger in a  right side-impact collision. Upon arrival, he is alert but distressed, complaining of excruciating pain to his right chest and “not being able to catch a full breath.” The nurse exposes the patient’s chest during assessment, and notices a section of the right lateral chest wall that appears to move inward during inspiration and outward during expiration, and his breath sounds are significantly diminished on the right side. The physician notes that while the flail segment is currently stable, the primary concern for the patient isn’t just the broken bones, but other underlying injuries such as a [BLANK-1].

A patient arrives with a GCS of 10 (E3, V3, M4), blood pressure is 210/120 mmHg, and the right pupil is slightly sluggish. A non-contrast Head CT is performed immediately.The CT scan confirms an Intracerebral Hemorrhage (ICH) in the basal ganglia. What is the immediate priority for blood pressure management in this patient?

The patient  is in the “Oliguric Phase” of AKI with a potassium level of 6.7 mEq/L. Which physiological mechanism is the primary cause of hyperkalemia?

The patient’s AKI has moved to the recovery phase, and creatinine and BUN levels have improved. He is being discharged home. The nurse provides discharge orders to the patient and his wife.Which statement by the patient indicates a need for further teaching?

The patient’s labs show a Potassium K+ of 6.4 mEq/L. The nurse visualizes the following EKG rhythm on the monitor. The nurse receives orders to treat the hyperkalemia. Hyperkalemia.png The patient asks the nurse why Dextrose 50% (D50) is administered with IV Regular Insulin? The nurse replies, “The dextrose is administered with the insulin to prevent [BLANK-1]

An elderly  female patient arrives via EMS at 10:15 AM. their last known well (LKW) time was 09:00 AM, per the daughter that lives with the patient. On assessment, the patient has global aphasia and severe right-sided hemiparesis. The heart rate is 124 bpm and irregularly irregular, blood pressure is 192/104 mmHg, R 22/min, and O2 sat at 94% RA. The client has a history of A-fib for which they take coumadin. However they are non-compliant with daily administration.After arrival at the emergency room, what is the highest priority action the nurse will plan to perform in order to rapidly diagnose the presence and type of stroke?

The patient continues to remain in the oliguric phase of AKI. The nurse receives new orders related to the patient’s current kidney function statusWhich of the following orders should the nurse question? (Select All That Apply)

48 hours later, the patient is in the Burn Unit. The capillary refill on the right hand is sluggish, and distal pulses are weak. Which of the following is considered a classic sign that the patient is starting to develop compartment syndrome?

I participated in the class quiz covering the Remote ID topic.