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Nurse's Notes	vital Signs
0800: 62-year-old client brought to emergency department by spouse after tripping at home 6 hours ago. Right midfoot swollen with large amount of bruising on toes and sides of foot. Less swelling on ankle. No external bleeding or wounds. Reports pain 10/10 and unable to stand on foot, unable to move without difficulty, increased pain with palpation of superior aspect of foot. Able to move toes and dorsiflex foot, pedal pulse palpable, capillary refill delayed. Has history of hypertension, L meniscus repair 6 years ago, hepatitis A as a child.	temprature 98.4°F (36.9°C) P: 110 RR 18 BP: 132/92 O2 sat 96%. Lungs clear. Alert and oriented to person, time, place. Takes daily amlodipine 10 mg and benazepril 20 mg.

Set 2: Question #1 of 6

1.Which 4 client findings from the nurse's notes are most important to address at this time?

□Hepatitis A history.

□Capillary refill time.#

□Unable to bear weight.#

□Elevated BP.

□Pain.#

□Swelling.#

1.bladder cancer 교육 correct?

①regulary cystoscopic test

②urinarysis test periodically

③cranberries intake a everyday 1 liter at least

#cranberries may preventive bladder cancer

•Biopsy.  •Urine cytology.•Imaging tests. Imaging tests, such as computerized tomography (CT) urogram or retrograde pyelogram,

2.발가락 통증 있는 급성 gout 어떻게 중재?

수분 섭취

알로퓨리놀 준다

발에 cradle 올려준다?

3.3도 화상 환자가 ~~예방하기 위해 우선적인 중재?

Debridement 연고 바른다

항생제 연고 바른다

무슨 연고 발라준다,

irrigation

4. 아기열 38.2도 중재?  고열일때 부모교육

lukewarm water sponge bath

얇은옷 입히고 다 벗김.

axillary BT 1시간마다 잼

5. hyperthermia 환자 뭘 먼저 해줘야되냐

tepid bath

hypothermia blanket

ace pack 겨드랑이랑 사타구니에 20분

requires immediate cooling measures. The most effective treatments include moving the person to a cooler place, immersing them in cool water (ideally at 90°F/26.7°C) or applying ice packs to major arteries

can be treated with a hypothermic blanket or by using other cooling methods. Hypothermia blankets are a type of cooling blanket used to lower body temperature

give them food if they want it

check on your child regularly, including during the night

keep them at home

give them either paracetamol or ibuprofen if they're distressed or uncomfortable – check the packaging or leaflet to make sure the medicine is suitable for your child, or speak to a pharmacist or GP if you're not sure

get medical advice if you're worried about your child, or if the paracetamol or ibuprofen is not helping

6. NIDDM 환자 hydrochlorthiazide 투여 후 틀린것?

avoid ca supplement at otc

increase gout risk

k supplement apply 매일

#increase uric acid

taking potassium supplements without medical advice, especially with certain conditions or medications, can be dangerous.

7. DM1환자 Thiazide Diuretics 복용중이다. corret understanding?

Na과 Water를 제한해서 섭취하겠다

K많은 음식을 섭취하겠다.

k 감소한다

low na diet한다

저칼륨혈증 모니터링

저나트륨혈증 모니터링

8.Continuous BP monitoring 필요할 때 라인 뭐 넣는지?

-Femoral artery line 잡는다

. Severe high blood pressure환자의 blood pressure를 지속적으로 monitoring하기 위해 필요한 카테터는?

inter-aortic ballooning catheter

Jugualr vein catheter

Pulmonary artery wedge pressure catheter

femoral arterial line catheter

9.협심증 환자. Coronary a. catheterization 예정. 환자 진술 f/u 필요한경우

NGT 3회까지 투약 가능

통증 있어도 운동 규칙적으로 매일 할거에요

Coronary a. catheterization 후 운동부하 검사 후 운동 어떻게 할지 정할거에요

다음주 에어로빅 운동 갈 것이다

After a coronary catheterization, avoid high-impact exercise and heavy lifting for at least one to two weeks to allow the insertion site to heal. Begin with light activities like short, slow walks, gradually increasing the duration and intensity as you feel comfortable.

10.입원환자 다리 통증, ~~ 호소(DVT 증상). 중재는?

다리 올려준다

베개를 받쳐준다

APC  (apixaban) 적용한다

"DVT APC apply" refers to using Apixaban (a DOAC, or direct oral anticoagulant) to treat Deep Vein Thrombosis (DVT).

11,신생아 외양이 눈이 위로 쭉, 귀는 낮게, 평평한 얼굴 등..(다운증후군 특징들)이 관찰되었다. 이 질환에서 흔히 나타날수 있는 임상 증상은? SATA

골다공증,

근육 약화,

갑상선기능저하

체중증가

TOF

poor muscle tone, a short neck, upward-slanting eyes, small ears, and a flat face.

congenital heart defects, hearing loss, vision problems (like cataracts and strabismus), digestive issues (such as blockages or celiac disease), increased risk of leukemia and infections, and sleep apnea. Other complications can include thyroid disorders, spinal problems, dental issues, and a higher risk of Alzheimer's disease

increased risk for osteoporosis due to factors like reduced physical activity, early menopause, and potentially lower vitamin D levels. Research shows lower bone mineral density (BMD) in people with DS, with this density decreasing faster with age. Contributing factors also include the use of certain medications, and genetic factors related to the extra chromosome 21.

Weight gain and obesity are common complications for people with Down syndrome due to factors like lower physical activity, reduced metabolism, hormonal imbalances (including hypothyroidism), and sleep apnea

11.0.9% N/S 달고 있는 무슨 수술 환자 RN-> LPN 업무 위임 가능한것?

IV 수액세트 교환(O)

약물 투여,

교육

12.crutch 사용 관련 간호 직원 교육 예정. 틀린 설명은?

패드부분이 겨드랑이 사이 손가락 3개 정도

맞는 목발 길이 잴 때 weight goes 앞쪽(손쪽)

손으로 잡았을때 팔이 slight bend 되어야 함

목발길이는 발끝에서 어깨까지

13.BiPAP SIMV mode 적용중인 환아. 맞는거 고르기 SATA

환자는 자발호흡이 아예 안되는 거다

알람이 울리면 호흡이 제대로 안되고 있는 거다

튜브에 물이 있는건 잘못된거다

High pressure 알람이 울리면 환자에게 공기가 제대로 안들어간거다(O)

A high-pressure alarm in an air conditioning system signifies that the system's discharge pressure has exceeded safe levels, often due to a failure in heat dissipation, and can lead to a compressor shutdown to prevent damage.

14.simv sata

simv mode is sminulaenously and will not initate ventilate associated breat High pressure alarm means air leakage~

Cpap independent breat 있을 때 가능한 모드이다.

document pt breat,

ventilate 관련해서 기록한다.

15. Ventilation mode에 대한 설명 맞는 것

PEEP - BiPAP에 대한 설명

NIPPB - PEEP에 대한 설명

ACMV –weanning시에 부적절

SIMV – self respiration 가능

#bipap-peep. cpap.included.

#NIPPB-NON invasive positive pressure. peep. cpap included

#Asist control mode ventilation-ventilation start apply.weanning time inappropriate

tachypnea. r alkalosis. if severed r acidosis. apply.copd. pul edema effect

#Simv-available self respiration. setting respiration availabe. r acidosis

16. Ventilator 설명으로 맞는 것은?

① CPAP는 ventilator 제거전

② SIMV는 환자가 자율적으로 호흡가능#

③ high pressure 알람은 ....