The level should be negative to small call the

Test urine for ketones and report to provider if they are outside the expected reference range. (The
level should be negative to small
Call the provider for the following.
 Blood glucose greater than 240 mg/dL. Test urine for ketones, if prescribed.
 Fever greater than 38.6° C (101.5° F), does not respond to acetaminophen, or lasts more than 24hr.
 Feeling disoriented or confused
 Experiencing rapid breathing
 Vomiting that occur more than once
 Diarrhea that occurs more than five times or for longer than 24 hr
 Inability to tolerate liquids
 Illness that lasts longer than 2 days
o Gastrointestinal Therapeutic Procedures: Interventions for Dumping Syndrome (Active Learning Template
- System Disorder, RM AMS RN 10.0 Chp 47)
 Provide six small meals a day when the client can resume oral nutrients
 Ambulate asap

Med surg
 Hemodynamics - (2)
o Electrocardiography and Dysrhythmia Monitoring: Assessing a Client who has Atrial Fibrillation (Active
Learning Template - System Disorder, RM AMS RN 10.0 Chp 28)
 Must receive adequate anticoagulation for 4 to 6 weeks prior to cardioversion therapy to prevent
dislodgement of thrombi into the bloodstream.
 Digoxin is held for 48 hr prior to elective cardioversion
o Heart Failure and Pulmonary Edema: Self-Management Techniques (Active Learning Template - System
Disorder, RM AMS RN 10.0 Chp 32)
 The client should measure weight daily at the same time. Notify the provider of a gain of more
than 2 lb in 1 day or 5 lb in 1 week
 Medical Emergencies - (3)
o Burns: Expected Laboratory Values (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp
75)
 Hgb and Hct : decreased (hemodilution) due to the fluid shift from the interstitial space back into
vascular fluid
 Sodium: remains decreased due to renal and wound loss
 Potassium: decreased due to renal loss and movement back into cells (hypokalemia)
 WBC count : initial increase then decrease with left shift
 Blood glucose : elevated due to the stress response
 ABGs : slight hypoxemia and metabolic acidosis
 Total protein and albumin : low due to fluid loss
o Hemodynamic Shock: Priority Intervention for Hypovolemic Shock (Active Learning Template - System
Disorder, RM AMS RN 10.0 Chp 37)

During hypovolemic shock, replace volume first
(0.9% NS or LR)
 Oxygenation status (priority)
 Place the client on high - flow oxygen, such as a 100% nonrebreather face mask. If the client has
COPD, insert a 2 L/min nasal cannula and increase the oxygen flow as needed.
 Maintain patent IV access.
 Use vasopressors only if blood pressure remains low after volume is replaced
o Emergency Nursing Principles and Management: Priority Action for Abdominal Trauma (Active Learning
Template - System Disorder, RM AMS RN 10.0 Chp 2)
 Hypothermia is a primary concern
 Victims of trauma are at risk for hypothermia due to exposure, unwarmed oxygen, and cold IV
fluids.