Exam 4 40 questions. Total of 70 points. 14 NGN questions READ LAST PAGE WITH NGNS BEFORE READING THE GUIDE TY. Still working on it but figured I should send something out. Know what to do when a patient is unresponsive in a hospital setting A nurse enters a client’s room and finds whim unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first. - Check for a carotid pulse Stages of shock Initial stages of shock (signs or symptoms acid) going into anerobic shock Body is compensating heart rate and Respiratory rate, Angiotensin/renin action to keep patient perfused maintains Blood pressure and oxygenation (confusion can occur in this stage as well due to oxygenation) Progressive: early sign cool and clammy skin Irreversible- leads to death A nurse is caring for a client who is in the compensatory stage of shock. Which of the following should the nurse expect. - Blood pressure 115/68 A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following finding support this conclusion? - Confusion When to call rapid response? Heart rate over 140/min or less than 40 Acute change in mental status Less than 40cc over 4 hours Less than 90% spo2 with O2 Stopped breathing/no pulse A nurse enters an adult client’s room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of he following actions, should the nurse take first? - Summon the code team The meaning of CVP and the role of hemodynamics CVP= preload (right heart preload) Increased: fluid overload, cardiac tamponade, R heart dysfunction Decreased: dehydration, volume loss, vasodilation A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? - Hypovolemia BLS BLS involves a hands-on approach or assessment and management to restore airway, breathing, and circulation VF or pulseless VT: initiate the CPR component of BLS, defibrillate according to BLS guidelines, establish IV access Admin IV antidysrhythmic medication such as epinephrine and vasopressin, according to ACLS guidelines A nurse is conducting a primary survey of a client who has sustained life-threating injuries due to motor vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right placing them in the selected order of performance. Use all the steps - Open the airway using jaw-thrust maneuverer Determine effectiveness of ventilator efforts Establish IV access Preform GCS assessment Remove clothing for a thorough assessment A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client’s circulation by palpating which of the following pressures. - Carotid Heart rate effects with cardiac output IF the heart beats 2 fast due to PVC or other dysrhythmias it will decrease Cardiac output. Cardiac output CO = HR (50-100) x SV (60-120) HR and SV compensate for each other if HR goes down, SV goes up etc HR Tachycardia is caused by hypovolemia, low BP, sympathetic nervous system, fever, exercise There is only so much the HR can compensate for low SV, for a healthy person over 180 the heart isn’t effectuality pumping blood Bradycardia (SV-up HR-down) Bradycardia (athletes) Alterations in HR: arrythmias, heart blocks, MI, if patient is on beta or calcium channel blockers Stroke volume SV is influenced by 3 factors preload, contractility, and afterload Contractility Contractility: the amount of squeeze done by the heart that will increase SV but also O2 demand of heart Contractility can be increased by: sympathetic nervous system and exercise SV decreased (contractility)= by lower o2 demand, MI or heart surgery, hyperkalaemia, hypocalcaemia, and metabolic acidosis Preload Amount of blood in the ventricle before contraction Factors influenced preload: blood volume, distribution of flood and volume in the body, atrial contraction (is the atrial beating in conjunction with our ventricle (if atria isn’t in synchrony then it will have an impact on preload. Frank-starting law = increase in preload= increase stretch= greater contraction There are times you can overstretch the heart (compliance) Compliance can either have an increase or decrease. An increase is caused an overstretch which is seen in CHF, dilated, cardiomyopathic No stretch or accommodation- MI, restrictive cardiomyopathy, stunned myocardium (trauma or surgery. Afterload Resistance (how clamped down is our patient) 3 factors that impact afterload Complain of the aorta (ability to stretch with each beat) Vascular resistance (amount of resistance that the heart has to beat against (hypoxia =increased vascular resistance) Viscosity of the blood A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following finding can compromise the readings. - Client is experiencing premature atrial contractions (dysrhythmias) S/s of all types of shock Types of SHOCK - Hypovolemic= lack of blood volume - Cardiogenic = pump failure - Obstructive shock= pump failure (not due to the heart) Distributive: - Neurogenic – mass dilation of blood vessels Anaphylactic Septic Hypovolemic shock - External blood loss usually caused by trauma/injury, interal blood loss, vessels, ectopic preg, pancreatitis, GI bleeds Fluid loss: major burns, emesis or vomiting, excessive diarrhea, dehydration, ascites, excessive use of diuretics Patho Signs - Blood volume = decreases preload, Cardiac outputis low=HR high x SV low MAP= low CO x high SVR Low BP, high HR, cool clammy skin, pale Labs: CBC, ABG, lactate (to see if they pt is anaerobic Treatment - Stop the bleeding/fluid loss Replace volume IVF blood Support BP and give pressors Cardiogenic Shock - Heart is not able to beat enough blood to fill the bodies needs - Causes: 4 main causes - 1) filling diastolic HF, over time ventricle wall become enlarged and decreased preload/CO - 2) contraction; cardiomyopathy /heart failures/MI - 3) arrythmias: conduction issues (reduce preload, contractibility, HR) - 4)Structural: valvular diseases (decreases preload) Symptoms - Angina - Low BP, high HR - Cool/clammy skin - Cardiomegaly, pulmonary Edema, JVD, peripheral edema Diagnosis - Serum lactate levels - ABG - Troponin (won’t see it rise for a few hours) - Chest Xray - EKG - ECHO (picture on what’s going on with the heart - CVP (sign fluid is filling up) - PCWP to see if left side is also filling up - CO/CI Treatments - - Give O2 perfusion is decreased Cardiovascular support (increase SVR with vasopressors) Increase contraction with inotropes Fixing Arrythmias – amiodarone, Pacing Temporary assist device Common herbal remedies that produce adverse effects on the cardiovascular system include St. John’s wort, motherwort, ginseng, gingko biloba, garlic, grapefruit juice, hawthorn, saw palmetto, danshen, echinacea, tetrandrine, aconite, yohimbine, gynura, licorice, and black cohosh A nurse in the emergency department is assessing a client who has internal injuries form a car crash. The client is disoriented to time and place, diaphoretic and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock. - Increased heart rate Septic shock: Causes: most times caused by some kind of bacterial. Bacteria causes an infection that leads to an increase of cytokines that cause vascular system to become more preamble to allow WBCs to enter to attack infection but bloods leave out with these opening leading to relative hypovolemia caused by third spacing. - Can lead to DIC due to increase systemic clotting due to systemic vasculature damage from continuous opening of vessels and clots produced to close the vascular openings (due to WBC response) - This permeability of vasculature also occurs in the lung vessels causes fluid to move from the vessel to the lung space causing ARDS. s/s s/s- Low BP, (less than 80/systolic), cold, clammy skin, Delayed capillary refill Mental status changes (confusion, disorientation - High WBC (over 10,000) Temperature high initially and then low Cool clammy skin, and decreased urinary output Test: - Blood cultures Lactate ABG CRP, cortisol CBC Treatment: (1st hour bundle THINGS THAT NEED TO BE DONE FIRST HOUR,): - Lactate, blood cultures, Broad spectrum ABX, Fluid, Pressors - Broad spectrum specific when cultures are known - IVF (crystalloids) 30ml/Kg - If still hypovolemic with fluids, then we give Vasopressors to keep a MAP of >65 - Support oxygenation (intubation/mech ventilation) s/s- Low BP, (less than 80/systolic), cold, clammy skin, Delayed capillary refill Mental status changes (confusion, disorientation High WBC (over 10,000) Temperature high initially and then low Cool clammy skin, and decreased urinary output Treatment: IV fluids, antibiotics TPA administration s/p MI 1. Open kit inside will be a vial of sterile water and TPA (blue cap) 2. Dilute the SPA with sterile water (do not shake the vial) 3. Withdraw 15mL in IV bolus 4. Admin bolus over 1 min Monitor for bleedings, chest pain, back pain, and vitals after administration every 15 min. A nurse in an emergency department is preparing to administer alteplase accelerated therapy to a client who is having a myocardial infarction. Which of the following actions should the nurse plan to take? (SATA) - Administer the medication within 30 of the client’s arrival to the department Reconstitute the medication with sterile water - Administer the medication in a 15mg IV bolus Assess the client for back pain Blood transfusion supplies Kevin said the answer to the question about transfusion equipment was to flush the Y tubing with normal saline after the transfusion. A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding? - The packed RBCs are connected by Y tubing to normal saline Discontinue Subclavian Central Line 1. Lower head of bed. Position insertion site below the patients hear level or use Trendelenburg position if tolerated 2. Ask the patient to breath hold during removal or remove at the end of inspiration if mechanically ventilated 3. Apply dry gauze over insertion site an pull the catheter in a slow but steady withdrawal position, applying pressure above the insertion site 4. Fi resistance is met stop procedure notify physician 5. Apply continuous and direct pressure for a minimum of 5 minutes A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client. - Bear down while holding breath Understanding PAWP and normal values PCWP- CVP for the left side of the heart(preload) 8-12 mmhg Increased: fluid overload/ aortic stenosis/regurgitation Mitral stenosis, left ventricular failure, cardiac tamponade, constrictive pericarditis Low: hypovolemia, vasodilation Deflate balloon as soon as you get pressure because you are essential blocking SVR/PVR- help you identify patients’ afterload You want 800-1200 Under 800 lower BP 1200 more resistance usually higher BP A nurse is monitoring the pulmonary artery wedge pressure (PAWP) for a client. The nurse should identify that a reading of 15 mm Hg is an indication of which of the following conditions? - Mitral valve regurgitation Understand epinephrine Epinephrine is a Alpha1, 2 and Beta 1 and 2 agonist that is the first line treatment for anaphylactic shock, and for restoring cardiac rhythm in situations of cardiac arrest – Kevin A charge nurse is teaching a group of nurses about agonist and antagonist. The nurse should include in the teaching that which of the following agonist medication bind to receptors and causes action that affects the cardiovascular system - Morphine EPI CBC labs interpretation and symptoms RBC 4.7-6.1 million/uL 4.2 -5.4 million/uL (woman) HGB males 14-18 g/dL 12-16(woman) – Low symptoms would be those associated with anemia (fatigue, low BP, fast HR, SOB, jaundice, pale cool skin) Platelets 150,000-400,000/mm3 – symptoms (purpura, petechiae, bleedings in gums or nose, bloody stools, fatigue) A nurse is caring for a female client who reports an increase in bruising the nurse should expect which of the following laboratory values? - 110,000 Symptoms with all cardiac rhythms and how it affects cardiac output and intervention (you don’t need to know junctional, or heart blocks; just basic rhythms. Sinus rhythm should have a regular rate with a rate 60-100 normal p and T wave with ORS complex (continue monitoring patient to make sure they don’t deviate from that Sinus bradycardia (SA node rhythm) beats less than 60 beats per minute but its regular. Causes: SLOW RATE Sick sinus syndrome (SA node damage) Low thyroid hormone Older adult Weak/damaged heart muscles Raised ICP (cushing triad Athlete (this is their base) Toxicity (BB, CCB, and digoxin) Electrolyte imbalances (hyperkalemia) Stimulation of vagal response (vomiting) Symptoms: patient hypotension/shortness of breath, chest pain, fatigue, sweaty/clammy If asymptomatic, just monitor them. Medications Atropine, dopamine, epi, cardiac pacing Sinus Tachycardia: atrial rate greater than 100 bpm and regular causes: TACHY HEARTS - Temperature elevation - Aerobics - Cardiac disease (too fast can lead to cardiogenic shock because bad heart cant handle - Hyperthyroidism - Yelp (pain) - Haemorrhage (hypovolemic shock) - Emotions (stress/feat) - Anemia - Respiratory conditions -Therapeutics (atropine, albuterol) -Stimulants (nicotine , alcohol, cocaine , amphetamines Treatments Does not always require treatment Identify the cause (ecg, cardiac stress test, Holter monitor, assess thyroid levels, assess blood levels (rule out infection or anemia), medication history. Medications: Beta blockers, Calcium channel blockers, pain medications, antipyretics AFIB: Atria are beating at a fast irregular rate (atria is quivering) can lead to blood clot and strokes. Rate can be irregular. If greater than 100 bpm it is called uncontrolled A-fib, if less than 100 it is called controlled A-fib Causes: After heart surgery, heart problems (mitral valve, CAD, MI, or pericarditis) Lung conditions (COPD) Sleep apnea Treatments: Stable: less than 100 with no symptoms, monitor rate Unstable: BP dropping, symptomatic, and its uncontrolled (rate greater than 100 BPM) then they need a synchronized cardioversion (helps them go back to regular cardio rhythm Before cardioversion you want to know how long they have been in unstable AFIb to know if you are going to give anticoagulation med for clots Before cardioversion a Transesophageal echocardiogram may be performed to look for clots, If no blood clots are present, the patient can be cardioverted Medications: to fix rhythm (diltiazem, adenosine. Amiodarone) , Other meds (anticoagulants (warfarin) . BB and Calcium channel blockers to maintain rhythm Ablation may be used to destroy some tissue in the heart to prevent abnormal firing of nodes Aflutter: occurs because of an abnormal electrical signal that is causing the atria to contract very rapidly (similar to atrial fibrillation). ECG would have no P waves but flutter waves (looks like sawtooths) Causes: heart valve problems (tricuspid or mitral valve) Myocardial infarction, heart surgery, overactive thyroid. Treatment: Calcium channel blocker (diltiazem, Cardizem), beta blockers (propranolol), digoxin Other meds (antiarrhythmic drugs (amiodarone), and anticoagulants to prevent blood clots. If not working then we need to cardiovert or an ablation Ventricular tachycardia (V TACH): abnormal heart rhythm that originates from the ventricles, caused by an electrical conduction system sending out an abnormal electric signal that causes the ventricles to contract rapidly. Blood cannot pump efficiently and cardiac output cannot be maintained. Can be short in duration and quick. Characteristics: QRS complex really wide (tombstones) not P or T wave rate from 100-250 bpm, with a regular rhythm. Can appear as monomorphic (all tombstones look the same) or polymorphic (not the same tombstones pattern throughout), Torsades de pointe Causes: Abnormal electrolyte levels (potassium), myocardial infarction, medication toxicity (digoxin), heart disease such as heart failure, CAD, or valve disease) Torsades de Pointes: common cause is medication that increases WT interval (amiodarone, sotalol. Procainamide), Low calcium, potassium, or magnesium levels Treatment: Requires immediate attention before it turns to Vfib Actives emergency response, follow ACLS protocol If STABLE (no symptoms, has pulse), antiarrhythmic medication may be considered amiodarone IV, if not effective, synchronized cardioversion. IF UNSTABLE (but still have a pulse) cardiac output can decrease Can see hypotension, mental status changes, weak pulse, cool/clammy, chest pain Synchronized cardioversion Antiarrhythmic meds such as amiodarone NO PULSE: start CPR, defib, and epinephrine Other meds can be given such as amiodarone or lidocaine, along with securing the airway In polymorphic V TACH (torsades de pointes, stop QT interval prolonged medication(amiodarone), magnesium sulfate may be considered (if patient is unstable with no pulse, treat it like VFIB (CPR and defib) Once patient returns to a normal rhythm, it may be necessary to implant an ICD (Cardioverter defibrillator) to prevent recurrence) Ventricular fibrillation: Heart rhythm that originates from the ventricles Ventricles help squeeze blood out of the heart and maintain cardiac output. There is an abnormal electoral signal that is causing the ventricles to quiver. - Cardiac output will fall, if not treated this rhythm can lead to death within minutes Characteristics: rapid rhythm with no organization fibrillatory waves, coarse fibrillatory waves (better chances of being revives) fine waves are more like asystole, (won't see qrs, p or T waves) looks like squiggly lines on the ECG strip Causes: heart disease/ heart attack Electrolytes imbalances (high or low potassium levels Hypoxia Drug overdose Treatment Get help immediately, patient will l have no pulse and be unresponsive, call code, and start CPR; follow ACLS protocol A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client? - Try to remain still once I have attached the gel pads Angina vs MI vs ketoacidosis Ischemia causes chest pain, anginal pain is often described as tight squeezing, heavy pressure, or constricting feeling in the chest. The pain can radiate to the jaw, neck, or arm. Pain unrelieved by rest or nitroglycerin and lasting more than 15 min differentiates angina from MI Stable (exertional) angina occurs with exercise or emotional stress and is relieved by stress Unstable (periinfarction) angina occurs with exercise or at rest, but increases in occurrence and severity over time Variant angina (prinzmetal’s) angina is due to a coronary artery spasm, often occurring during periods of stress Expected findings: Anxiety/feelings of impending doom Chest pain: substernal or precordial Can radiate down the shoulder or arm or present as jaw pain Can be described as crushing or aching pressure (nausea, dizziness) Physical assessment Findings: pallor, and cool, clammy skin Tachycardia and heart palpitations Tachypnea and shortness of breath Diaphoresis Vomiting Decreased level of consciousness Makers (MI): Myoglobin (earliest markers but doesn’t last over 24 hrs.), Creatinine kinase-MB: peaks around 24 hr. after onset of chest pain. Level no longer evident after 3 days. Troponin 9I or T: any positive value indicates damage to cardiac tissue and should be reported. Troponin I levels no longer evident after 7-10 days, troponin T: levels no longer evident ECG ST elevation with MI Cardiac catheterization treatment for MI Care for MI involves vitals every 5 min until stable, continuous cardiac monitoring, hourly urine output, LAB data for enzymes, Admin o2 2-4 L/min Obtain and maintain IV access Medications: Nitro 3-5, can cause orthostatic hypotension, instruct clients to stop activity and rest, place under tongue and take every 5 minutes call 911 if pain doesn’t resolve after the 1st dose. Morphine sulfate is an opioid used to treat pain, Beta Blockers have antiarrhythmic and antihypertensive properties Thrombolytic agents: alteplase and reteplase are used to break up blood clots Thrombolytic agents have similar side effects and contraindication as coagulants, for best results, give within 6 hr. of infarction Antiplatelet agents: aspirin and clopidogrel to prevent platelet aggregation Anticoagulants : heparin and exorphin are used to prevent clots from becoming larger or other clots from forming DKA Undiagnosed or untreated DM1 non adherence to diabetic regimen, or reduced missed dose of insulin Stress, illness, infection, trauma, surgery Most common cause is infection Can result from dehydration and acidosis Expected findings: Flushed, Dry warm skin, hypotension, tachycardia, kussmaul breathing, confusion, abdominal pian, N/V decreased LOC, blurred vision, weight loss, weakness BG of over 300 Nursing actions Monitor vital Q15 then Q4 when stable Collect blood for metabolic profile before initiation of intravenous fluids Infuse 1L of 0.9% NACL over 1 hour after drawing blood supplies After 2-3 hr. or when BP returns to normal administer 0.45 NACL at 200-500 mL/hr When BG decreased to 20 infuse 5% dextrose Ensure potassium levels in range before insulin therapy Admin regular insulin bolus of 0.1-0.15 unit/kg Give sodium bicarbonate w/potassium if IV patient PH lowers than 7 Acidosis/Alkalosis and Metabolic/Respiratory symptoms and intervention. Objective data ALWAYS FIX THE PROBLEM THAT IS CAUSING THE IMBALANCE Respiratory Acidosis (Hypoventilation) - Respiratory depression from opioids, poisons, anaesthetic Clients who with inadequate chest expansion due to muscle weakness or trauma (pneumo or hemothorax). Airway obstructions, alveolocapillary blockage to a pulmonary embolus, thrombus, ARDS, chest trauma, drowning, or pulmonary edema, inadequate mechanical ventilation Results in: - Increased CO2, increased or normal H+ - Vitals: initial tachycardia and hypertension bradycardia and hypotension develop as acidosis worsens Dysthymias: VFIB is the first sign in intubated patients receiving anaesthesia Neurologic: initial anxiety, irritability, and confusion; lethargy and possibly coma develop as acidosis worsens Respiratory: ineffective shallow, rapid breathing Skin: Pale or cyanotic s/s: - Treatment: - Oxygen therapy, maintain patent airway, and enhance gas exchange (positioning and breathing techniques, ventilatory support, bronchodilators, mucolytics. Respiratory alkalosis: hyperventilation: - Caused by hyperventilation due to fear, anxiety, intracerebral trauma, salicylate toxicity, or excessive ventilation. Hypoxemia from asphyxiation, high altitudes, shock or early-stage asthma or concertation Results in: decreased Co2, decreased or normal H+ concentration S/S: - Vital signs: tachypnea Neurologic: inability to coventrate, numbness, tingling, tinnitus, and possible loss of consciousness Cardiovascular: tachycardia, ventricular and atrial dysrhythmias Respiratory: rapid, deep inspiration Treatment: - Oxygen therapy Anxiety reduction intervention Rebreathing techniques (bag) Metabolic acidosis - Results from excessive hydrogen ions Diabetic ketoacidosis Starvation Lactic acidosis can result from: heavy exercise, seizure activity, hypoxia Excessive intake of acids: ethyl alcohol, methyl alcohol, aspirin Inadequate elimination of hydrogen ions: kidney failure, sever lung problems Inadequate production of bicarbonate: kidney failure, pancreatitis Impaired liver or pancreatic function: liver failure Excess elimination of bicarbonate: diarrhea Results in: - Decreased HCO3 Increased H+ Manifestations: - Dysrhythmias - Vital signs: bradycardia, weak peripheral pulses, hypotension, tachypnea Neurologic: headache, drowsiness, confusion Respiratory: rapid, deep respirations (Kussmaul respirations) Skin: warm, dry, pink Metabolic Alkalosis - Caused by HCO3 excessive Oral ingestion of excessive amount of bases (antacids) Venous admin of bases (blood transfusions, total parenteral nutrition, or sodium bicarbonate acid deficit, caused by loss of gastric secretions(through prolonged vomiting, nasogastric suction), potassium depletion (due to diuretics), laxative overuse, Cushing’s syndrome increased digitalis toxicity Results in - Increased HCO3 Decreased H+ Manifestations - Vital signs: tachycardia, normotensive or hypotensive Dysrhythmias, atrial tachycardia, ventricular issues when pH increases Neurologic: numbness tingling, tetany muscle weakness, hyperreflexia, confusion, convulsion Respiratory: depressed skeletal muscles resulting in ineffective breathing Manifestations; - Varies with causes: (GI loses: administer antiemetics, fluids, electrolytes replacements) if related to potassium depletion, discontinue causative agent) Heroic phase of disaster response Characterized by a high level of activity with a low level of productivity. There is a sense of altruism, and community members exhibit adrenaline-induced rescue behavior. This phase often passes quickly. While the activity level may be high, the capacity to asses risk may be impaired and injuries can result. A charge nurse is discussing the phases of community response to disaster with nursing staff. Which of the following statements indicates an understanding of the heroic phase of disaster response - Personal are willing to work in dangerous conditions to provide assistance Snake bite Children ages 1 to 9 are at highest risk for snakebites. Keep arm at heart level or lower to reduce ethe spread of venom The nurse should be familiar with indigenous snakes in the community. Generally, ice, tourniquets, heparin, and corticosteroids are contraindicated in the first 6 to 8 hr. after the bite. Antivenom based on the type and severity of a snake bite is most effective if administered within 4 to 12 hr. Provide measures for respiratory support (oxygen, airway management, mechanical ventilation). Monitor compromised circulation (resulting from excess perspiration, vomiting, diarrhea). Restore fluids with IV fluid therapy. Monitor blood pressure, cardiac monitoring, ECG A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in teaching? - (maybe) the nurse should maintain continuous cardiac monitoring because the client is at risk for arrythmia (maybe) immobilize the limb a the level of the heart Immobile the affected extremity with a splint Bee sting Question is about how to remove the stinger -Kevin Scrape it with fingernail, credit card (any hard surface) A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teachings? - Remove by scarping Triage Green – can walk with minor injuries Yellow – Usually can walk and have injuries that are not live threating (broken bones etc) Red- requires immediate medical intervention, (patient has a RR over 30, delayed cap refill, changed LOC) Black - dead or not going to make it A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following should the nurse take? - Place a yellow tag on the client’s upper body A nurse is the triage officer in the emergency department when the four clients arrive following a factory explosion. Which of the following clients should the nurses care for first - An unconscious adult client who has sucking chest wound, respirations of 38, and capillary refill of <2 seconds - (second option probably the first) a client who has a piece of wood punctured into the chest wall and has audible hissing coming form the wound side A nurse is assisting with triaging clients following an explosion which of the following clients should the nurse identify as the highest priority - An conscious adult client who has second-degree burns on both lower legs; respiratory rate is >30/min Preplanning in response of disaster A charge nurse is discussing staff nurses’ responsibilities in preplanning for response to a disaster. Which of the following responsibilities should the nurse include in the discussion? - Identify community resources that are available Disaster preparedness education A community health nurse is providing a community education program about disaster preparedness. Which of he following should the nurse recommend the clients include in their family disaster readiness supply kit or “go bag” - Pencil and paper Whistle Copies of insurance Household bleach (always everything but antibiotics (pocket knife, bank account info) Smallpox Kevin said it’s a select all that apply that involves, knowing it gets confused for varicella, that its eradicated from most of the world, and how its transmitted (direct contact form person to person) A nurse is providing staff education about smallpox as a bioterrorism threat. Which of the following statements indicates an understanding of this agent? (Select all that apply) - Smallpox is transmitted person to person Naturally occurring smallpox has been eradicated from the world Smallpox is often confused with varicella A nurse is planning a staff education session regarding biological weapons of mass destruction. Which of the following should he plan to include in the session? (Select all that apply) - Anthrax, smallpox, botulism Intubation precautions and awareness: think safety Have resuscitation equipment to include a manual resuscitation bag with a face mask at the bedside at al times Ensure intubation attempts las no longer than 30 seconds before another reoxygenation Monitor vital signs and verify ET tube placement by checking end tidal carbon dioxide levels and chest Xray Monitor for hypoxemia, dysthymias and aspiration. Maintain a patent airway. Assess the position and placement Suction oral and tracheal secretion to maintain tube patency Clients receiving intubation can require sedation or paralytic agents to prevent completion Continuously monitor the during the weaning process and watch for signs of weaning intolerance. Respiration greater than 30/min or less than 8, blood pressure or heart rate changes more than 20% of baseline, SaO2 less than 90% Dysthymias, elevated ST segment, labored respirations, restlessness or anxiety/ change of consciousness. Following extubation monitor tube monitor for signs of respiratory distress or airway obstruction (ineffective cough, dyspnea, stridor) Assess SpO2 and vital signs every 5 min Encourage coughing, deep breathing, and use of the incentive spirometer A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the clients bedside? - Bag valve mask A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left sides chest wall expansion upon respiration. Which of the following complications should the nurse expect - Movement of the ET tube into the right main bronchus A nurse is assessing a client immediately after the provider removed the client’s endotracheal tube which of the following findings should the nurse report to the provider? - Stridor What is a pulmonary artery catheter for? Hemodynamic monitoring (CVP, PAP, PAWP, and cardiac artery pressure) Mixed venous oxygenation Infusion ports can be available A nurse is preparing a client for transfer to the ICU for a placement of a pulmonary artery catheters. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? - Hemodynamic status Cardiac arrest after returning to ROSC. Keep the client cool with ice packs to the groin or a cooling blanket after resuscitation to lower metabolic need- Kevin After a return of spontaneous circulation following the recusation of a patient show had a cardiac arrest, therapeutic hypothermia is prescribed. Which of the actions will the nurse include in the plan of care - Apply external cooling device NGN what to know (based on all recording/lectures/tutoring) First question is about a basic EKG: what interventions to do and what to monitor, look at whether the rhythm is compensating for something. Know cardiovert vs defib, we cardiovert AFIB, V Tach(with pulse) and SVT, we defib Pulseless Vtach and Vfib. Adenosine, BB, amiodarone with SVT. V Tach: BB, amiodarone and cardioversion. Think what can cause these rhythms (I have that in the rhythm section of BP (5 points) BOWTIE Another cardiac rhythm question with murmurs as objective data of what kind of rhythm it is. If you having a murmur in the aortic you’re having a swish and flow (probably a ventricle problem) Pulmonic issue (more like a right atrial issue) (5 points) BOWTIE Cardiac hematology and cardiology, non-essential, essential, contraindicated, you. Heart failure iron deficiency anemia, diuretics, supplements, labs to expect with diuretics, what is contraindicated with diuretics, what is contraindicated with heart failure, what do HF exacerbation look like. IF you know heart failure well you should be fine (6 POINTS) POST op PACU patient what to report the provider (highlight findings questions those are usually easy and since its PACU it's probably going to have to do with post intubation problem (4) They will give you ABGs and you have to know what to do and what monitor. Know the different symptoms and treatments/ what to monitor with respiratory acidosis/alkalosis and metabolic acidosis/alkalosis (intubation is an option, bicarb, ET tube placement) ( BOWTIE 5 points) Sepsis 4 priority treatment in the first hour (4 points) A patient with sepsis and dialysis: what to report to the provider. (Infection of the port) probably going to be swelling of the port and high wbc or fever (2 points) Angina vs MI drop down, DKA is an option 2 but it’s not that, know what symptoms angina have vs MI or how they would present differently and treatment (2 point drop down) Drop down is a scenario using critical thinking in the ER setting, given disease symptoms and how you would treat it. (he didn’t want to give me any info because he said if he did I would know what it is so it should be easy) (drop down. I think there is a Pulmonary embolism question based on recordings but he hasn’t talked about it.
