MDC 4 Exam 2 Rasmussen Questions with correct Answers

A patient comes to the ED having diminished breath sounds on his left lung and asymmetrical chest expansion when asked to breathe. The nurse feels the patient's trachea has deviated to the right side of the throat. What ...

A patient comes to the ED having diminished breath sounds on his left lung and asymmetrical chest expansion when asked to breathe. The nurse feels the patient's trachea has deviated to the right side of the throat. What is the patient suffering from? - ANSWER Pneumothorax A provider tells the nurse that a patient is having a simple pneumothorax. What treatment might be prescribed for the patient? - ANSWER Chest Tube A provider tells the nurse that a patient is having a tension pneumothorax. What could the nurse anticipate about how this will be treated? - ANSWER With a needle decompression thoracotomy A nurse sees a patient coming into the trauma bay with paradoxical chest movement. What might the patient be having? - ANSWER Flail Chest A provider tells the ED nurse that the patient has a flail chest. What does the nurse anticipate will happen next for the patient? - ANSWER Intubation and mechanical ventilation What is an early manifestation of hypovolemic shock? - ANSWER Decreased urine output A nurse is caring for a patient who is critically ill and has a fever, low BP and yellowish mucus coming from the nose. What type of shock is occurring with this patient? - ANSWER Septic Shock What is the main nursing issues revolving around rib fractures? - ANSWER Pain! Puncturing vasculature or organs. What can the nurse teach the patient who has had a rib fracture to decrease pain? - ANSWER Splint when coughing A nurse is caring for a patient with ARDS in the ICU. What manifestations might she see? - ANSWER Low oxygen levels that do not get better with 100% oxygen applied, bilateral pulmonary edema that is not cardiac related, broken glass lung appearance on the X-ray. A client ate peanuts and has an allergy to peanuts and tree nuts. What manifestations might the nurse see upon client arrival related to anaphylactic shock? - ANSWER Stridor and angioedema A client is having anaphylactic shock due to a bee sting. What medication should be given to treat this? - ANSWER Epinephrine A nurse is caring for a patient with ARDS. What treatment orders might the nurse see from the provider for the patient? - ANSWER Place them prone and on PEEP What are complications of PEEP? - ANSWER Pneumothorax Low BP What is ventilator associated pneumonia? - ANSWER Infection from being on the ventilator for a long time A nurse is learning about ARDS. What are the causes of ARDS? - ANSWER Sepsis, Infection, burns, near drowning, trauma, shock. A client with a bone infection is getting information on ensuring his infection does not progress into sepsis or septic shock. What might be some risk factors of the conditions? - ANSWER Infection risks, chancer, chemo, immunocompromised states, immunosuppressants, HIV A nurse will be preparing to care for a newly intubated patient. What are some things she must prepare and remember while caring for the patient? - ANSWER Place ambu bag at bedside, suction PRN, switch tube once a shift, assess respiratory status every 2 hrs, oral and mouth care every 2 hrs, wash hands, expect orders for PPI or H2RB, A patient is suspected to have a PE while in the ED. What might be some manifestations of this occurring? - ANSWER Low o2 saturation, low BP, sudden severe SOB, chest pain, LOC changes, petechiae, lung edema , ascites. A client was recently just extubated and now is showing signs of stridor and low oxygen levels. What might of occurred and who should be called? - ANSWER Irritation fo the throat form the tube. Call RRT What are clinical manifestations of hypovolemic shock? - ANSWER weak and thready pulse, decreased BP, increased HR, altered LOC, shallow and fast respiration, long capillary refill, decreased H/H, low urine output. A client has fluid volume excess due to heart failure. What are some of the important cardiac findings for this condition? - ANSWER Bounding pulse, JVD, central venous pressure is high, wedge pressure is high What must the nurse do immediately when a patient presents with an inhalation injury? - ANSWER Intubate to assume an airway, assess respiratory status. A burn patient presents to the ED. What are some of the signs they may present with leading to an inhalation injury? - ANSWER SOB, soot around nose, singed facial hairs, drooling, not swallowing, black membranes. What things could cause an elevated wedge pressure? - ANSWER FVE, left ventricular failure What are the components of DIC? - ANSWER Inappropriate clotting that uses up all the clotting factors and bleeding due to not having enough clotting factors bath the same time. A client comes in to the ED experiencing DIC. What treatment might the provider order for this condition? - ANSWER Clotting factors, blood, plasma, platelets, heparin or other anticoagulant What could happen if DIC is not treated? - ANSWER Refractory shock, septic shock, excessive blood loss A client is scheduled to go in for an escharotomy. What does this procedure entail? - ANSWER Involves surgical incision through the hardened dermis in 3rd and 4th degree burns to allow for circulation. Calculate the TBSA according to rule of 9s for this patient back of right arm is burned, entire backside. - ANSWER Back of right arm= 4.5% Entire backside= 18% Total= 22.5% Calculate the TBSA according to the rule of 9s for this patient left and right legs front and back groin back and front of lower abdomen - ANSWER left and right legs front and back= 9% groin=1% back and front of lower abdomen= 18% Total= 28% A patient has had massive blood loss following trauma. The nurse is concerned about hypovolemic shock. How should the nurse position the patient to prevent this? - ANSWER Either supine or in modified trendelenberg with feet up What are important interventions to be done during the acute phase of a burn injury? - ANSWER Prevent infection Prevent further skin injury and repair the wound Increase nutrition and calories What s/s prompts the burn nurse to know that fluid resuscitation has been completed? - ANSWER Occurrence of clear yellow urine at least 30 ml/ hr or 0.5 ml/kg/hr What might occur during the emergent phase of burns? - ANSWER A fluid shift hat causes hyperkalemia that resolves once fluid misgiven back to the patient. A client presents to the ED with a sucking chest wound. What cares shoulder delivered to the patient? - ANSWER Place an airtight gaze dressing over site. Intubate and place chest tube. Calculate the total amount of fluid that will be given to this burn patient within the 1st 24 hrs of fluid resus. Round to nearest whole number. Patient wights 135 lbs and has a TBSA of 30% - ANSWER 4 mls x 61.36 kg x 30%= 7,363 ml in 24 hrs Calculate the amount of fluid that will be given to this burn patient in the 1st 8 hours of fluid resus. Round to nearest whole number. Patient weights 280 lbs with a TBSA of 80% - ANSWER 4 mls x 127.3 kg x 80% / 2 = 20,360 ml in the first 8 hrs A patient with a severe spinal cord injury and may go into neurogenic shock. What are some of the signs and symptoms that might be seen? - ANSWER Low HR and BP, poikilothermia. A patient is diagnosed with neurogenic shock. What are key nursing interventions the nurse can provide for the patient? - ANSWER Ensure airway, Stabilization of the spine, keep patient in warm room. A nurse is going over orders before providing a patient with wound care. She sees the patient is allergic to sulfa drugs. What wound care dressing should not be applied to the patient? - ANSWER Silver sulfadiazine A client who is in severe neurogenic shock from a spinal cord injury from a car accident is given norepinephrine. There was no indication of a prior allergy to the medication, but the client is reporting the IV site is painful and itchy. What should the nurse do first? - ANSWER Stop the IV infusion Epinephrine does what to the vessels as norepinephrine does what? - ANSWER Epinephrine= vasodilates while Norepinephrine= vasoconstricts A client who has had an MI and may potentially go into cardigenic shock should not get which medication and why? - ANSWER Norepinephrine because further vasoconstriction can cause severe chest pain and decreased perfusion A patient is in a fluid volume deficit due to hypovolemic shock. How might their wedge pressure look like? - ANSWER It will be low A client is diagnosed with cariogenic shock after having a MI. What are key manifestations of this condition? - ANSWER SOB, crackles, pink sputum, low BP. A provider enters in to give dobutamine to a patient with cardigoenic shock. What is this medication and what does it do? - ANSWER Dobutamine is a inotropic medication that is used to improve how well the heart pumps. A provider tells the nurse the patient with a PE will be going to a test to confirm the clots presence. What is the name of this test and what is critical the nurse do before she sends the patient down? - ANSWER CT angiogram. Check for a shellfish or iodine allergy as the patient is going to get contrast! A patient is in septic shock. What orders might the nurse be presented with that are a part of the sepsis bundle? - ANSWER Lactate levels Blood cultures before giving ABXs Give broad ABXS Fluids given Vasopressors to increase BP A patient who had a PE is now in the ICU. What medications might be ordered for this patient to prevent clots? - ANSWER Anticoagulants such as heparin or warfarin A nurse notices a patient is prescribed both heparin and warfarin together. Is it okay to give both at the same time? - ANSWER Yes because the patient will likely go home on warfarin and will need to be introduced to it while being weaned off heparin A patient after having a PE will be going home on warfarin. What are some key teaching points the nurse should give him? - ANSWER Watch for bleeding- use bleeding precautions. Have steady intake of vitamin K food as it can counter the effects of the medication. Calculate the MAP for this blood pressure and determine if the patient will get good perfusion: Round to nearest whole number BP 95/48 - ANSWER 95 + 2 ( 48) /3 = 64 The patient is not perfusing well as normal MAP is 70-110 Calculate the MAP for this blood pressure and determine if the patient will get good perfusion: Round to nearest whole number BP 140/75 - ANSWER 140 + 2 (75) /3 =97 The patient is perfusing well as the MAP is between 70-110 If a patient with a ARDS has a good blood pressure, can they be given a diuretic to rid fluids? - ANSWER Yes but will likely need to be in low doses When might vasopressin be used in shock? - ANSWER In severe cases to prevent losses Explain what occurs in the compensatory stage of shock - ANSWER MAP decreases 10-15, vasoconstriction, increased thirst, decreased output, body tries to compensate, low pulse pressure, increased RR Explain what occurs in the progressive stage of shock - ANSWER Decreased MAP, anoxia or nonmetal organs, hyperkalemia, acidosis, hypoxia, ischemia, LOC changes, chest pain, unconsciousness Explain what can occur in the refractory stage of shock - ANSWER severe hypoxia, ischemia, necrosis, MDF is released, toxins can build up causing MODS and death What labs could be anticipated for any shock patient? - ANSWER F/E levels, H/H, increased lactic acid levels, ABG, high K levels, WBC count is elevated A nursing student is learning about the types of distributive shocks. What are they? - ANSWER neurogenic, septic, anaphylactic What is capillary leak syndrome? - ANSWER In burn patients, when the fluid leaks through the vessels causing a shift in vascular volume outside the vessel A patient comes in with having cardiac tamponade and obstructive shock. What is obstructive shock? - ANSWER Occurs when cardiac function is impaired due to obstruction causing inability for the heart to pump blood out A patient comes in with a severe MI that may progress into cardiogenic shock. He reports he has been using sildenafil for a fib for the past 20 years. what drug should not be given to the patient despite the shock manifestations? - ANSWER Nitroglycerin Which type of burn may need skin grafting? - ANSWER Full thickness burns A patient reports to the ED having a burn with a blister formed. What type of burn might this be? - ANSWER 2nd degree partial superficial or deep A patient is being discharged after skin grafts for a burn. What teaching is critical to provide in caring for the graft? - ANSWER No ROM near skin graft or skin area taken from. A patient is in septic shock. calculate how much fluid the patient will get if they weigh 160 lbs. Round to nearest whole number - ANSWER 30 mls x 72.8 kg = 2,182 ml A patient is in septic shock. calculate how much fluid the patient will get if they weigh 250 lbs. Round to nearest whole number - ANSWER 30 mls x 113. 6 kg = 3,409 ml What are important lab findings related to DIC? - ANSWER low fibrin levels, low platelets, increased PT/ aPTT, increased d dimer. What interventions should the nurse perform for the client in DIC? - ANSWER Check all drainage for blood and monitor I/O, check for petechiae or purpura, no sharp objects or injections, watch vitals signs and assess LOC What symptoms is MODS based on? - ANSWER Low grade fever high HR, SOB, increased WBCs, elevated glucose, pulmonary edema, renal and liver dysfunction after doing well for a short time. When might dialysis be needed for a MODS patient? - ANSWER When the creatinine is high and output is less than 480 ml/ 24 hrs What action should the nurse take when giving care to a patient in MODS? - ANSWER Assess organ function, given ventilatory support, inotrophics, compensate for the dysfunction A nurse caring for a patient on a vent notices the high pressure alarm is going off. What must she do next? - ANSWER Assess tube for obstruction, suction ,bag valve them until problem solved A nurse caring for a patient on a vent notices the low pressure alarm is going off. What must she do next? - ANSWER Look for disconnected tubing, leaks or poor connections A nurse caring for a patient on a vent notices the high respiratory rate alarm is going off. What must she do next? - ANSWER Assess need for weaning, give sedatives, paralytics, things to relax patient and decrease anxiety CMV ventilator hashes type of breathing pattern while SIMV has this type: - ANSWER CMV= full support with each breath being from the vent SIMV= patient can help with breaths Why might a PE be overlooked? - ANSWER Patient may not have the classic manifestations which can lead to variability in the condition