NR 341 Final Exam 64 Questions with Answers,100% CORRECT

NR 341 Final Exam 64 Questions with Answers high school student comes to ed with headache, fever, and neck pain - CORRECT ANSWER expect lumbar puncture bc indicative of bacterial meningitis Status epileptics medi ...

NR 341 Final Exam 64 Questions with Answers high school student comes to ed with headache, fever, and neck pain - CORRECT ANSWER expect lumbar puncture bc indicative of bacterial meningitis Status epileptics medication - CORRECT ANSWER benzodiazepines (Lorazepam (ativan) is drug of choice) When the first line drugs are not effective for status epileptics, given to place pt in induced coma - CORRECT ANSWER phenobarbital Delirium nursing interventions - CORRECT ANSWER quiet environment, reorient, speak slowly, dark room, maintain consistent routine, identify threats to safety what to monitor following electrical burns - CORRECT ANSWER telemetry for 24 hours Priority for facial burns - CORRECT ANSWER airway/intubate Patients with burns on face/neck are at risk for what? - CORRECT ANSWER airway obstruction Patient has VS showing infection on burn site - what to do? - CORRECT ANSWER get burn and wound culture process of getting blood cultures for burns - CORRECT ANSWER Do blood cultures before any antibiotics are given Burns stress ulcers and prevention - CORRECT ANSWER Curling's ulcer; NG tube is the prevention priority for carbon monoxide burns - CORRECT ANSWER oxygen with non rebreather mask other priority for burns - CORRECT ANSWER fluids superficial burn (1st degree) - CORRECT ANSWER like a sunburn (epidermis and maybe small portion of dermis) Partial thickness burn (2nd °) - CORRECT ANSWER epidermis and most of dermis Full thickness burn (3rd °) - CORRECT ANSWER Same as partial thickness but may extend into subcutaneous tissue; nerve damage - Thick, dry leathery appearance Deep Full thickness burn (4th °) - CORRECT ANSWER Destruction of all layers plus muscles, tendons & bones - Black with no edema Escharectomy - CORRECT ANSWER surgical removal of eschar priority intervention for DKA - CORRECT ANSWER fluids interventions for DKA and HHS - CORRECT ANSWER insulin drip w/ regular insulin, *check blood glucose every hour!! , monitor labs, electrolyte replacement - fluid replacement: First use 0.9% NS Then 0.45% NS Dextrose added when glucose approaches 200 mg/dL - electrolyte replacement Potassium Maintain between 4-5 mEq/: Phosphorus (K-phos replacement) Magnesium difference between DKA and HHS - CORRECT ANSWER DKA → occurs Type 1 DM, BG > 350, metabolic acidosis, kussmaul's respirations, fruity breath, flushed/dry skin, orthostatic hypotension, ketones in urine, weight loss HHS → occurs in Type 2 DM, NO ketoacidosis, BG average > 600, more electrolyte imbalances and renal dysfunction, higher serum osmolarity than DKA Insulin drip - CORRECT ANSWER monitor glucose every hour, check electrolytes every few hours for mass causality - CORRECT ANSWER greatest good for greatest number of people who would you give a black tag to in a mass causality - CORRECT ANSWER Full cardiac arrest Open or unresponsive head injury No pulse Leg fracture and large bone (large bones like femur and pelvis) - biggest concern - CORRECT ANSWER fat embolism treatment for fat embolism - CORRECT ANSWER extremity immobilization Long bone leg fx or pelvic fx complications - CORRECT ANSWER fat embolism or compartment syndrome Rhabdomyolysis - CORRECT ANSWER CK lab can show this Tx → IV fluids to achieve a urine output of 100-200 ml/hr 5 P's - CORRECT ANSWER pain, pallor, pulselessness, parasthesia, paralysis why be wary of SaO2 monitors when pt. has carbon monoxide poisoning - CORRECT ANSWER Cannot distinguish between oxyhemoglobin & carboxyhemoglobin Insulin therapy (DKA & HHS) - CORRECT ANSWER Fluid replacement initiate first; monitor K+ Hourly glucose monitoring Decrease glucose by 50 to 75 mg/dL/hr When glucose is < 200 mg/dL, adjust infusion to maintain 150 - 200 mg/dL - keep K+ between 4 - 5 Transitioning to subQ therapy - CORRECT ANSWER Blood glucose < 200 mg/dL - Ketosis must be resolved before transition Two of the following criteria met (DKA): pH > 7.30 HCO3 > 15 mEq/L Anion gap ≤ 12 mEq/L Insulin therapy - transitioning therapy - CORRECT ANSWER Basal/bolus insulin regimen preferred Long-acting/short- or rapid-acting insulin Administer subQ insulin prior to d/c IV insulin Monitor Q6-8 hours Determined by meal schedule, and if NPO, then Q6h ARDS and cerebral edema - CORRECT ANSWER Caused by rapid intracellular fluid shifts during IV administration of fluids identify ventricular pacemaker - CORRECT ANSWER fires before P waves what to do for new onset of severe chest pain - CORRECT ANSWER give O2 first and then EKG VAP bundle - CORRECT ANSWER Elevate HOB 30-45 degrees Awaken daily and assess readiness to wean and extubate Stress ulcer disease prophylaxis (PPIs) Protonix Pepcid Venous thromboembolism (VTE) prophylaxis Oral Care Q2h - suction oral secretions and brush teeth Chlorhexidine once a shif what does CVP measure - CORRECT ANSWER systemic fluid volume what does a cvp of 1 indicate - CORRECT ANSWER hypovolemia what does a cvp of 26 indicate - CORRECT ANSWER fluid overload and can indicate cardiogenic shock normal cvp levels - CORRECT ANSWER 2-6 Disseminated Intravascular Coagulation (DIC) - CORRECT ANSWER a condition in which blood clots form throughout the body, blocking small blood vessels -often caused by injury or infection that causes overactive clotting important time frames for pt. experiencing a stroke - CORRECT ANSWER - Door to CT scan completion 25 minutes - FIRST PRIORITY!! - Admission to monitored bed 3 hours difference between dialysis and CCRT - CORRECT ANSWER dialysis is faster than CCRT expected action of dialysis - CORRECT ANSWER filters blood, maintains electrolytes, gets rid of excess fluid liver condition needing immediate attention - CORRECT ANSWER varices bleeding and abdominal ascites with SOB treatment for ruptured esophageal varices - CORRECT ANSWER endoscopic intervention, octreotide, vasopressin labs to check for liver cirrhosis - CORRECT ANSWER AST, ALT, ammonia causes of liver cirrhosis - CORRECT ANSWER Toxins/drugs (acetaminophen) Viral hepatitis (Hepatitis B) Hypoperfusion/shock/ischemia Dysfunction → portal hypertension, varices causes of mallory weiss tear - CORRECT ANSWER NSAIDs, retching s/s of mallory weiss tear - CORRECT ANSWER Clots and arterial bleeding Bright red blood identifying pt. who may have mallory weiss tear - CORRECT ANSWER Forceful retching Dry heaves May be seen in bulimic pt Long-term NSAIDs or aspirin #1 priority for acute pancreatitis - CORRECT ANSWER volume replacement Thyroid storm - CORRECT ANSWER Think hypermetabolic 2 important signs to look for with pancreatitis - CORRECT ANSWER cullen's sign (bruising around umbilicus) turner's sign (bluish flank discoloration) - report immediately! parenteral feeding appropriate when - CORRECT ANSWER GI needs rest or is not operational how often to check residual for enteral feedings - CORRECT ANSWER every 4 hours if giving TPN and next bag is not ready, what do you do - CORRECT ANSWER hang D10 (10% dextrose) Peptic ulcer - CORRECT ANSWER get IV access going What therapy is for swallowing? - CORRECT ANSWER speech Patient with dysphagia - CORRECT ANSWER Bedside swallow screen before meds and meals Pacemaker NOT working, what is the first priority - CORRECT ANSWER Assess for malfunction Pt is on BiPap and needs education - CORRECT ANSWER need respiratory therapist Pt has wheezing, crackles, diminished breath sounds - CORRECT ANSWER give albuterol when giving TPN and lipids - CORRECT ANSWER check BG G-tube → pull out 245, push all back in, hold for one hour, then recheck