ATCN EXAM-with 100% verified solutions 2024-2025, Exams of Nursing

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ATCN EXAM-with 100% verified solutions 2024- 2025 Which resuscitation adjunct under the "G" primary assessment is this? -"L" laboratory studies (ABG's/Type and cross) Which resuscitation adjunct under the "G" primary assessment is this? -"M" monitor for continuous cardiac rhythm and rate assessment Which resuscitation adjunct under the "G" primary assessment is this? -"N" naso/orogastric tube consideration Which resuscitation adjunct under the "G" primary assessment is this? -"O" oxygenation and ventilation analysis (pulse oximetry/ETCO2/capnography) Which resuscitation adjunct under the "G" primary assessment is this? -"P" pain assessment and management Trauma primary survey for "H"? history and head to toe assessment Trauma primary survey for "I"? inspect posterior surfaces 10 Signs and sx of tension pneumothorax 1.chest pain 2.air hunger 3.respiratory distress 4.tachycardia 5.hypotension 6.tracheal deviation away from injury 7.unilateral absence of breath sounds 8.elevated hemithorax w/out respiratory movement 9.neck vein distention 10.cyanosis (late sign) Signs and sx of cardiac tamponade \1. Becks Triad= increased venous pressure(distended neck veins), decreased arterial pressure(hypotension), muffled heart tones 2. PEA 3. JVD &/or Kussmauls sign 4. Use FAST to dx 1.Metabolic acidosis is corrected by control of hemorrhage and admin of fluids and blood 2.The degree of metabolic acidosis is measured by the base deficit from the abg's. The base deficit helps estimate level of perfusion and pt's response to resuscitation Acid base balance, base deficit and shock 1. Normal -2 to 2 2. Mild -5 to -3 3. Moderate -9 to -6*** (-6 or more indicates severe injury and significant mortality) 4. Severe -10 or more Base deficit chart 1. normal 2. mild 3. moderate 4. severe Lactate levels help determine organ perfusion. Obtain lactate levels and correct to less than 2 Lactate levels and shock The approach to trauma care typically begins with what? notification that a trauma patient is arriving When preparing to receive a trauma patient, what should you keep in mind? safe practice, safe care What does "Safe practice" mean when receiving trauma patients? take into consideration the protection of the team (universal precautions/PPE/preparing equipment prior to patient arrival) What does "Safe care" mean when receiving trauma patients? that the patient is going to the right hospital, in the right time, for the right care Trauma primary survey for "A"? airway and alertness with simultaneous cervical spinal stabilization Trauma primary survey for "B"? breathing and ventilation Trauma primary survey for "C"? circulation and hemorrhage control Trauma primary survey for "D"? disability (neurological status: AVPU/GCS) Trauma primary survey for "E"? exposure and environmental control Trauma primary survey for "F"? full set of vital signs and family presence Trauma primary survey for "G"? get resuscitation adjuncts (LMNOP) an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. Reduced tissue perfusion causes cellular hypoxia-> cellular conversion from aerobic to anaerobic metabolism ->leads to accumulation of lactic acid -> metabolic acidosis define shock Urine output measures organ perfusion and adequate resuscitation Adults- 0.5 ml/kg/hr Peds- 1 ml/kg/hr baby- 2 ml/kg/hr Urine output and hypovolemic shock epidural hematoma the airway with cervical spine control When multiple victims are present at the scene of a major motor vehicle crash, the highest priority is given to tachycardia and hypotension Symptoms of compression of the vena cava in the pregnant trauma patient include: intubation of the patient assessment of the arterial blood gasses the need for chest tube placement The intervention that the nurse must anticipate in a patient who has sustained a severe crush injury to the chest and is SOB include: forceful manual compression and pelvic rock of the pelvis to determine instability For pelvic fractures NEVER place an occlusive dressing over the wound (taped on three sides) For an open bubbling chest wound tearing of a bridging vein between the cerebral cortex and a draining venous sinus Most common underlying cause of a subdural hematoma? 1. Respiratory distress 2. Asymmetry of breath sounds 3. Deviation of trachea to the opposite side of the defect 4. Marked decreased in cardiac output 5. Hypotension 6. Muffled heart sounds signs of tension pneumothorax the neck muscles are strong What is NOT an anatomical difference of children? burns that destroy the entire thickness of the skin -dark leathery appearance -mottled, or wax like appearance -painless -dry surface third degree burns muffled heart sounds distended neck veins hypotension S/S of cardiac tamponade (Beck's triad) retrograde urethrogram Radiographic procedure to r/o urethral injury Patient with RR of 10 blood or vomit in the oral cavity cervical spine injury Potential indications for nasal intubation infusion of IV crystalloid fluids judicious use of vasopressors close monitoring of the patient's BP and pulse anticipate invasive hemodynamic monitoring Treatment of neurological shock -remove damp clothing -warm fluids orally if pt can drink -placing the injured extremity in warm circulating water at 40 C Management of Frostbite - Administer IV fluids -Administer Sodium Bicarb -Close monitoring of renal perfusion/health (rhabdo) -Close monitoring of compartment syndrome The management of a crush injury infusion of warm fluids peripheral IV access short, large caliber IV catheters Increase heat in room Minimize draft, keep doors closed' Administer humidified and warm O2 (41C) in ET Remove all wet clothing Minimize body exposure Apply warm blankets Wrap child's head in warm towels Promote use of convective air heating devices Monitor temperature (core if possible) Administer fluids and blood through warmer (42C) Trauma Resuscitation Room alcohol seizures drugs chronic resp. conditions Patient condiitons which will alter the base deficit value CPP= MAP-ICP Central Perfusion Pressure (CPP) 70-100 mmHg Normal CPP for adults 0-10 mmHg Normal ICP at rest late sign of ICP, systolic will go up diastolic will go down, pulse drops, resp drop, temp goes up Cushings triad mild: 13-15 moderate: 9-12 severe disability: 3-8 vegatative state: <3 GCS scores anticipate the need for volume replacement due ti osmotic diuresis When using Mannitol for ICP elevation remember to >20 sustained What ICP warrants physician notification? 0-total paralysis 1-palpable of visible contraction 2-active movement with full ROM against gravity 3-active movement with full ROM against gravity AND some resistance 4-active movement, full ROM against gravity and Moderate resistance 5-normal active movement, full ROM against gravity and resistance muscle function test results measured from bottom of chin to top of shoulder Appropriate C-collar size absent distal pulses and poor capillary refill Not reliable in diagnosing compartment syndrome increasing HR Children only have one compensatory mechanism 30% A child can lose what percent of their blood before SBP decreases? hypoxia In Ped's bradycardia is often sign of bradycardia and cardiac arrest Hypoxia is the most common cause of ________ in childred