NUR 2755 Final Exam Multidimensional Care IV- MDC 4 Rasmussen College, Exams of Nursing

Download NUR 2755 Final Exam Multidimensional Care IV- MDC 4 Rasmussen College and more Exams Nursing in PDF only on Docsity! NUR 2755 Final Exam Multidimensional Care IV- MDC 4 Rasmussen College MDC4 Final Exam 1. Why teach patient to deep breath and cough after surgery 2. prevent pneumonia 3. Normal drainage for surgical site? 4. Clear (serous) or pale/red/watery (serosanguineous) 5. Worrisome sign of post op patient?? 6. Restlessness 7. Clearly if patient is presenting to ER with heat exhaustion, what is the priority action of the nurse? 8. IV Fluids 9. Action is patient has bee sting. . if available? 10. Epi 11.Community disaster preparedness, what would be an organization to help? 12. *Medical Reserve Corporation* i. FEMA 13. Red Cross P a g e 1 | 25 14.DMAT?? 15. Disaster Medical Assistance Team Federal employees i. License is good in ALL 50 states 16.How many days of medical supplies should you have if needed for a disaster, just making a disaster plan? 17. 3 days 18.Cimetidine for burn patients?? Why?? 19. Help with gastric ulcers 20.Triage tags. . . what would we put on them to help?? 21. Na me Age Injury i. (Anything to help identify) Any treatments we did 22. Who we can contact/who has been contacted. Triage colors P a g e 2 | 25 41.How to determine if patient can have tPA after stroke AFTER CT?? 42. Onset of symptoms within 3 hours. 43.Long term Phenytoin therapy (seizures), what do we expect to see/a side effect, but we wouldn't stop the medication? (Expected side effect) 44. Excessive gum tissue growth i. *DO NOT STOP MEDICATION SUDDENLY* P a g e 5 | 25 45.What would be a potential finding in postical phase of a generalized tonic clonic seizure what we would want to monitor for?? 46. Drowsiness 47.Priority intervention in postical phase of tonic clonic seizure?? 48. Airway - assess breathing pattern 49.Prep for an EEG?? They know they'll have one in the morning, so what prep do they need to do or not do beforehand?? 50. Can eat i. NO Caffeine 51.What do you expect to see in a patient in ictal phase of generalized tonic clonic seizure?? 52. Jerkin g Stiffness i. Loss of consciousn ess Loss of bowel/blad der 53.What to do when someone is coming out of a coma - had head injury and they're starting to wake up now after a few days what would we want to do??? P a g e 6 | 25 54. Orient them 55.Decerebrate assessment 56. rigid arms, wrists/hands c shaped & flexed outward possible arched back 57.Patient is getting IV heparin for a PE, what would PTT be at for therapeutic levels?? 58. Higher --> like if its at 25, we would want to increase the rate of heparin P a g e 7 | 25 75.External disaster examples 76. Tornad o Flooding Hurricane 77.When we see a patient passed out/unconscious at home, with cherry red skin color, what do we assume??? 78. Carbon monoxide poisoning 79.Make sure that if a patient we did Parkland Formula, and still low urine output, what else can we do?? 80. Increase fluid rate Monitor urine output Check electrolytes 81.Parkland formula 82. 4 mL x TBSA (%) x body weight (kg). 50% given in first 8 hours, 50% given over the next 16 hours. 83.Patient with a burn, what electrolyte would we typically initially see with 3rd spacing of fluid?? 84. High potassium P a g e 10 | 25 85.What patient would be at high risk for developing a PE?? 86. Hx of DVT Smoking i. Oral birth contr ol Preg nanc y Imm obilit y 87. Major long bone fracture Hx of falls i. Post Op patients P a g e 11 | 25 88.How would you determine if patient is receiving good ventilation?? 89. Equal chest rise Stable vitals Skin color Capillary Refill 90.What type of alarm would you hear if patient has mucous plug and needs suctioning?? 91. High pressure alarm 92.initial phase of shock 93. MAP decreased by 10 mmHg from baseline. Mild vasoconstriction. Increased heart rate. Vital organ function is NOT disrupted. Indicators of shock are difficult to detect at this stage. THIS STAGE IS STILL REVERSIBLE. 94.Nonprogressive phase of shock 95. MAP decreases by 10-15 mmHg from baseline. Moderate vasoconstriction. Increased heart rate and decreased pulse pressure. Chemical compensation. Decreased urine output, stimulation of thirst reflex, mild acidosis, mild hyperkalemia. Tissue hypoxia occurs in nonvital organs and in the kidneys but is not great enough to cause permanent damage. Restlessness, tachycardia, increased respiratory rate, falling systolic blood pressure, narrowing pulse pressure, cool extremities, and a 2%-5% change in oxygen saturation. THIS STAGE IS STILL REVERSIBLE. P a g e 12 | 25 105. Red to white Moderate Edema Yes pain i. Blisters are rate 106. Yes eschar (its soft and dry) Healing time is 2-6 weeks i. Grafts can be used in prolonged healing time 107. What happens to a patient that has drowned? 108. Alveoli are collapsing, and pulmonary edema occurs P a g e 15 | 25 109. What kind of scenarios would we see hospital disaster plan activated?? 110. Large influx of patients Example: explosion 111. Wellness for nurses to prevent burn out and PTSD 112. Counseling i. Encourage & Support coworkers Monitor each other's stress levels Take breaks when needed 113. Talk about feelings Drink plenty of water i. Healthy snacks for energy 114. Keep in touch with family, friends and SO Do not work more than 12 hours 115. How do we treat frostbite? 116. rapid rewarming: bath with warm water, pain management 117. What are some concerns with frostbite? P a g e 16 | 25 118. Edema and swelling --> elevation above level of heart. 119. Patient has overheated, hot to touch, flushed face and passed out at a sporting event. (Heat Stroke). What do we do? 120. Get out of the sun, hydration (sips), cool them down - get clothes wet. The priority is to get them out of the sun and into the shade and cool them down! 121. With overheating/heat stroke, do we want to cause shivering?? Why or why not? 122. No! Shivering is the body's was of warming the body. P a g e 17 | 25 138. What will we HEAR with a pneumothorax? Expected finding 139. Diminished breath sounds 140. What do you see with a flail chest? The most distinctive sign?? 141. Paradoxical chest movements 142. What is the initial reaction for a low-pressure alarm, what would you check first?? 143. low pressure alarm = not getting enough oxygen. Bag the patient manually. 144...................................................................................High pressure alarm, absent breath sounds in right upper chest............what is it likely to be?? 145. Pneumothorax 146. Patient has head to toe trauma and at risk for developing ARDS, what is the earliest sign? 147. Increased respiratory rate 148. What is the most common first symptom with a patient with a PE? 149. Chest pain P a g e 20 | 25 150. Pain response in an unconscious patient? (peripheral pain response) 151. Squeezing the nail beds 152. What are measures for a patient with a head injury, how do we prevent increase intracranial pressure? 153. Decrease stimulus Slow movements i. Don't cough hard or blow nose Deep Breaths 154. Slow exhale to help with pain control P a g e 21 | 25 155. Patient has clear fluid coming from nose, what tests would we do or see? 156. Positive for glucose i. Yellow halo on white linen or filter paper 157. Patient with spinal cord injury, how to lessen change of AD? 158. Bowel/Bladder Program 159. How to know if spinal shock is still continuing in a spinal cord injury patient? 160. Absent/decreased reflexes i. **Protect the head! 161. Patient is having a seizure, what would you do? 162. Left side Lay flat i. loose n clothi ng padde d side rails prote ct head P a g e 22 | 25