NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – R, Exams of Nursing

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NUR 2755 Multidimensional Care IV MDC4 Final Exam Why teach patient to deep breath and cough after surgery

• prevent pneumonia Gave double dose of medication, what to do first?
• Assess patient What to do when patient comes back from surgery, and they're declining (rapid, shallow respirations, elevated heart rate, blood pressure dropping), what do you do??
• Call rapid response team Allergy exposure situation

• more exposure to allergen the more risk to developing a reaction

Patient in lithotomy position for surgery, where would their experience post op discomfort??

• Shoulders Why do we have drainage tubes/what's the purpose??
• To help prevent infection Why do we give a patient with multiple sclerosis Baclofen??
• To treat muscle spasms Patient has head to toe trauma and at risk for developing ARDS, what is the earliest sign?
• Increased respiratory rate What is the most common first symptom with a patient with a PE?
• Chest pain Pain response in an unconscious patient? (peripheral pain response)
• Squeezing the nail beds

What are measures for a patient with a head injury, how do we prevent increase intracranial pressure?

• Decrease stimulus Slow movements Don't cough hard or blow nose Deep Breaths Slow exhale to help with pain control

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

Patient has clear fluid coming from nose, what tests would we do or see?

• Positive for glucose Yellow halo on white linen or filter paper Patient with spinal cord injury, how to lessen change of AD?
• Bowel/Bladder Program Patient with Parkinson's, when should you schedule their most demanding activities???
• When the drug therapy/medication peaks for them.

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

Normal drainage for surgical site?

• Clear (serous) or pale/red/watery (serosanguineous) Worrisome sign of post op patient??
• Restlessness Community disaster preparedness, what would be an organization to help?
• Medical Reserve Corporation FEMA Red Cross

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

DMAT??

• Disaster Medical Assistance Team Federal employees License is good in ALL 50 states How many days of medical supplies should you have if needed for a disaster, just making a disaster plan?
• 3 days Cimetidine for burn patients?? Why??
• Help with gastric ulcers Triage tags... what would we put on them to help??

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

• Nam e Age Inju ry (Anything to help identify) Any treatments we did Who we can contact/who has been contacted. Triage colors Somebody that has a thrombotic stroke, what is important assessment item, especially in the first 24 hours??
• Pupil response to light/size Someone had an ischemic stroke and getting thrombolytic treatment, what

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

are we trying to control in the first 24 hours??

• Blood pressure How to determine if patient can have tPA after stroke AFTER CT??
• Onset of symptoms within 3 hours. Long term Phenytoin therapy (seizures), what do we expect to see/a side effect, but we wouldn't stop the medication? (Expected side effect)
• Excessive gum tissue growth DO NOT STOP MEDICATION SUDDENLY

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

What would be a potential finding in postical phase of a generalized tonic clonic seizure what we would want to monitor for??

• Drowsiness Priority intervention in postical phase of tonic clonic seizure??
• Airway - assess breathing pattern 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??
• Can eat NO Caffeine What do you expect to see in a patient in ictal phase of generalized tonic clonic seizure??

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

• Jerkin g Stiffne ss Loss of consciousness Loss of bowel/bladder 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???
• Orient them Decerebrate assessment
• rigid arms, wrists/hands c shaped & flexed outward possible arched back

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

Patient is getting IV heparin for a PE, what would PTT be at for therapeutic levels??

• Higher --> like if its at 25, we would want to increase the rate of heparin

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

Gene Alteration CYP2C19 and history of PE, what to do to prevent further issues?

• IVCF - Inferior Vena Cava Filter Mean Arterial Pressure, how to correlate with blood loss??
• Lower blood volume = lower MAP How to calculate MAP??
• Double the bottom number of blood pressure, add that to the top number and then divide by 3. Example: BP is 120/80, 80+80 = 160 160 + 120 = 280

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

280/3= 93.

MAP would be 93. What to educate elderly patients on about rehydration to prevent shock??

• Increase fluids, drink on a regular schedule What lab value will be off in a patient with shock, septic shock?
• Lactic Acid What to remember when determining triage or prioritization of patients??
• ABCs Sick calls and tension with staff after a long week of critical care patients, what is important to remember in this aspect>>

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

• Debriefing

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

External disaster examples

• Tornad o Floodin g Hurrica ne When we see a patient passed out/unconscious at home, with cherry red skin color, what do we assume???
• Carbon monoxide poisoning Make sure that if a patient we did Parkland Formula, and still low urine output, what else can we do??
• Increase fluid

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

rate Monitor urine output Check electrolytes Parkland formula

• 4 mL x TBSA (%) x body weight (kg). 50% given in first 8 hours, 50% given over the next 16 hours. Patient with a burn, what electrolyte would we typically initially see with 3rd spacing of fluid??
• High potassium What patient would be at high risk for developing a PE??
• Hx of

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

DVT

Smokin g Oral birth control Pregnancy Immobility Major long bone fracture Hx of falls Post Op patients

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

How would you determine if patient is receiving good ventilation??

• Equal chest rise Stable vitals Skin color Capillary Refill What type of alarm would you hear if patient has mucous plug and needs suctioning??
• High pressure alarm initial phase of shock
• MAP decreased by 10 mmHg from baseline. Mild vasoconstriction. Increased heart rate. Vital organ function is NOT disrupted.

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

Indicators of shock are difficult to detect at this stage. THIS STAGE IS STILL REVERSIBLE. Nonprogressive phase of shock

• 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. Progressive phase of shock

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

• Decrease of more than 20% MAP. Anoxia of nonvital organs, hypoxia of vital organs. Moderate acidosis, moderate hyperkalemia, tissue ischemia. Some tissues die. Patient may have a sense of impending doom or "something bad". Patient may become confused and thirst increases. Rapid weak pulse, low blood pressure, pallor to cyanosis of oral mucosa and nail beds, cool and moist skin, anuria, and 5%-20% decrease in oxygen saturation.

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

Refractory phase of shock

• FINAL PHASE Final stage and also irreversible stage. Occurs when too much cell death and tissue damage has happened. Vital organs have extensive damage and cannot respond effectively to interventions, so shock continues. Severe tissue hypoxia with ischemia and necrosis. Buildup of toxic metabolites. MODS. Death. Clearly if patient is presenting to ER with heat exhaustion, what is the priority action of the nurse?
• IV Fluids Action is patient has bee sting.. if available?
• Epi

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

When patient presents to ER with suspicion of sepsis, what to do in the first few hours??

• Lactic acid Blood cultures Antibiotics AFTER blood cultures How to calculate TBSA?
• A&P head: each 4.5% (9% entire head) A&P chest: 18% each A&P arm: 4.5% each side on each arm (9% entire each arm) A&P leg: 9% each side, each leg. (18% entire each leg) Groin: 1%

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

Deep partial thickness burns

• Red to white Moderate Edema Yes pain Blisters are rate Yes eschar (its soft and dry) Healing time is 2-6 weeks Grafts can be used in prolonged healing time What happens to a patient that has drowned?
• Alveoli are collapsing, and pulmonary edema occurs

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen

GUARANTEED SUCCESS GRADED A+

What kind of scenarios would we see hospital disaster plan activated??

• Large influx of patients Example: explosion Wellness for nurses to prevent burn out and PTSD
• Counseling Encourage & Support coworkers Monitor each other's stress levels Take breaks when needed Talk about feelings Drink plenty of water Healthy snacks for energy Keep in touch with family,

NUR2755 / NUR 2755 Final Exam

(Latest 2021 / 2022): Multidimensional

Care IV / MDC 4 – Rasmussen