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NURS 239 REVISED STANDARD EXAM
Patient is allergic to penicillin, what other antibiotic could the patient be allergic to as well? - ANSWERS-Rocephin (Ceftrioxine) Keflex (Cephalexine) Maxipime (Cefepime) What is a side effect of aminoglycosides? - ANSWERS-Ototoxicity, check hearing loss What does the nurse do if vanco levels come back too high? - ANSWERS-hold the medicine and call the doctor A nurse is caring for a C. Diff patient, what interventions/precautions are correct to take? - ANSWERS--wash hands with soap and water -clean with bleach -DO NOT give patient immodium -contact precautions (enteric) Patient comes into the ER with a stable blood pressure, has a fever, is septic, but is not in shock yet, what is the priority intervention? - ANSWERS--cultures -antibiotics -fluids -tylenol
How do you determine adequate tissue perfusion for your patient?
- ANSWERS--MAP is 65 -adequate urine output -Good LOC -good cardiac output How would you know if the GI tract is affected after a trauma? - ANSWERS--paralytic ileus -hypoactive bowel sounds The nurse is caring for a patient with DIC, what interventions should be implemented? - ANSWERS--bleeding precautions -No IVs or injections -Avoid rectal tubes or probes -Oral care done with a soft toothette
- Weigh the dressings
- Suction on lowest setting What will the labs of a DIC patient look like? - ANSWERS-- Increased D.dimer -FDP increased -decrease in platelets -decreased fibrinogen
-blood pressure must be treated first! If the patient is in septic shock, their CVP is decreased, urine output is low, what order would you question from the physician?
- ANSWERS-Diuretics; lasix, bumex hyperdynamic phase of septic shock - ANSWERS-- widened pulse pressure -increased temp -increased RR -warm flushed skin hypodynamic phase of septic shock - ANSWERS-- decreased BP -decreased temp -decreased RR -decreased CVP -cold to touch -decreased cardiac output
- increased lactic acid (late stage)
- tachycardia Patient with septic shock has been given fluids and there is no change in BP, what intervention comes next? - ANSWERS- Norepinephrine (Levophed)
Patient comes in after being struck by lightening, what do you expect symptom wise from the patient? - ANSWERS-neuro- delated 12-24 hours cardiac - watch for dysrhythmias, cardiac monitoring 1st Degree Burn: Superficial - ANSWERS--sunburn -superficial -red, hot, painful -blanches still 2nd Degree: Superficial Partial Thickness - ANSWERS-- blisters
- blanching
- extreme pain
- red, mottled, moist
- peeling 2nd Degree: Deep Partial Thickness - ANSWERS-- Red/white, mottled
- NON-BLANCHING
- May or may not be painful
- EDEMATOUS 3rd Degree: Full Thickness - ANSWERS-- White or charred
A trauma is arriving to the ED in five minutes, what will the nurse need to grab first? - ANSWERS-2 large bore IVs What are contributing factors to DIC? - ANSWERS--ebola -sepsis -abdominal trauma Patient presents with a trachea shift, absence of breath sounds on left side, worsening hypotension. What does the nurse suspect? - ANSWERS-Hemothorax How do we know when someone has MODS? - ANSWERS--all systems are effected -hyperbilirubemia
- increased BUN/Creat
- decreased GI motility -increased liver labs -increased lactic levels How does a male patient present when having an MI? - ANSWERS--jaw pain -sweaty -shoulder pain -crushing chest pain
How does a female patient present having an MI? - ANSWERS-- indigestion -back pain -fatigue -nausea Nursing interventions for a patient having an MI? - ANSWERS- morphine, oxygen, nitro, aspirin (MONA) nitro education - ANSWERS-take up to 3x, then need to get to er check BP first! -check if patient has taken viagra Labs for heart attack - ANSWERS--troponin (peaks in 24 hours) -CKMB What causes the chest pain during an MI? - ANSWERS-decreased oxygenation to the myocardium Patient is having an MI with crushing chest pain, BP is low, sweaty, what can you now not give? - ANSWERS-Nitro
fibronlytic therapy criteria - ANSWERS--no more than 12 hours from the onset of chest pain -within 30 min of diagnosis of STEMI -ST elevation on EKG -ischemic chest pain is unrelieved by SL nitro -No predisposition to hemorrhage -No HTN -No recent sx -Not if had angina for 30 days Patient has taken three nitro and is complaining of a headache - ANSWERS--this is normal and suspected Patient just got a PCI done and is started on Cardizem (diltiazem). Why? - ANSWERS-Prevent Vasospasms used to treat arrhythmias, especially atrial fibrillation Patient HR is 48, you listen and hear wheezing, what med will you hold? - ANSWERS-- Beta Blockers (-lols) 3 B's of Beta Blockers -bronchospasm -bradycardia
-blood sugar (masked) Patient is having severe chest pain, and its been on and off for a week, what is this? - ANSWERS--stable angina How do you know when you can start decreasing nitro? - ANSWERS-when the patient is free of chest pain Patient is having an MI and is put on colace, why? - ANSWERS-to prevent vagaling -no straining You come on to shift, who will you assess first? - ANSWERS-- unexpected or new changes -post procedure pt -patient after heart cath and is bleeding signs and symptoms of cardiac tamponade - ANSWERS-Beck's Triad: JVD muffled heart sounds hypotension How do you know a LOW dose of Dopamine is therapeutic? - ANSWERS-Increases Urine Output
-ammonia level is high -jaundice -dark urine, bilirubin -urine output normal -poop is pasty -INR is increased -PTT is increased -PT is increased Clotting Cascade: Intrinsic Pathway - ANSWERS-Heparin (PTT) extrinsic pathway of coagulation - ANSWERS-Coumadin (PT) Portal hypertension signs and symptoms - ANSWERS--esophageal varices -GI bleed -Ascites -Spleenomegaly -Hemmorhoids Treatment for ascites - ANSWERS--albumin -spironolactone -paracentesis
Patient with liver failure has asities, hepatic encephalopathy. What lab values might you anticipate? - ANSWERS-- Abnormal Ammonia (normal: 15-45)
- Low Platelets (normal: 150-450k) -. Low WBC
- Increased Liver Enzymes Chronic renal failure skin - ANSWERS-- dry
- yellowish tan/brow
- pruritus Chronic liver failure skin - ANSWERS-yellow/brown (jaundice) Petechiae Good skin turgor (edema) Bruising Shiny early signs of hepatic encephalopathy - ANSWERS-hand writing changes (asterixis) Stage 1: mild confusion, sleep disturbances
Intrarenal Phase of AKI - ANSWERS-rhabdo Post renal phase of AKI - ANSWERS-kidney stone, foley kinked, prostate, ovarian cancer, bladder issues Patient comes back from dialysis and looks very agitated, confused, and hypotensive, what is the patient experiencing? - ANSWERS--disequilibrium syndrome -Tx = fluid bolud Patient with acute liver failure is having hematemesis, what is your priority for this patient? - ANSWERS-protect the airway- consider intubation Organ donation triggers - ANSWERS--GCS less than or equal to 5 -loss of 2 or more cranial reflexes -hypothermia protocol initiated -family changes code status -plan to D/C mechanical ventilation -Physician charts grim/grave prognosis Immunosupressant therapy after transplant - ANSWERS--higher risks for infection -cyclosporine is hepato and nephro toxic, high risk for cancer -corticosteriod watch for infection and increase in blood sugar
Bleeding Esophageal Varices Treatment - ANSWERS-- prevent first if possible
- balloon tamponade
- banding
- Octreotide (Sandostatin) OR Vasopressin
- Severe bleeding: FFP to replace clotting factors & Vit K What electrolyte causes a positive Chvostek's sign? - ANSWERS- Low calcium OR high phosphorus (inversely related) Patient comes in with dark urine, a fever, flank pain. They have glomerulonephritis, what do you think they might have had? - ANSWERS-Recent sore throat How long do you have to get an organ from one body to another if they donate - ANSWERS-Heart: 4 hours Liver: 12 hours Kidneys: 24 hours 80kg patient needs fluid volume replacement, how do you know they are adequately getting tissue perfusion? - ANSWERS-MAP of 70
priority intervention for a patient with an open chest wound? - ANSWERS-tape dressing with to three sides Normal signs of aging with the chest? - ANSWERS-stiffer shallow breath sounds muscle weaker less elasticity Patient is back from a thoracotomy, their Hgb is lower at 8, but their SpO2 is normal, what should the nurse do? - ANSWERS- Potential risk for Hypoxia Monitor HGB Someone is in a car accident, they have a tension pneumothorax on the right side, what are expected findings with this patient? - ANSWERS--deviation of trachea to unaffected side -HR and BP decreased -decrease/absent breath sounds on affected side -increase in intrathoracic pressure -decrease in cardiac output Tracheotomy Care - ANSWERS--hyperoxygenate before suctioning
-suction no more than 10 seconds -only suction when pulling out -no more than 3 times when suctioning
- never on high
- sterile or aseptic technique Patient is coming out of Sx, they had a thoractomy and lobectomy, what is the nurses highest priority? - ANSWERS-ABGS What to do if the chest tube falls out of the patient? - ANSWERS-- apply 3 sided dressing -assess patient first! -prepare for another chest tube insertion Causes of pulmonary embolism - ANSWERS--a-fib -long bone fx -DVT -any kind of cancer -trauma -amniotic emboli What is the definition of atrial fibrillation? - ANSWERS-Pooling blood; not a good contraction; decreased blood flow to atrium
