Exam 1: NSG233/ NSG 233 (Latest 2023/ 2024 Update) Med Surg 3 Exam| Questions and Verified Answers| 100% Correct| Grade A- Herzing
Exam 1: NSG233/ NSG 233 (Latest 2023/
2024 Update) Med Surg 3 Exam| Questions
and Verified Answers| 100% Correct| Grade
A- Herzing
Q: what will the SPO2 of a Carbon Dioxide Poision pt look like
Answer:
it will be Nl
Q: whats does Hypothermia put pt’s at risk for?
Answer:
hypoxia
acidosis
dysrhythmias
Q: a pt w/ dysrhythmias secondary to hypothermia is having secondary v-fib, what should RN
know?
Answer:
pt must be rewarmed to >90F (32.2c) prior to defibrillation!!!!!
Q: who all is screened in IPV?
Answer:
q pt.
ask “do you feel safe at home?”
Q: whats the pt w/ Compensatory Shock look like?
Answer:
Normal BP
tachycardia
tachypneic
PaCO2<32 cold, clammy confused/agitated respiratory alkalosis Q: whats Compensatory Shock? Answer: first phase of shock, pt is able to maintain fluid vol, normal BP Q: whats Progressive Shock? Answer: shocks begins to fail to meet metabolic needs bp starts to lower Q: whats the pt w/ progressive Shock look like? Answer: systolic <90 MAP <65 NEEDS fluid for BP TACHYYY >150
rapid, shallow RR
crackles
mottled, petechiae
lethargic
metabolic acidosis
Q: whats the pt w/ irreversible Shock look like?
Answer:
REQUIRES MECHANICAL / PHARMACOLOGIC SUPPORT
erratic
REQUIRES INTUBATION/MECH VENT
jaundice
anuric – requires dialysis
profound acidosis
Q: whats MODS
Answer:
Multiple organ dysfunction syndrome
- altered organ function in acutely ill pt, requires mech vent for organ support
-can be a complication of shock
-common in sepsis pt
Q: how do you assess a MODS pt?
Answer:
tools such as APACHE, SAPS, PIRO, SOFA
Q: what can cause hypovolemic shock?
Answer:
external fluid loss – traumatic blood loss
internal fluid shifts – severe dehydration , severe edema, ascites
get pdf at learnexams.com
whats the order of tx of hypovolemic shock?
1-stop fluid loss!!
2- place 2 Lg bore IV (18 gauge)
- admin 0.9%NS (isotonic), whole blood or PRBC.
MUST WARM FLUIDS W/ MASSIVE TRANSFUSION D/T HYPOTHERMIA RISK.
what position should a hypovolemic shock pt be in?
modified Trendelenburg – restores intravascular volume
pt is undergoing hypovolemic shock d/t a hemorrhage, what should rn do to treat underlying cause?
Stop bleed – pressure.
pt is undergoing hypovolemic shock d/t severe NVD, what should rn do to treat underlying cause?
give meds to stop NVD
what types of fluids are administered to a hypovolemic pt?
NS
LR
albumin
plasma/ RBC
pt comes in w/ poisoning. whats the most important for RN to maintain?
airway stabilization
whats the s/s of carbon dioxide poisoning?
headache
dizzy
confused
palpations
muscle weakness
intoxication coma
death
whats the priority nursing assessment for a pt w/ carbon dioxide poisoning?
access carboxyhemoglobin levels
what will the SPO2 of a Carbon Dioxide Poision pt look like
it will be Nl
whats does Hypothermia put pt’s at risk for?
hypoxia
acidosis
dysrhythmias
a pt w/ dysrhythmias secondary to hypothermia is having secondary v-fib, what should RN know?
pt must be rewarmed to >90F (32.2c) prior to defibrillation!!!!!
who all is screened in IPV?
q pt.
ask “do you feel safe at home?”
whats the pt w/ Compensatory Shock look like?
Normal BP
tachycardia
tachypneic
PaCO2<32
cold, clammy
confused/agitated
respiratory alkalosis
whats Compensatory Shock?
first phase of shock,
pt is able to maintain fluid vol, normal BP
whats Progressive Shock?
shocks begins to fail to meet metabolic needs
bp starts to lower
whats the pt w/ progressive Shock look like?
systolic <90 MAP <65 NEEDS fluid for BP TACHYYY >150
rapid, shallow RR
crackles
mottled, petechiae
lethargic
metabolic acidosis
whats the pt w/ irreversible Shock look like?
REQUIRES MECHANICAL / PHARMACOLOGIC SUPPORT
erratic
REQUIRES INTUBATION/MECH VENT
jaundice
anuric – requires dialysis
profound acidosis
whats MODS
Multiple organ dysfunction syndrome
- altered organ function in acutely ill pt, requires mech vent for organ support
-can be a complication of shock
-common in sepsis pt
how do you assess a MODS pt?
tools such as APACHE, SAPS, PIRO, SOFA
what can cause hypovolemic shock?
external fluid loss – traumatic blood loss
internal fluid shifts – severe dehydration , severe edema, ascites
what does a hypovolemic shock pt look like?
low intravascular volume
low Venus return
low stroke vol
low CO
low tissue perfusion
what can cause neurogenic shock?
spinal cord injury
spinal anesthesia
other CNS damage
depressant action of meds
lack of glucose – insulin
whats neurogenic shock?
Normally, during states of stress, the sympathetic stimulation causes the BP and HR to increase.
In neurogenic shock, the sympathetic system is not able to respond to body stressors = opposite CM
clinical manifestations of neurogenic shock?
sx of parasympathetic stimulation
dry, warm skin
hypotension w/ bradycardia
whats the medication TX of anaphylactic shock?
IM/ SCepinephrine – FIRST TX LINE
1:1,000 CONCENTRATION
NEVER IV
Diphenhydramine (Benadryl) – given IV – reverse effects
Albuterol (Proventil) – may given to reverse histamine induced bronchospasm
whats the medical TX of neurogenic shock?
goal: -restoring sympathetic tone via spinal stabilization or proper positioning
-prevent further damage
-maintain patent airway
cautious fluid resuscitation
vasopressors = increase bp
atropine = increase HR
whats the medical TX of septicemia?
collect blood culture
broad spectrum IV antibiotics until organism identified
fluid first for hypotension – usually 0.9% NS
-vasopressors for pt non responsive to fluids
anticoagulants – prevent DIC
whats the medical TX of cariogenic shock?
fix cause – ex: stent placement
tx like HF = decrease workload
decrease preload = diuretics
decrease SVR = arterial vasodilation
decrease HR
(digoxin, beta blocker)
increase contractibility (digoxin, dopamine)
whats a pt w/ shock look like? overall.
increased RR
decreased BP
Increased HR
Decreased urine output
increased blood sugar
cool, clammy skin
whats the interventions RN can due to help w/ family of shock pt?
keep informed
encourage fam to stay w pt
Allowing family presence in the critical care areas of the hospital enhances the family role and builds trust in the caregivers
how can an RN help w family cope w sudden death of pt
- quiet location
- take whole fm together
-reassure everything possible was done
-avoid using “passed on”
-use touch, offer coffee, water, Chaplin services
-encourage family support
-advoid giving sedation to fam member
-encourage viewing pt if desired
-cover misconfigured / injury areas on pt
-go w fam to see pt / dont leave fam alone
-allow fam to touch pt
-spend time w fam, listen to them
-encourage talking
-avoid unnecessary info
whats CISM
critical incident stress management
facilitates healthy coping
3 steps :defusing, debriefing, and follow up
describe the Defusing process in CISM.
immediately post critical incident
-staff encouraged to discuss feelings
-contact info to talk to someone
describe the debriefing process in CISM.
participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time.
- by the end of this step : should feel closure
describe the follow-up process in CISM.
Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy
describe the ESI for triaging pt’s
level 1: urgent
level 5: lease urgent
based on patient acuity and resources needed.
whats the responsibilities of triage nurse?
pt assessment & reassessment
initiate emergency tx prn
manage/ communicate pt in waiting room
provide edu
sort pt into priory group
transport pt to appropriate tx area
whats the goals for pt w/ hemorrhage
control bleed
maintain adequate blood vol of tissue oxygenation
prevent shock
whats the antidote for warfarin
vit K
What’s the antidote for heparin?
protamine sulfate
whats a pt w heat exhaustion look like?
high body temp accompanied w/ :
headache
anxiety
syncope
profuse diaphoresis
gooseflesh
orthostasis
what position should a heat exhaustion pt be in?
supine in cool environment
how are fluids given to heat exhaustion pt ?
IV
Po – if tolerated – sodium supplement & electrolytes
whats the goal for a frost bite pt?
restore nl body temp
-Constrictive clothing/jewelry are removed, remove wet clothes
if involving lower extremities – dont allow ambulation.
whats the medical tx for frost bite pt?
controlled, rapid rewarming
frozen extremities placed in 37-40C bath for 30-40 mins
analgesics given -rewarming can be painful
dont handle altered body part
once rewarmed : protect/prevent further injury, elevated. sterile gauze/cotton placed between affected phalanges = prevents maceration, bulky dressing placed.
whats frost bite?
trauma d/t freezing temperatures and freezing of the intracellular fluid and fluids in the intercellular spaces.
results in cellular and vascular damage
may result in venous stasis and thrombosis
what body parts are commonly affected by frost bite?
feet
hands
nose
ears
how are frost bite degrees labeled?
1 degree : numbness, redness
2 degree :blistering, no major damage
3 degree: all skin layers – permanent damage
4 degree : full depth tissue destruction
whats Nonfatal drowning?
survival for at least 24H post submersion that caused respiratory arrest.
common consequence = hypoxia
whats Corrosive poison?
alkaline and acid agents that can cause tissue destruction after coming in contact with mucous membranes.
nursing management for poisoning pt.
control airway, ventilation, O2
determine substance ingested, amount, time since ingested
s/s
age, wt
health hx
Gastric lavage
actived charcoal
how is Gastric Lavage Use in pt who Ingested Poisons?
only useful within 1 hour of ingestion, sustained-release substances, or massive life-threatening amounts of a substance.
why is gastric aspirate said & sent to the lab?
for toxicology screenings
how is activated charcoal administered?
PO or NGT
small intermittent doses to decrease vomiting
should be diluted as a slurry – easier to drink
what potions can’t be used w activated charcoal?
corrosives
heavy metals
hydrocarbons
ions
lithium
why is potassium administered w/ or after meals?
decreases gastric irritation
how to administer potassium
mix orals liquids, powders, and effervescent tablets in atheist 120ml of water, juice or carbonated beverages
when is IV K+ indicated?
cannot take PO
severe hypokalemia
rn establishes adequate urine output
never give undiluted via IV
the the goals of pts undergoing alcohol withdrawal?
adequate sedation- usually via benzoos
pt rest & recover w/o injury to peripheral vascular damage
why is a drug Hx required for pts undergoing alcohol withdrawal?
to elicit information that may facilitate adjustment of any sedative requirements.
whats the purpose of bentos in a pt w/ alcohol withdrawal
reduce agitation
prevent exhaustion
prevent seizures
promote sleep
meds given to alcohol withdrawal patients?
lorazepam
Haloperidol
esmolol
whats the main goal of tx for a pt w a wound?
restore physical integrity and function to injured tissue while minimizing scarring and preventing infection
what should a documented wound look like in a chart?
photographs – especially for DM case
size, color, shape, drainage, depth
when/how wound happened
why is it important to determine when a wound occurred?
tx delay = increased infection risk
what the aspects of a wound assessment?
inspection
extend of damage / presence of foreign body
sensory motor ad vascular function
laceration
skin tear w irregular edges & vein bridging
avulsion
tearing away of tissue from supporting structures
abrasion
denuded skin
ecchymosis/ contusion
blood trapped under skin – bruise
hematoma
tumorlike mass of blood under skin
stab
incision. of skin w well defined edges
usually by sharp object
typically deeper than is long
cut wound
incision of the skin with well-defined edges
usually longer than deep
patterned wound
wound represents outline of an object
whats the nursing management of hypothermic patients
remove wet clothing
continuous monitoring
rewarming – active internal & passive external
supportive care
monitor ABC
monitor core body temp via esophageal, rectal or bladder
what is supportive care in a pt w hypothermia?
external cardiac compression
defibrillation of ventricular fibrillation (pt w temp under 90F has spontaneous Vfib)
mechanical vent & heated humidified oxygen
administer iv fluids
administer sodium bicarb
anti arrhythmic meds
inser cath
what does the administration of warmed IV fluids correct in a hypothermic pt?
corrects hypotension
maintain urine output maintain core rewarming
whats the purpose of administering sodium bicarb to a hypothermic pt?
correct metabolic acidosis PRN
why do we insert indwelling catheters in hypothermic pts?
to monitor urinary output and kidney function
When is active rewarming used and give examples of what it is?
moderate – severe hypothermia
less than 28°C to 32.2°C [82.5°F to 90°F])
cardiopulmonary bypass
warm fluids
warmed humidified o2
warmed peritoneal lavage
When is passive rewarming used and give examples of what it is?
mild hypothermia
32.2°C to 35°C [90°F to 95°F]).
over the bed heaters
warming blankets
why might pts w mild hypothermia experience dysrhythmias or electrolyte disturbances?
cold blood from peripheral tissues has high lactic acid levels
so when blood goes to core = decreased core temp
= dysthymia and electrolyte disturbance
whats decompression sickness?
AKA “the bends”
occurs in pt who engaged in high diving or high altitude flying
nursing tx for decompression sickness?
patent airway and adequate ventilation
100% o2
chest xray for aspiration
start 1 IV line w LR or NS
s/s of decompression sickness
joint/extremity pain
numbness
hypesthesia
loss of ROM
neurologic sx mimic those of a stroke – indicating an air embolus
— transfer pt to hyperbaric chamber
when is Antivenin most effective?/
given within 4 -12 hour after snakebite
assess circumference of affect part q 15 mins
whats the premedication of Antivenin
Benadryl or cimetidine
-antihistamines decrease allergic response
how to administer Antivenin
premeditate
give within 4-12 hours
give Antivenin via IV infusion ( sometimes IM)
may be diluted in 500-1000ml of NS
infuse slowly, increase rate after 10 mins if no reaction
total dose infused after first 4-6 hours post bite
no limit of how many Antivenin vials to give
whats the three stages of Lyme disease
- bulls-eye rash -5cm w red borders – erythema migrans typically in axilla groin or thigh within 4 wk of tick bite. accompanied w flu like sx.
- stage 2 occurs is antibiotics not initiated. within 4-10wks. sx of joint pain memory loss poor motor function and cardiac abnormalities. facial nerve palsy most common sx.
- weeks- years post bite. long term affects such as arthritis, neuropathy. 10-20% of pt experience this even w proper tx.
whats flail chest frequently a complication of ?
blunt trauma from steering wheel
describe flail chest
3 + adjacent ribs fractured at 2+ sites resulting in free floating rib segments.
during inspiration detached rib moves paradoxical manner, pulling inward, reducing amount of air inhaled. on expiration, flail segment bulges outward.
s/s of Pneumothorax
depend on size/cause
pain sudden and pleuritic
minimal respiratory distress w slight chest discomfort & tachypnea w a small/uncomplicated Pneumothorax.
large Pneumothorax = ARDS, axioms, air hungry, dyspnea, use of accessory muscle , cyanosis
assessing Pneumothorax
tracheal alignment
expansion of the chest
breath sounds
percussion of the chest.
simple Pneumothorax = midline trachea, chest expansion decreased , diminished breath sounds
goal of Pneumothorax
The goal of treatment is to evacuate the air or blood from the pleural space.
medical Tx of Pneumothorax
chest tube (28 Fr) is inserted near the second intercostal space; this space is used because it is the thinnest part of the chest wall, minimizes the danger of contacting the thoracic nerve, and leaves a less visible scar.
tube is directed posteriorly to drain the fluid and air
then suction applied
whats a simple Pneumothorax
spontaneous Pneumothorax
air enters plural space through a breach of parietal or pleura
commonly – rupture of a bleb
whats a Traumatic Pneumothorax
air escapes from a laceration in the lung itself and enters the pleural space or from a wound in the chest wall.
whats Tension Pneumothorax
air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall.
could be complications of another Pneumothorax
whats PCA Pump
patient-controlled analgesia
any method that allows a person in pain to administer his or her own pain relief.
commonly IV morphine bolus
considering for a PCA pump
cognitive assessment
LOC
developmental status
assess pt/ fam teaching about pain management
is pt opioid tolerant? (pt taking 60mg + morphine for 1 week+)
asses pain level
sedation assessment via RASS
respiratory assessment
o2 sat
what should an RN observe a crush injury pt for/
hypovolemic shock dt extravasation of blood into injured tissues once compression was released
spinal cord injury
erythema
fractures
acute kidney injury
what causes septic shock
invading organisms
whats a septic pt look like
proinflammatory cytokinesLeads to Systemic Inflammatory Response Syndrome
= low bp decreased co, tissue perfusion, impaired cellular metabolism
whats the Compensatory Stage of Shock
mild decrease in BP triggers RAAS system to compensate
increases epinephrine/ norepinephrine
Adrenals also release cortisol = increase glucose
adrenal glands to release renin & aldosterone = fluid / NA retention = increasing BP
whats the Progressive Stage of Shock
bp low enough body can’t compensate
lack of o2 to muscle = heart ischemia
increased capillary leakage = hypovolemia, fluid overload
high metabolic demand = metabolic acidosis
whats the Irreversible Stage of Shock
profund hypotension hypoxia and acidosis
needs mechanical vent
MODS
recovery unlikely
plan for end of life w fam
nursing interventions in the tx of septic shock
collect blood culture
broad spectrum IV until organism identified then switch to narrow
fluid for hypotension
add vasopressors for shock
anticoagulants prevent DIC
Inotropic Medications
DobutamineDopamine
Epinephrine
Milrinone
Improve contractility, increase stroke volume, increase cardiac output
Vasodilators
Nitroglucerine
Nitroprusside
Reduce preload and afterload, reduce oxygen demand of the heart
can cause hypotension
vasopressors
Norepinephrine
Dopamine
Phenylephrine
Vasopressin
Epinephrine
increase blood pressure
what are abnormal carboxyhemoglobin levels?
nonsmokers: >2%
smokers : >9%
Rhabdomyolysis
Destroyed skeletal muscle cells empty contents into circulation, causing kidney problemsS/S: muscle pain & weakness, elevated CK, dark brown urineCan lead to acute kidney failure (Tx: Fluids)
septicima
growth of bacteria in the blood
Intra-abdominal injury care
Risk for hemorrhage – monitor for shockLiver – right shoulder painSpleen – left shoulder painIf stable –> CTIf unstable –> FAST exam (focused assessment with sonography for trauma)Management: ABCs, C-spine precautions, NPO, antibiotics/tetanus, monitoring, surgery PRN
Sepsis
Life threatening response to septicemia