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NR 341 Final Exam with correct answers
Organ Donation Triggers - correct answer -1. talk about ventilator withdrawal/terminal wean
- comfort care measures
- GCS < or = 5
- Brain death testing
- Positive apnea test Apnea Test - correct answer --ran for 8-10 mins -take patient off vent but keep O -positive: no respiratory movement = increased CO Support for Organ Donation - correct answer --thyroid: levoythyroxine -DI: DDAVP/vasopressin/desmopressin and monitor UO -pancreas:(BG will run high) insulin, q 1 hour accu checks -blood pressure: disconnect with SNS, neuro storm, put patient on levophed and vasopressin -respiratory: vent dependent, maintain Hgb around 10 Serum CO2 - correct answer -HCO Nursing role for the donor patient - correct answer -scripted and consistent Brain death testing - correct answer -A: Apnea test B: EEG C: Cerebral angiography D: Radionuclide cerebral perfusion scan -will have A and C or D Circulatory Death - correct answer --after heart stops -OD's Organ Recipient Meds - correct answer -1. Prednisone
- Tacrolimus/Cyclosporine (need lab draws for therapeutic levels and nephrotoxic)
- Mycophenolate Mofetil Organ Recipient Precautions - correct answer --need to wear a mask -no raw fruit or veg unless properly washed -no fresh flowers/plants -no pet therapy Complications to Immunusuppressants - correct answer -1. HTN - put on BP meds
- Nephrotoxicity - keep all lab appointments
- Hyperlipidemia - put on meds to control levels
- Hyperglycemia - taught BG control
- Infection - BS ABX, antifungal, antiviral Rejection - correct answer --need to biopsy first Kidney Biopsy - correct answer --apply a pressure dressing -keep patient on effected side -bed rest for 24 hrs -assess for bleeding, flank pain, hematocrit, labs -avoid lifting objects for 5-7 days Liver Biopsy - correct answer --need to coach the patient how to breathe through the procedure since the liver is accessed
through the ribs -monitor for bleeding and pneumothorax -keep patient lying on right side for minimum of 2 hours Primary Survey - correct answer --done in 1-2 mins to set priority for patient -LOC: AVPU -A: Airway -> fire, chemical, C spine injury -B: Breathing -> contusion, fractured ribs, flail chest, neuro dysfunction to not able to move diaphragm deep enough, abdominal trauma affected diaphragm -C: Circulation -> control hemorrhage, 2 large bore IVs and administer fluids -D: dysfunction - neuro disabilities and cranial nerves -E: elements - is the patient safe, what is their exposure? -F: full set of VS/family - get quick info, allergies, what happened at scene, med hx -G: Get resuscitation adjuncts: FAST and EFAST FAST - correct answer -US to scan abdomen EFAST - correct answer -US scan to abdomen + lungs Secondary Survey - correct answer --patient needs to be stabilized first -HI: -H: full history -I: inspecting full head to toe and back of patient Halo Vest Care - correct answer -1. Inspect the pins on the halo traction ring. Report to HCP if pins are loose or signs of infection are present, including redness, tenderness, swelling, or drainage at insertion sites.
- Clean around pin sites carefully with half-strength hydrogen peroxide, water, or alcohol on a cotton swab as directed.
- Apply antibiotic ointment as prescribed.
- To receive skin care, have patient lie down with the head resting on a pillow to reduce pressure on the brace. Loosen one side of the vest. Gently wash the skin under the vest with soap and water, rinse area, and then dry it thoroughly. At the same time, check the skin for pressure points, redness, swelling, bruising, or chafing. Close the open side and repeat the procedure on the opposite side.
- If the vest becomes wet or damp, carefully dry it with a blow dryer.
- Encourage patient to use assistive device (e.g., cane, walker) to improve balance; encourage use of flat shoes.
- Remind patient to turn the entire body, not just the head and neck, when trying to look sideways.
- In case of an emergency, keep a set of wrenches close to the halo vest at all times.
- Mark the vest strap to maintain consistent buckling and fit.
- Avoid grabbing bars or vest to assist the patient.
- Keep sheepskin pad under vest. Change and wash pad at least weekly.
- If perspiration or itching is a problem, encourage patient to wear a cotton T shirt under the sheepskin. The T-shirt can be modified with a Velcro seam closure on one side. Tidaling in water chamber of chest tube - correct answer --water going up and down Water seal bubbling - correct answer --air leak See no air leak - correct answer --have the patient deep breathe and cough -if there is still no air leak: check the system for kinks -if there is still no air leak: lung has sealed over and chest tube ready to come out Steps when taking out chest tube - correct answer --notify provider or no air leak -cross clamp chest tube -Xray in 4 hours to see if pneumothorax developed -unclamp when come back from Xray -provider will let us know if it coming out -never leave the chest tube clamped when patient comes back
Carbon Monoxide - correct answer -put on 100% nonrebreather Support each organ: Burns - correct answer --Resp: vent -Kidneys: volume or CRRT if not enough volume since concerned about rhabdo as well -cardio: volume and pressors if we need them, positive inotrope Type of ulcer for burns? - correct answer -curlings ulcer Wound Management: Burns - correct answer --sterile and PPE before entering room -may need an escharotomy or a fasciotomy to release the pressure -topical ABX - assess for allergies to sulfa Nutritional Support: Burns - correct answer --need 5000 cal/day -high risk for paralytic ileus, may be on TPN Complications for Trauma/Burns: Hypothermia - correct answer --concern: cardiovascular dysfunction, coag problems, dysrhythmias (bradycardia, Afib, Vfib) -tx: positive inotropes, FFP, warm blankets, warm IV fluids and blood products, convection air blanket, increase room temp Complications for Trauma/Burns: Compartment Syndrome - correct answer --concern: pain, pallor, paralysis, pulselessness, paresthesia, paralysis, pressure, concern is decreased BF to tissue and necrosis -tx: prevent, fasciotomy Complications for Trauma/Burns: Rhabdomyolysis - correct answer --concern: acute renal failure -tx: fluids, UO needs to be 100-200 mL/hr Complications for Trauma/Burns: Venous Thromboembolism - correct answer --concern: PE -Tx: early mobility, blood thinners Burn Electrolyte Management - correct answer --Potassium: d/t cell damage will have hyperkalemia -tx: kayexalate, D50, insulin, if see cardiac instability would give calcium and possible bicarb Hypoglycemia - correct answer --BG < -causes: meds, NPO, noncompliance -sx: tachycardia, diaphoresis, hangry, may be asymptomatic if on BBs -tx: rule of 15 Rule of 15 - correct answer --give 15 grams or 4 oz (120 mL) of apple juice, re-check BG 15 mins later, if still low repeat, if over 70 give complex carb + protein (graham crackers and milk, PB, cheese or meal tray) -call provider to find out cause (could be d/t tapering of a steroid dose and insulin not adjusted) Hyperglycemia - correct answer --BG > -Causes: illness, noncompliance, age, decreased activity, meds nutrition (TPN), high stress surgeries DKA - correct answer --acute -type 1 diabetic -sx: 3 P's, blurred vision, change in LOC, ketones -> decrease in pH -> causes nausea/vomiting/abd pain -> metabolic acidosis -
kussmaul respirations, hyperkalemia -very dehydrated with loss of 6L or more -concern: dehydration and dysrhythmias, hyperkalemia DKA Tx - correct answer -1: ABC, C would be cardiac monitor and fluids, fluids is highest priority 2: Fluids: 2 large bore IVs, 1-2 NS in first hour, then slow down fluids and 1 L in next 2 hours 3: when glucose is around 250, add D5W to the regimen (K needs to be >3.3), need to 20-30 K+/hr to keep up with demand of loss
Switching off Insulin - correct answer -1. need to tolerate diet
- stable BG
- corrected anion gap
- awake and alert -give basal lantus 2 hours prior to stopping insulin infusion -meal coverage and correction HHS - correct answer --gradual onset -type 2 diabetics -cause: new diagnosis, not controlled enough on current regimen, noncompliance, infection, flu -many of these patients also have comorbidities -sx: same as DKA but no ketones, pH is normal -will be extremely dehydrated starting at 12L fluid lost -concern: dehydration, dysrhythmias, hyperkalemia HHS Tx - correct answer --need to rule out stroke since stroke can manifest in the same manner -same tx as DKA, but volume is at a slower rate How should you position a patient with burns to ear/face/neck? - correct answer -with no pillow DI causes - correct answer --central: tumor, brain dead, CNS infections, TBI -nephrogenic: dont recognize ADH at kidneys DI Symptoms - correct answer --hypovolemia -hypotension, tachycardia (losing up to 20 L/day) -water loss leaves sodium behind and causes hypernatremia -worry about neuro dysfunction, daily weights, -serum osmo elevated -urine will be dilute (low osmo, low specific gravity <1.005). DI Tx - correct answer --conserve water - want to keep water in the bloodstream -desmopressin (DDAVP) - central -thiazide -> nephrogenic - makes the nephrons more sensitive to ADH -low sodium diet -drink water -IV fluids, equal to urine output -too much meds can cause SIADH and vise versa DI concerns - correct answer --hypovolemia -neuro changes d/t high sodium SIADH Causes - correct answer --cancer, stroke, CNS disorders, lung disorders (small cell lung cancer) SIADH Sx - correct answer --volume overload mostly in veins -diluted sodium d/t excess water SIADH Tx - correct answer --meds to get rid of volume -diuretics: Na must be > -hypertonic saline to boost up sodium in order to give them diuretic -conivaptan IV -tolvaptan PO -fluid restriction 500-1000mL in 24 hours -good oral care q 1-2 hours d/t fluid restriction -lay flat to 10 degrees to decrease the brain response to ADH, increases preload and that should help turn off some of the triggering of ADH -daily weights -PROM and AROM
Magnesium - correct answer - Vtach - correct answer -1. confirm if real, stable, unstable, or dead?
- get VS Vtach Stable - correct answer --time for meds -amiodarone 150 mg IV bolus + infusion -needs a filter -SE: hypotension Vtach unstable - correct answer --consider sedation, synchronized cardioversion -followed by 150 mg IV bolus + infusion Vtach no pulse - correct answer --call a code -start CPR (30:2) -once code cart arrive, attach pad and defibrillate -CPR again and admin 1 mg epi IVP q 3-5 mins followed by 20 mL NS, let circulate for 2 mins -defibrillate -CPR and give 300 mg amiodarone IVP -once they convert back need to give amiodarone infusion Vfib - correct answer --treat same as Vtach no pulse -will have no pulse Torsades de Pointes - correct answer --polymorphic Vtach -run as Vtach and give magnesium 2 g IVP as directed Asystole - correct answer --flatline -first assess patient to make sure in 2 leads -verify that the patient has no pulse. -not a shockable rhythm -run as a code but no defibrillation -need to consider causes (5 H's, 5 T's) Pulseless Electrical Activity - correct answer --rhythm on ECG but no pulse -run same as asystole -do not give amiodarone since it is not a dysrhythmia 5 H's: Hypoxia - correct answer --give oxygen -may need to intubate 5 H's: Hypovolemia - correct answer --Bolus NS infusion and see if responding 5 H's: Hypothermia - correct answer --warm patient up 5 H's: H+ ions (acidosis) - correct answer --draw ABGs -give bicarb 5 H's: hypo/hyperkalemia - correct answer --cant fix hypokalemia as well - give 10-20 mEq/hr -hyperkalemia: D50, insulin, calcium, bicarb 5 T's: Tablets - correct answer --NG tube with gastric lavage -activated charcoal 5 T's: Tamponade - correct answer --needle decompression 5 T's: Tension Pneumo - correct answer --needle decompression
-chest tube 5 T's: Thrombosis (PE) - correct answer --TPA 5 T's: Thrombosis (MI) - correct answer --would see STEMI on ECG -troponin elevated -if able to revive, need to get to cath lab Causes of acute GI bleed - correct answer --AVMs -ulcers -esophageal varices -crohn's, UC, diverticulitis GI bleed assessment findings - correct answer --hypovolemia (tachy/hypotension) -hyperactive BS (blood going through GI tract) -emesis/stool (color) -orthostatic BP :Lying: 120/80 HR 82, standing 118/78 HR 115 = mild to moderate Lying: 120/80, HR 80, standing 80/50, HR 125 = moderate to severely dehydrated GI Bleed Treatment - correct answer --control bleeding -1. stabilize patient, 2 large bore IVs/central line, give fluids (isotonic), blood products (PRBCs/FFP 3-4/1), octreotide: if risk of portal HTN, IV/SQ, will decrease blood flow to splanchnic and decrease portal HTN, monitor BG GI Bleed Concern - correct answer --hypovolemic shock -airway (upper bleed increased risk of aspiration) -may need to be intubated to protect airway -roll to side then suction if vomit Cirrhosis Causes - correct answer -ETOH, gall bladder, cardiac, hepatitis, drugs Cirrhosis Early Assessment Findings - correct answer --increases liver enzymes -mild assessment changes Cirrhosis End Stage Assessment Findings - correct answer --normal liver enzymes (all of the liver cells have died) -massive assessment changes d/t livers inability to do its job -neuro changes: increasing ammonia levels -respiratory: right pleural effusion (no breath sounds in lower lung field), increased RR (diaphragm with start to get pushed up as ascites grows, increases risk of PNA) -GI: ascites, spider angiomas on abd, jaundice, clay colored stools -petechiae and leukopenia d/t splenomegaly -PT/INR increasing d/t lack of vitamin K -third spacing d/t low albumin -renal: hepatorenal syndrome Cirrhosis Early Labs - correct answer --increased liver enzymes Cirrhosis End Stage Labs - correct answer --normal liver enzymes -increased ammonia -increased bilirubin -increased PT/INR -decreased albumin -decreased platelets/WBCs Cirrhosis Treatment - correct answer --tracking fluid retention -daily weights -abdominal girth measurements -paracentesis if ascites gets too large
and increase in labs Pancreatitis Concerns - correct answer --organ support -calcium level -tx like they have shock
