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 NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (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 GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ friends and SO Do not work more than 12 hours How do we treat frostbite? - rapid rewarming: bath with warm water, pain management What are some concerns with frostbite? - Edema and swelling --> elevation above level of heart. Patient has overheated, hot to touch, flushed face and passed out at a sporting event. (Heat Stroke). What do we do? - 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! NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ With overheating/heat stroke, do we want to cause shivering?? Why or why not? - No! Shivering is the body's was of warming the body. NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ What causes serious arrhythmias in patients with hypothermia?? - Blood pooling in the extremities, blood is shunted from getting to the heart. Therefore, lactic acid lab will be abnormal. This will cause the arrhythmias. NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ What will we HEAR with a pneumothorax? Expected finding - Diminished breath sounds What do you see with a flail chest? The most distinctive sign?? - Paradoxical chest movements What is the initial reaction for a low-pressure alarm, what would you check first?? - low pressure alarm = not getting enough oxygen. Bag the patient manually. High pressure alarm, absent breath sounds in right upper chest what is it likely to be?? NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+ - Pneumothorax How to know if spinal shock is still continuing in a spinal cord injury patient? - Absent/decreased reflexes **Protect the head! Patient is having a seizure, what would you do? - Left side Lay flat loosen clothing padded side rails protect NUR2755 / NUR 2755 Final Exam (Latest 2021 / 2022): Multidimensional Care IV / MDC 4 – Rasmussen GUARANTEED SUCCESS GRADED A+