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NSG 239 Exam 2 Flashcards | StudBud
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NSG 239 Exam 2
NSG 239 Exam 2
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1
What complication is associated with LIGHTNING INJURIES?
may appear stunned or confused
may result in cardiac arrest.
may have confusion or be comatose.
CNS injury
2
TREATMENT OF BITES: SATA
Tetanus prophylaxis
Leave puncture wounds open
Antibiotics if bite is > 4-6 hours old.
Cover wound with clean gauze
Avoid cleaning with copious irrigation and debridement.
Rabies prophylaxis weight-base dose: 4 injections on days 0, 3, 7, and 14.
3
Severe HYPOTHERMIA s/s: SATA
Increased RR, HR, BP
Cardiac dysrhythmias
Decreased neuro reflexes
Hyperactive neuro reflexes
Decreased RR, HR, BP
Decreased pain responsiveness
4
Fire, explosion, loss of critical utilities, violence ▪Communication problems:computers, equipment are Internal disaster
False
True
5
SNAKE BITES • Treatment: SATA
Ensure patent IV line
Remove constrictive clothing and jewelry
Mark, measure, record circumference of bite
Contact poison control for antivenin guidance
Monitor heart function and blood pressure
Resuscitation equipment
6
Hospital Drowning Treatment: SATA
Gastric decompression with NG tube or orogastric tube
Oxygen administration or intubation
Ensure spine stabilization
Check airway clearance/ventilatory support
7
Assessment: Refractory : SATA
Release of toxic metabolites and enzymes damage vital organs
Disseminated intravascular coagulation (DIC)
Multiple Organ Dysfunction Syndrome (MODS)
Lungs, liver, GI, heart, brain, kidney functions lost
8
Preventative medication for Acute Mountain Sickness is Acetazolamide (DIAMOX)
True
False
9
A MAP of 70-100 is normal
False
True
10
Anaphylactic Shock s/s: SATA
Hypotension
Tachycardia
Hives
Pruritis
Bronchospasm
Rhinorrhea
11
A high lactic acid value means
lactic acidosis
, can be caused by: Severe loss of water from the blood (dehydration).
False
True
12
Reduce absorption of poisoning with: SATA
Dermal cleansing
Gastric lavage
Sacral lavage
Activated charcoal within 1 hour of ingestion
Activated charcoal within 48 hour of ingestion
Eye irrigation
13
NURSE COMPETENCIES : SATA
Broad knowledge base
Priority setting
Technical skills
Slow assessment
PATIENT SAFETY
Initiative
14
FIRE RESPONSE: Turn OFF oxygen
True
False
15
Neurogenic Shock: Parasympathetic stimulation: SATA
Bradycardia
Dry, warm skin (poikilothermic)
Hypotension
Impaired breathing
16
Vasopressors are commonly used to correct hypotension.
norepinephrine is the preferred first line vasopressor
False
True
17
Less vital organs become anoxic and ischemic in the compensatory stage
True
False
18
HEAT STROKE Treatment: SATA
Axillary or Oral thermometer
Administer fluids
Oxygen
Ensure large-bore IV
Rectal thermometer
Cooling blanket
19
Do not jump in a body of water if being chased by bees
False
True
20
Mass Casualty Incidents always require assistance resources outside the affected community like the Red Cross or FEMA.
True
False
21
In severe hypothermia, perform extracorporeal rewarming → cardiopulmonary bypass or hemodialysis
False
True
22
Sepsis: Assessment: SATA
low or high grade fever
Mild hypotension (increase in systolic), elevated WBC count
Warm extremities d/t vasodilation
Increased RR, increased HR, decreased urine output
23
When is Oxygen therapy used during shock?
Used at any stage of shock
Used at any compensatory stage of shock but only with decrease in O2
Used at any refractory stage of shock but only with decrease in O2
Used at any stage of shock but only with decrease in O2
24
Neurogenic Loss of sympathetic tone : Spinal Injuries
True
False
25
ABG and Lab Results: SATA
PaO2 80-100 mm Hg Decreased
Lactic acid < 1 mmol/L Increased
pH 7.35-7.45 Decreased
BUN/Cr – Increased Urine osmolality and specific gravity increased
Potassium 3.5-5 mEq/L Increased
PaCO2 35-45 mm Hg Increased
26
Hemoglobin F: 12-16 g/dL, M: 14-18 g/dL Increased (fluid shift, dehydration) Decreased (hemorrhage)
True
False
27
Cardiogenic shock: Medication Management: SATA
Pain management (Morphine)
Sympathomimetics (Dopamine and Dobutamine)
Vasodilator (Nitroprusside or Nitroglycerine)
Diuretics (Furosemide)
28
Hypovolemic Shock Medications: SATA
Oxygen therapy
Positive Inotropic agents: Dobutamine, epinephrine
Vasopressin: vasoconstriction, incrz systemic vascular resistance, incrz BP
Vasoactive agents: Norepinephrine
29
Clients in septic shock have increased blood glucose and may need insulin
True
False
30
Impairment of the heart to pump effectively as a result of a non-cardiac factor
Distributive shock
Hypovolemic shock
Obstructive shock
Cardiogenic shock
31
Assessment: Progressive: SATA
Seizure activity
Rapid, weak pulse
Confusion/sense of impending doom
Decrease in MAP > 20 mm Hg
Conditions causing shock need to be corrected within 1 hour of onset
Decreased 02 (80%)
32
Stages of FROSTBITE: SATA
Grade1 - No visible changes
G3:small blister w/dark fluid/cool,numb,blue or red body part, nonblnchable
Grade1 - hyperemia/edema
Grade 2 hyperemia/edema
Grade 4 – blistering, numb, cold, bloodless, necrosis into muscle and bone
Grade 2 - large fluid-filled blisters/partial thickness skin necrosis
33
Treatment for High Altitude Pulmonary Edema (HAPE)
Nifedipine
Acetazolamide (DIAMOX)
Dexamethasone
systemic antibiotics
34
ANTHROPODS Treatment: topical antiseptic ▪ Some bites may require antibiotics
True
False
35
Assess for Human trafficking: Know the warning signs: SATA ▪ Physical signs:
back pain, missing patches of hair
burns, bruises, vaginal/rectal pain
Hungry, Starvation
Unusual tattooing or branding marks
Headache, dizziness
jaw problems, and head injuries
36
Poison/gas exposure → look for SLUDGE symptoms: SATA
Salvation
Urination
Defecation
Emesis
Gi Upset
Lacrimation
37
Types of Distributive shock: SATA
Anaphylactic
Septic
Neurogenic
Nephrogenic
38
FROSTBITE INTERVENTIONS: SATA
Tetanus shot
Tight non-adherent sterile dressing
Rapid rewarming
Assess for Compartment Syndrome
Elevate body part above heart
Topical/systemic antibiotics
39
Neurogenic Shock Medications: SATA
Norepinephrine
Inotropic agents - Dopamine
Phenylephrine
Corticosteroids
Atropine
IV fluids
40
Hospital policy says how and who activates the Emergency Preparedness Plan
False
True
41
Septic Bundle – within 1 hour: SATA
Heparin/platelets/clotting factors for DIC
Hydrocortisone
Insulin
Oxygen therapy – Mechanical ventilation (ARDS)
42
HEAT STROKE s/s: SATA
Tachycardia
Hypotension
Elevated cardiac troponin
Mental status changes
Tachypnea
Hot dry skin (may continue to perspire)
43
Cardiogenic shock: Management : SATA
Oxygen
Echo
Pulmonary artery catheter insertion
Angioplasty and stenting if blocked artery
Balloon pump inserted in aorta to reduce heart workload
Hemodynamic monitoring
44
Hematocrit F: 37-47%, M: 42-52% Increased (fluid shift, dehydration) Decreased (hemorrhage)
True
False
45
Septic Shock (Distributive): SATA
Endotoxins (gram- )cause massive vasodilatn, inflammation, cap permeability
DIC
Systemic inflammatory response syndrome (SIRS)
Signs and symptoms resemble the late stages of hypovolemic shock
46
DISASTER TRIAGE MASS CASUALTY
: SATA
Yellow: urgent, but can wait a few minutes
Yellow: urgent, but can wait a few hours
Red: emergent/needs attention now
Purple: Extreme danger/ Surgery needed
Green: walking/wounded/non-urgent
Black: dying or dead
47
RN completing an asesment on a pt incompensatory stage of shock. Which of the following findings should RN expect? SATA
Cool extremities
RR 32
HR 110
DIC
Increased urine output
Weak pulse
48
ED ENVIRONMENT
:
Requires RN specific certifications
False
True
49
Cardiogenic Shock Diagnostics: SATA
ECG: records electrical activity of the heart using electrodes
Cardiac Cath: reveal blocked or narrowed arteries
Ballooning: help blood flow and taking some of the workload off your heart.
Chest X-ray: Shows size, shape of heart and if there's fluid in your lungs.
Arterial line: BP monitoring and titration of vasoactive infusions.
Echo: Evaluates the heart's pumping strength ie. post Heart Attack
50
Emergency Severity Index (ESI): SATA
Level 5: Minor
Level 1: Critical
Level 4: Non-urgent
Level 3: Urgent
Emergent (1&2)
Level 2: Emergent
51
Racemic epi: nebulized, can give IV
True
False
52
Cardiogenic Shock Assessment : SATA
Pulmonary Edema
Auscultation: faint heart sounds, gallop rhythm
Tachycardia, tachypnea, decreased BP, cool, clammy skin
oliguria, cyanosis, confusion
Pulmonary artery pressure (PAP) increases
Chest pain
53
A decrease in intravascular volume of at least 15-30%
Hypovolemic
Distributive
Cardiogenic
Obstructive
54
Bees/wasps – remove jewelry and stinger, ABCs, epinephrine/antihistamines, apply ice packs
False
True
55
Diphenhydramine (antihistamine) + pepcid used for Anaphylactic shock
False
True
56
Enhance elimination for Poison with Golytley q 4-6 hr
True
False
57
PRIMARY SURVEY: SATA
D (Diagnosis) AVPU: neuro assessment
Pulseless: CAB (Circulation, airway, breathing) = INITIATE CPR
Masive bleding /uncontroled external hemorrhage: STOPPING BLEED IS PRIORITY
D (disability) AVPU: neuro assessment
58
Treatment of hypovolemic shock to increase CO, circulation to heart and improve blood flow to vital organs
Lateral
Reverse trendelenburg
Supine
Modified trendelenburg
59
Septic Shock Assessment: SATA
UTI
MODS evident
Low WBC count
ARDS
Poor clotting with uncontrolled bleeding
Cold, clammy skin
60
The nurse should keep the affected extremity at heart level, not above or below it following a rattlesnake bite.
True
False
61
Assess for Human trafficking: Know the warning signs: SATA ▪ Psychosocial signs:
Eager to flee
Stress, anxiety
suicidal ideation
self-loathing
fear, paranoia
depression, shame
62
LABS for Heat exhaution : elevated hct, hyponatremia, mild azotemia, abnormal liver function, elevated CK
True
False
63
Common cause of Cardiogenic Shock
Myocardial infarction
Valvular rupture
Dysrhythmias
Valvular stenosis
Cardiomyopathies
Myocardial degeneration
64
S/S of Refractory phase: SATA
Therapy is effective
Cold, dusky extremities
Rapid loss of consciousness
Unmeasurable O2
Nonpalpable pulse
Shallow respirations
65
Multiple organ dysfunction syndrome: Identified failure of critical organ function in patients that have sustained SIRS
True
False
66
PRIORITY INTERVENTIONS FOR MCI: SATA
Decontaminate
Move to a hospital
Treat and stabilize
Evacuate Self
67
Use aseptic technique MEWS Know CLABSI and CAUTI protocols
Vasoconstrictive prevention
Septic Shock prevention
Nephrogenic shock prevention
Cardiogenic Shock prevention
68
Septic Bundle – within 1 hour: SATA
Urine cultures, chest x-ray, sputum culture, wound culture
Draw lactate level
Broad-spectrum antibiotics (Vancomycin & Zosyn)
Fluids
Obtain blood cultures
Vasopressors (norepinephrine)
69
S/S for High Altitude Pulmonary Edema (HAPE): SATA
Tachycardia and tachypnea when mobile
Fatigue, weakness
Cyanosis of lips and nailbeds
Chest x-ray → pulmonary infiltrates
ABG → respiratory alkalosis/hypoxemia
Persistent dry cough
70
Endotoxins (gram-negative bacteria) and mediators : Septic Shock
True
False
71
EVENT RESOLUTION/DEBRIEFING: SATA
Incident commander Deactivates the ERP
Debriefing ▪ Crisis Support
MRC Medical Reserve Corps ▪Volunteer medical,public health care profesionl
Implement toxin specific intervention
Incident commander Calls the stand down
Debriefing ▪ Administrative review
72
Give Dexamethasone for client with HACE: HIGH-ALTITUDE CEREBRAL EDEMA
True
False
73
AVOID administering antivenin for black widow bites
False
True
74
HEAT EXHAUSTION Treatment: SATA
Rehydrate with water or dioralyte
Stop physical activity
Avoid Sun between 11a-2p
Wear tight form fitting clothes
75
4 Stages i-C-P-R of shock : SATA
Progressive Compensatory mechanisms begin to fail
Compensatory Body compensate thru vascular constriction increased HR
Refractory Irreversible shock with organ failure → (MODS)
Compensatory Body compnsates increase cardiac output restore tissue perfusn
Progressive Overall metabolism aerobic
Initial Decrease in MAP < 10 mm Hg
76
To be dx w/ SIRS, 2 or more of the ff: low or high body temp, increased HR, increased RR, and an abnormal WBC count.
True
False
77
EMTALA - Emergency Medical Treatment and Labor Act:
No one can be denied a medical screening
False
True
78
First Aid Frostbite care▪ Observe for
early signs: white, waxy skin
▪ Use body heat to warm affected area
False
True
79
Black widows and scorpions – apply ice, ABCs, transport to hospital
True
False
80
Lungs are most often the first organ initiating the MODS cascade.
True
False
81
Blood volume is not lost, its distributed to interstitial tissues where it can’t perfuse organs (relative hypovolemia)
Hypovolemic shock
Distributive shock
Obstructive shock
Cardiogenic shock
82
Patient is in septic shock if they require vasopressor therapy to maintain MAP > 65 mmHg, and lactate is > 2mmol/L
False
True
83
Hypovolemic Shock--Causes/Risk Factors: SATA
Liver disease (blood clotting regulation)
Hemorrhage
Inadequate clotting
Dehydration
Diabetes (diabetic ketoacidosis)
Severe vomiting/diarrhea
84
Which of the following patients is at risk for obstructive shock?
Client who has gram-negative bacterial infection
Client who has been experiencing nausea and vomiting for several days
Client who is having occasional PVCs on ECG monitor
Client who with a large saddle pulmonary emboli
85
Risk factors for Obstructive Shock: SATA
Pulmonary artery stenosis
Arterial stenosis
Tension Pneumothorax
Pulmonary Embolism
Diabetes
Cardiac Tamponade
86
Hypovolemic Shock Management: SATA
Place in modified Trendelenburg position
Fluid (<30%) restore intravascular volume(>30%) to blood replacement
Fluid (<30%) blood replacement (>30%) to restore intravascular volume
Volume expansion with 0.9% NaCl, Lactated Ringer’s, Plasma, RBCs
87
Epinephrine – first action and priority in Anaphylaxis
False
True
88
Throbbing headache ▪ Anorexia, N/V, chills ▪ Irritability ▪ Apathy ▪ Feels like a hangover
Acute Mountain Sickness (AMS)
High Altitude Illness (HAI)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
89
Drowning is the Leading cause of accidental death
True
False
90
Cardiogenic Shock is NOT a direct pump failure
False
True
91
Human sepsis is thought to be systemic inflammatory response syndrome (SIRS) that is activated by invasive infection
True
False
92
Warm-high carb liquid (O J) is a Hypothermia intervention
False
True
93
ALTITUDE RELATED DISEASES: SATA
High Altitude Pulmonary Edema (HAPE)
High Altitude Cerebral Edema (HACE)
Acute Mountain Sickness (AMS)
High Altitude Illness r/t exposure to low partial pressure of o2@high elev
94
s/s of High Altitude Cerebral Edema (HACE): SATA
Apathy
Unable to perform ADL’s (acting drunk)
Mental health changes
Ataxia (impaired coordination)
Extreme Apathy
Cranial nerve dysfunction
95
SECONDARY SURVEY: History (SAMPLE)
Medication history
Events or environmental factors leading to illness or injury
Symptoms
Allergies
Past health history
Last meal/oral intake
96
Pink frothy sputum (late sign) for
HIGH-ALTITUDE PULMONARY EDEMA
True
False
97
Assessment: Compensatory: SATA
Decrease in MAP of 10-15 mm Hg
Stimulation of thirst reflex
Anaerobic metabolism of nonvital organs
Tachycardia /Tachypnea
Mild acidosis, Decrease O2 (90 – 95%)
Increase in lactic acid
98
Nurse’s role during disaster event: SATA
Triage- outside/inside
Interprofessional collaboration
Triage inside only
The greatest good for the greatest number!
Who can stay and who can go?
The greatest number for the greatest good!
99
Draw 0.5ml of __ 20 units in 1 ml into syringe and make up to 50 ml using NaCL 0.9% Start pump at 0.45ml/hour
How do you prepare dilaudid IV infusion?
How do you prepare vancomycin IV infusion?
How do you prepare vasopressin IV infusion?
How do you prepare epinephrine IV infusion?
100
Health care facility FIRE RESPONSE: Maintain respiratory status manually
False
True
