Exam 1
What is an advanced directive?
legally binding document that delineates patient's wishes
This rhythm has no p-waves and is irregular
atrial fibrillation
A patient with a RASS score of +3 should have which medication titrated?
Norepinephrine, Midazolam, Phenylephrine, Furosemide, Vecuronium
midazolam
A patient developed hypovolemic shock from severe dehydration. What should be administered first?
fluids before vasopressors
Which lab will determine when DKA has been corrected?
Anion Gap
How often will the nurse document vital sign when titrating norepinephrine (Levophed)?
Every 15 minutes
What is the treatment for torsades de pointes?
magnesium bolus, CPR
Analyze the blood gas with compensation - pH: 7.32, CO2: 48, HCO3: 26
uncompensated respiratory acidosis
What are the s/s of increasing ICP?
change in LOC, pupillary changes, vision changes, nausea, widening pulse pressure, irregular respiratory pattern
How is fluid resuscitation calculated in the burn patient?
4mL x kg x TBSA % burned; 1/2 given in the first 8 hours after injury, remaining 1/2 given over the following 16 hours
zeroing to atmospheric pressure per protocol, keep tubing primed with NS and pressure bag inflated, leveling with the phlebostatic axis, maintaining a closed system, assessing waveform, assessing for complications like bleeding
ventricular tachycardia and ventricular fibrillation
The ventilator shows a high-pressure alarm. What should the nurse do first?
Assess the pt, check for kinks/obstruction/biting
Explain the difference between a subdural and epidural hematoma
epidural has a "lucid period" and is arterial, subdural can be chronic and venous
The nurse would adjust the ultrafiltration rate on the CRRT machine based on these two hemodynamics values
CVP, BP
What are the 3 components of the Glascow Coma Scale Assessment and how are they scored?
Eye opening 1-4, verbal response 1-5, motor response 1-6
score 3-15
What is the correct ratio for compressions to rescue breaths?
30:2, visible chest rise and fall, minimizing interruptions
HOB 30*, oral care q2hr, suctioning prn, early mobility, daily sedation vacation, hand hygiene/universal precautions
What is the treatment for cardiogenic shock?
positive inotropes, diuretics, vasodilators, IABP, treat underlying causes
A patient presents to the ER after missing two scheduled hemodialysis treatments. What EKG change would the nurse expect?
peaked t-waves
The nurse is caring for a patient on vecuronium. What assessment with the nurse perform to assess effectiveness of the medication?
train of four (TOF)
Dobutamine increases which hemodynamic value?
cardiac output
The nurse is caring for a patient who is receiving Cisatracurium (Nimbex). What other class of medication will the nurse ensure is ordered?
sedation
Name 4 components of the sepsis bundle
measuring lactate, obtaining blood cultures, administering 30mL/kg crystalloids, antibiotics, vasopressors for refractory hypotension
The adult patient has third degree burns to the Anterior and Posterior Trunk. How will the nurse document the percentage burned using the Lund and Browder Chart?
26%