LPN MS 2 Review 2 of 3

Assessment

100

What is the best pulse to determine brain profusion (adult)? 

Carotid 

200

Symptoms of anaphylactic shock 

Airway edema, stridor 

hypotension 

Tachycardia 

Cyanosis 

Absent deep tendon reflexes r/t decreased is 

Remember anaphylaxis is a type of distributive shock

300

What are basic assessment priorities in nursing? 

1. AIRWAY 

2. Breathing 

3. Circulation 

400

Puncture wounds are a high risk of _____. 

The nurse should assess the need for ___________ administration 

Infection 

Tetanus vaccine 

Additionally, individuals who experience a wound that puts them at risk for tetanus (such as a puncture wound or deep cut) and who have not received a tetanus vaccine in the past 5 years may require a tetanus booster shot, usually in the form of Td vaccine.

500

Symptoms of hypovolemic shock 

Hypotension 

Tachycardia 

Tachypnea 

Pale cool/clammy skin

Slow capillary refill 

Decrease urine output 

AMS 

Decreased bowel tones 

Client Education

100

Post-MI Diet education 

Low fat: Avoid fried foods, cheese, butter,

Low sodium

Increase fiber

Reduced sugar 

200

Carbon Monoxide education 

Carbon monoxide (CO) is poisonous and prolonged exposure to it can cause brain damage, unconsciousness, and death.

Carbon monoxide gas is odorless, tasteless, and colorless.

A carbon monoxide detector is the best protection against prolonged exposure to carbon monoxide in the home.

Carbon monoxide can cause headaches and nausea, then coma and death 

Treated with 100% O2 (usually NRB, hyperbaric chamber if severe and chamber is available)

300

Teaching for anaphylaxis history 

Keep IM epinephrine on hand:

Epinephrine, an adrenergic agonist, reverses the most severe manifestations of anaphylactic shock and is the first medication to be administered  

Benadryl can be taken AFTER epi 

Albuterol may be administered AFTER epi if ordered 

400

DNR education 

The patient needs an order to be DNR 

If alert and oriented patient makes all decisions 

Forms may require explanation (DNR/DNI/COMFORT etc.) 

500

Common injuries of the older adult are from _____. How can this be prevented? 

Falls. 

• Home Safety Assessment: stairs, throw rugs, door thresholds, need for safety bars
• Exercise: maintain strength 
• Medication Management: orthostatic hypotension
• Vision Check
• Foot Care
• Assistive Devices
• Nutrition
• Hydration
• Fall Awareness
• Regular Check-ups

Cardiac Arrhythmias

100

Atrial fibrillation can cause _____. Patients should be placed on a ______ to prevent this. 

Stroke, a blood thinner (warfarin, rivaroxaban, etc.) 

200

Strip 1 - Identify 

V-tach (monomorphic) 

300

Strip 2: Prepare for _____

Defibrillation 

400

Strip 2: identify 

a fib 

500

Strip 2: What medication should be prescribed to the patient to prevent complications? 

Blood thinner (warfarin, rivaroxaban) 

Misc.

100

DVT Care

Elevate affected leg 

Apply warm compress 

Never rub the affected leg 

Bed rest to reduce embolus 

Administer blood thinners as ordered 

Pain control 

Monitor for PE: Watch HR/O2/BP 

200

PAD Symptoms

• Intermittent Claudication
• Leg Weakness
• Coldness
• Color Changes: pale or bluish discoloration of the feet or legs when elevated, Redness when dependent (dependent rubor)  
• Decreased Hair Growth
• Delayed Wound Healing
• Non-healing Sores
• Shiny Skin
• Weak Pulses

300

What reasons would you call an RRT? 

When would you NOT call an RRT? 

RRT: 

Change in mental status (newly confused, decreased LOC) 

New onset shortness of breath 

New onset severe hypertension >200/90

New onset chest pain 

Concerning change in VS (hypotension, bradycardia, tachycardia) 

NO RRT: 

More pain medication 

Upset patient and would like to talk to the provider as soon as possible. 

400

Deep laceration: Initial intervention 

#1 APPLY PRESSURE 

Then, raise the extremity above the level of the heart 

A tourniquet is a last resort 

500

GCS of the table? 

1. Eye Opening: The table doesn't have eyes to open, so it would score 1 (no eye opening).
2. Verbal Response: The table doesn't have the ability to speak, so it would score 1 (no verbal response).
3. Motor Response: The table doesn't have limbs to move, so it would score 1 (no motor response).

= 3

Medications

100

Verapamil education

Calcium channel blocker:

Avoid grapefruit 

Take as prescribed 

Change position slowly to avoid orthostatic hypotension 

Don't stop suddenly (rebound hypertension) 

Monitor BP regularly 

200

Atenolol education

Beta-blocker: 

May cause bradycardia 

Take as prescribed 

Change position slowly: avoid orthostatic hypotension.

Monitor BP regularly 

Do not stop abruptly (rebound HTN) 

300

Warfarin education 

Take as prescribed

Monitor for bleeding: avoid injury, soft toothbrush and electric razors, and seek help if you sustain a head injury, internal injury, MVC, etc.). 

Regular monitoring: INR checks 

Dietary: Limit vitamin K-rich foods (green leafy vegetables) 

Over-the-counter meds/supplements: communicate to the provider due to interactions. 

400

What cardiac arrhythmia is adenosine given for? How is it administered? 

SVT 

6mg rapid PIV push, AC vein or higher 

If unsuccessful, may give second dose of 12mg 

500

What cardiac arrhythmia is atropine administered for?

Symptomatic bradycardia