Priority
A. Pneumonia with temp of 101.1 on IV antibiotics
B. Pancreatitis with pain 4/10 while ambulating hallways
C. Patient difficult to arouse with subsequent blood glucose of 31
C (patient's glucose is severely low and affecting neurological status)
A, B: expected finding
You see a patient with active cough pending cultures being transported to radiology wearing a mask
EXPECTED - patients should always wear a mask to prevent spreading of bacteria/virus if active cough or diagnosed communicable infection
C. Diff
Contact Precautions
This is always your first intervention when mom or baby have hemodynamic compromise.
What is REPOSITION the mom
POOF
P: Position
O: Oxytocin (stop it)
O: Oxygen
F: Fluids (Increase the IVF)
Vigorous coughing caused my manipulation of the tube or coughing in a patient with a tracheostomy tube can result in what?
Accidental decannulation
A. 32 weeks pregnant with pain in the groin area
B. 39 weeks pregnant with artificial rupture of membranes with new onset variable decelerations
C. 38 weeks pregnant on Pitocin with 3 contractions in 10 minutes
B (possible cord prolapse causing cord compression and eliminating blood flow to baby)
A - likely round ligament pain
C - standard number of contractions
Graves Disease with exophthalmos
EXPECTED this is a common finding with Graves Disease along with nervousness, irritability, trouble sleeping, fatigue, shaky hands, muscle weakness, sweating or trouble tolerating heat.
Epiglottitis
Droplet
This is a term used when a contraction lasts longer than 2 minutes and/or more frequently than 3 in 5 minutes.
What is Tachysystole (or Hyperstim)
Always start by turning OFF the Pitocin in this situation
During a fire evacuation, it is important do which of the following? Select all that apply
A. Evacuate stable/"walkie talkie" first (starting with closest to fire)
B. Use PASS to extinguish the fire first (top to bottom)
C. Use only the staff elevators to evacuate patients
D. Ventilated patients are transported using Bag Valve Mask and manually ventilated during evacuation
A and D (correct evacuation practices)
B - not priority and when it can be extinguished go bottom to top
C - NO elevators during fire
A. Major depressive disorder who is slowly starting to talk about their triggers
B. Pt with VP Shunt laying flat in bed difficult to arouse
C. Pt on Warfarin with INR of 3 seconds
B (increased intracranial pressure and having neurological symptoms)
A - good sign they are talking about triggers
C - normal INR for Warfarin therapy
58 y/o male who recently started going to the gym 5 days a week, eliminating fast food, quit smoking and drinking 3 months ago with a BP of 173/98
UNEXPECTED - this is severe hypertension which should be improving with his recent lifestyle modifications
Tuberculosis
Airborne (Negative airflow)
Your patient is 34 weeks pregnant newly diagnosed with pre eclampsia. List the answers to the following treatment plan:
1. This medication is used to protect the brain and prevent seizures
2. This medication is used to lower the blood pressure
3. This is the primary NURSING intervention to decrease stimulation
1. What is Magnesium Sulfate
2. What is Labetalol
3. What is dark, quiet environment
These are examples of secondary prevention in health promotion and illness prevention?
What are SCREENINGS?
Mammo, self breast exams, colonoscopy, annual pap smear, self testicular exams
PRIMARY = Prevent (vaccines, healthy lifestyle, no smoking, no drugs, safety equipment)
TERTIARY = Treat (manage symptoms of diseases you have such as following ADA diet for diabetics)
MASS CASUATY TRIAGING - who will you treat first?
A. Open tib/fib fracture and swollen ankle
B. Head trauma with blown pupils and agonal breathing
C. 2nd and 3rd degree burns to face and neck with RR 28
C (most critical and treatable)
A - stable not priority
B - "Black Tag" non viable
Your colleague asks you to come help her with her patient while suctioning out the tracheostomy tube. She asks you to hyper oxygenate the patient for her before and in between passes.
EXPECTED - You should try to always have 2 nurses or RT when suctioning a ETT or trach tube.
Diphtheria
Droplet Precaution
Your patient delivered a 9lb 10oz baby boy 3 hours ago. This is her 5th baby/delivery. Upon assessment you find her uterus is boggy and deviated to the left and large amount of red blood on bed. What is your first intervention?
What is Fundal Massage and empty the bladder.
Likely hemorrhage due to uterine atony (risk factors include large baby and 4 previous deliveries). Make sure the bladder is empty and you massage the fundus
Your patient with severe GERD should be instructed on what dietary education?
What are:
stay upright 1-2 hours after you eat, wear loose clothing (non restrictive), sleep with your HOB elevated and avoid eating close to bedtime
A. Patient had a cardiac catheterization and takes daily Metformin
B. Patient on Streptomycin received a trough level immediately before next dose is due
C. AB- blood type receiving O- PRBCs
A (contrast and Metformin are contraindicated)
B - normal time for trough
C - AB- can receive A-, B-, AB- or O- blood
Your patient is demonstrating confabulation to deal with a recent cancer diagnosis. This will be demonstrated by displaying ritualistic, repetitive behaviors.
UNEXPECTED - this is signs of OCD not confabulation
Confabulation is telling "extreme" made up stories that they begin to believe themselves.
Patient who had recent Kidney transplant
Protective Isolation
This is the biggest risk factor to BABY when a mom has uncontrolled diabetes during pregnancy.
What is HYPOGLYCEMIA?
Baby receives it's sugar through the placenta from mom during pregnancy. Upon delivery, when the cord is cut the baby must regulate it's glucose on it's own. The pancreas is now used to making enough insulin to regulate a HIGH glucose from mom so it will keep making that and eat up all the baby's ingested glucose quickly!
Four days following a stroke, a patient is to start oral fluids and feedings. Prior to feeding the patient, what should the nurse evaluate first?
Gag reflex and ability to swallow