critical care

Question 1

CPR

Answer 1

unconscious, check carotid/neck pulse, chest compressions, open airway using chin lift, give breaths

Question 2

airway obstruction

Answer 2

stand behind pt, place arms around waist, make fist, thumb side of fist above belly-button, 5 in and up thrusts

• IF pregnant/obese, chest thrusts
• IF infant, place over arm with head lower than rest of body, 5 back slaps with heel of hand in between shoulder blades, turn infant over and 5 chest thrusts
• ONLY remove object if visible

Question 3

inflated cuff trach

Answer 3

for pts at risk of aspiration (e.g. unconscious, mechanically ventilated), not used for conscious patients because uncomfortable

Question 4

nursing trach care

Answer 4

semi-Fowler’s for pt, wear PPE (e.g. mask, goggles, clean gloves), remove soiled dressing, sterile gloves, remove old canula, put new one, clean around stoma with sterile water, dry, replace with sterile gauze

Question 5

nursing impaled object

Answer 5

stabilize object, NEVER remove

Question 6

deflated cuff trach

Answer 6

used for pts not at risk of aspiration

Question 7

SIRS/systemic inflammatory response syndrome

Answer 7

inflammatory response (e.g. high HR, high RR, fever)

Question 8

sepsis

Answer 8

SIRS + infection source (e.g. UTI, pneumonia)

Question 9

septic shock

Answer 9

sepsis + hypotensive DESPITE adequate IV fluid resuscitation

Question 10

MODS/multiple organ dysfunction syndrome

Answer 10

septic shock + multiple organ damage (e.g. low platelets, AKI, ARDS/acute respiratory distress syndrome

Question 11

nursing triage: red

Answer 11

life threatening injury that pt may survive if treated within next hour

Question 12

nursing triage: yellow

Answer 12

pt can wait 1-2 hours without loss of life/parts of body

Question 13

nursing triage: black

Answer 13

unlikely to survive

Question 14

nursing triage: green

Answer 14

“walking wounded”

Question 15

ex. of yellow situations that nurses should triage

Answer 15

abdominal wounds without hemmorhage, fracture requiring open reduction/pieces of a broken bone put back into place using surgery, debridement, external fixation/rods are screwed into bone and attached to a stabilizing structure on the outside of the body, eye injury, CNS injury

Question 16

ex. of green situations that nurses should triage

Answer 16

upper fracture, minor burns, sprains, small cuts, behavior disorders

Question 17

ex. of black situations that nurses should triage

Answer 17

unresponsive, spinal cord injuries, 2nd/3rd degree burn with 60% of body surface area, seizures, profound shock, no pulse/BP, pupils dilated

Question 18

s/s of shock

Answer 18

low BP, high HR, weak pulse

Question 19

time to triage

Answer 19

3-5 mins