final exam Flashcards
(120 cards)
1
Q
what diagnosis should the nurse suspect for a patient with flu-like symptoms w/pea-sized, red nodules on the pads of their fingers?
A
endocarditis
2
Q
what action should the nurse if they assess muffled, distant heart sounds and a decrease in chest tube output 2 hrs following a coronary artery bypass graft?
A
report to the provider
3
Q
what IV medication should be given for a client w/severe chest pain?
A
morphine
4
Q
a nurse is suspecting a post-PCI patient for admission, what equipment should the nurse gather?
A
telemetry
5
Q
what finding would be indicative of emergency in a patient with PVD?
A
absent pulse
6
Q
what action should the nurse take for a client with 3rd degree frostbite?
A
initiate water baths at 110-115 F
7
Q
which chief complaint almost always takes priority in emergency department prioritization?
A
chest pain
8
Q
what distinguishes a level 1 trauma center?
A
specialists available 24/7
9
Q
what symptoms may be seen a patient with heat exhaustion?
A
flu-like symptoms after spending time in warm temperature
10
Q
what action should the nurse take upon caring for a client who has protein and calorie malnutrition r/t AIDs?
A
assess their body weight and what they’ve been able to eat
11
Q
what instructions should be provided for a patient d/c post-nasal fracture?
A
- sleep w/ head elevated
- hydration
- report excessive bleeding
- avoid strenuous activity/sports
12
Q
why may vitamin K be given for a patient w/liver failure?
A
promote clotting and prevent bleeding
13
Q
what s/s are expected in the early stages of hepatitis?
A
nausea/vomiting
14
Q
what increases the risk for hemorrhagic stroke?
A
high BP
15
Q
what s/s of multiple sclerosis are caused by involvement of the brain stem and cranial nerves?
A
- tinnitus
- tremors
- vertigo
16
Q
which electrolyte imbalance is most likely to lead to electrical dysrhythmias?
A
potassium imbalance
17
Q
when is it suggested to go to the ED for a nose bleed?
A
- 20 mins of bleeding
- tasing blood
- excessive swallowing
- heavy blood loss
18
Q
what should be avoided following surgical intervention for serious nose bleeds?
A
- vigorous nose blowing
- ASA/NSAIDs
- heavy lifting x1 month
19
Q
what is expected on the PFT of a patient with pulmonary fibrosis?
A
decreased vital capacity
20
Q
what is the diagnostic finding of pulmonary fibrosis on CT scan?
A
honey comb pattern
21
Q
what is the goal of lung cancer care?
A
relieve symptoms and increase survival time
22
Q
which organ does combination TB drug therapy cause the most harm to?
A
risk for liver failure
23
Q
how often do sputum samples have to be collected with a patient receiving TB drug therapy?
A
q 2-4 weeks
24
Q
your patient who has just undergone cardiac cath PCI w/femoral approach complains of back pain and inability to urinate. Upon assessment you note abdominal distension. What do you suspect to be happening?
A
retroperitoneal bleeding
25
what stage of PAD is asymptomatic?
stage I
26
what stage of PAD is associated with claudication?
stage II
27
what stage of PAD has rest pain?
stage III
28
what stage of PAD has necrosis and gangrene?
stage IV
29
what heart sound is trademark of mitral regurgitation?
loud holosystolic murmur
30
regurgitation or stenosis of which valve would respiratory symptoms be more prevalent in?
mitral (its closer to the lungs)
31
what is a common cause of dilated cardiomyopathy?
chemotherapy
32
what medication is given for SVT?
adenosine
33
how should the doses of adenosine be given?
1st 6 mg, then 12 mg
34
what nonpharm can be used for SVT?
valsalva and vagal maneuvers
35
what medications are given for vtach?
amiodarone, lidocaine, BBs, CCBs
36
how does a pt present with v fib?
- no pulse
- no respirations
- no perfusion
- no cardiac output
37
after CPR, what is the priority intervention for Vfib?
defibrillation
38
what medication class can be give to a patient with heat stroke for shivering?
benzos
39
what temperature should we stop interventions to cool patient with a heat stroke?
stop cooling them when they get to 102F
40
what prehospital actions should be taken for frostbite?
- find shelter
- use body heat to warm (underarms, underclothes, etc.)
41
what actions should be taken in the hospital for frostbite?
- rewarm in water (99-102F)
- pain control
- iv rehydration
- elevate above heart
- tetanus immunization
- assess for compartment syndrome hourly
- abx
42
why should dry heat and massage be avoided with frostbite?
causes further damage
43
what actions must be avoided for snake bites?
do NOT:
- incise
- suck wound
- apply ice
- use tourniquet
44
what actions should be taken for a snake bite once in hospital?
- supplemental O2
- 2 IVs
- anti-venom
- airway equipment at bedside
45
should we shock asystole?
no, there is nothing to shock
46
what should the nurse do for PEA?
initiate CPR
- don't shock
47
what symptom is common for cytomegalovirus (AIDs illness)?
loss of vision
48
what are the prehospital care actions for lightning strike injuries?
- stabilize spinal column
- ABCs, BLS, ACLS
- get everyone else out of danger
49
what is the nursing priority for a patient who comes to ED after lightning strike?
- cardiac monitoring
- EKGs/tele
50
what actions should the nurse take for a patient with lightning strike injury following cardiac monitoring?
- tetanus shot
- mechanical ventilation
- assess for hidden traumatic injuries
51
what actions should be taken for snake bites prehospital?
- call 911
- safety and rest
- remove jewelry/restrictive clothes
- take pics of snake
- immobilize extremity at heart level
52
what actions should be taken for a nurse once in hospital?
- O2 admin
- 2 large bore IVs
- antivenom administration
- airway equipment at bedside
53
what are the poisonous snakes in this area?
- cottonmouths
- copper heads
- rattlers
- water moccasins
54
what 2 spiders are concerning for toxic reactions?
black widow and brown recluse
55
what should we apply to spider bites?
ice
56
what actions should be taken for a patient who has just arrived to the ED for spider bites?
- BP monitoring (shock)
- antivenom admin
- tetanus prophylaxis
57
what is the first action that should be taken if a disaster occurs near a hospital?
initiate disaster response protocol
58
what prehospital actions should be taken for frostbite?
- shelter from cold
- remove wet clothing
- warm clothes/blankets
- drink warm fluids
59
what actions should be taken in the hospital for frostbite?
slowly rewarm the area
60
what symptoms are associated with heat stroke?
- no sweating
- throbbing headache
- red/hot/dry skin
- rapid pulse
- AMS/unresponsive/coma
- body temp >104F
61
what prehospital actions should be taken for heat stroke?
- call 911; go to ED
- ensure patent airway
- remove from hot environment
- remove clothing
- cold water/ice chips over body
- fan them
62
what actions should be taken when a patient with heat stroke arrives at the hospital?
- O2, large bore IV (cooled NS)
- cooling blankets
- rectal probe Q15
- foley for UOP
- benzos (shivering)
63
what are the risks for heat stroke?
- older/younger
- mental/behavioral conditions
- illicit drugs
- homeless
- athletes
64
what is necessary for 3rd degree heart block tx?
pacing
65
what are the causes for heart blocks?
- MI
- digoxin toxicity
- myocarditis
- CCBs/BBs
- cardiac surgery
- age changes
- cardiomyopathy
66
what action should be taken for PEA?
CPR
67
what action should be taken for asystole?
CPR
- atropine, epi, vasopressin
68
what medication is given for SVT?
adenosine
69
what treatment is necessary for v. fib?
DEFIB
70
what tx is for stable Vtach?
elective cardioversion
71
what tx is for unstable Vtach w/pulse?
synchronized cardioversion at bedside
72
what tx is for pulseless Vtach?
defibrillation and CPR
73
what medication is given for Vtach?
amiodarone
74
what education is given for HIV prevention?
- abstinence
- monogamous sex
- condoms are good
- no anal
75
how long do HIV prep meds have to be taken to be effective?
1 week
76
what is the black box for HIV prep meds (tenofovir-emtricitabine)?
hepatitis B exercise
77
what should the patient do if they miss 2 days of prep?
start over (won't be protected until taking for7 days)
78
what test confirms HIV after a positive elisa?
western blot
79
what CD4 is indicative of AIDs?
<200
80
if a patient with HIV were to develop small, itchy, purple-brown, raised lesions on their MM and skin, what should the nurse suspect?
kaposi's sarcoma
81
List 4 opportunistic infections that may occur with AIDs?
- pneumocystis jiroveci
-toxoplasmosis encephalitis
- candida albicans
- mycobacterium tuberculosis
82
what symptoms are associated with HIV?
- fever
- night sweats
- chills
- headaches
- muscle weakness
- sore throat
83
what s/s are associated with MS?
- numbness
- tingling
- vision problems
- walking difficulties
- pain
- dizziness
- fatigue/weakness
84
what MRI findings are indicative of MS?
plaques in at least 2 places on brain/spinal cord
85
what are the findings of CSF with MS?
- increased myelin proteins
- increased WBCs
86
following a T5 SCI, the patient experiences loss of sensation below T5 for 32 hr, how would you define this occurrence?
spinal shock
87
what s/s are seen with autonomic dysreflexia?
- severe headache
- HTN
- profuse sweating
88
what tx is necessary for autonomic dysreflexia?
- elevate HOB
- identify/remove triggers
- monitor vitals
- administer antihypertensives
89
what may cause autonomic dysreflexia?
full bladder, constipation, unrelieved pressure or constrictive clothing w/injuries above T6
90
what long-term complications may result from SCI?
- prolonged immobility
- skin breakdown
- infection
- VTE
- osteopenia
- depression/suicidal thoughts
- impaired sexuality
91
what nursing actions should be taken for AKI?
- strict I/Os
- daily weights
- monitor electrolytes
- fluid challenge
92
what are common causes of AKI?
- sepsis
- shock
- cardiac surgery (CBP)
- nephrotoxic drugs
- radiocontrast drugs
- CKD
- DM
93
what is Becks triad?
- JVD
- muffled heart sounds
- hypotension
94
what are the risks of cardiac tamponade?
pericarditis
95
what are causes of pericarditis?
- TB
- radiation
- trauma
- renal failure
- mets and lung cancer
96
what are s/s of pericarditis?
- substernal pain (aggravated w/inspiration, swallowing and coughing
- pain worse when supine
- pericardial friction rub auscultated
- fever
- a. fib
97
what medications are given for pericarditis?
- NSAIDs
- corticosteroids
- abx
- colchicine 0.5 mg x 3months
98
what is the tx for pericarditis?
- surgical excision
- pericardiectomy
- pericardial window
99
what labs are seen with pericarditis?
- increased WBC
- EKG ST elevation
100
why does pyrazinamide increase the risk for gout?
it elevates uric acid levels
101
what should the nurse ensure is close by for a patient with mouth wired shut?
- suction and wire cutters
102
what actions should be taken to prevent ventilator associated pneumonia?
- elevate HOB at least 30 degrees
- daily weaning assessment
- oral care
- suctioning
- hand hygiene
103
what are the major risk factors for head and neck cancers?
tobacco and alcohol
104
what are the warning signs for head and neck cancers?
- difficulty swallowing
- lump/pain
- color changes in mouth
- persistent oral bleeding
- numbness in mouth
- hoarseness
105
what are the diagnostics for head and neck cancer?
- CT/MRI/PET
- biopsies
106
what is the tx for head and neck cancer?
- surgery
- chemo/radiation
- biotherapy
107
what is the parkland formula?
mL = 4mL x %TBSA x kg
108
how much of the total volume of fluid using the parkland formula should be given within the first 8 hr?
1/2 the total
109
which rhythm is characterized by wide QRS, no P waves and regular rate above 100?
Vtach
110
what actions should be taken for chronic venous insufficiency?
- compression
- elevate
111
what action is likely needed if a patient has low urine output and hypotension following surgical repair of AAA?
give fluids
112
what are the s/s of AAA?
- continuous back pain
- pulsations in the abdomen
113
what does ST depression indicate?
NSTEMI
114
a patient develops hoarseness and cough 2 hr after a burn injury, what should the nurse prepare for?
intubation
115
what interventions should be taken for a copper head bite?
- monitor CBC (clotting issues)
- wound care (infection/skin break down common)
116
what interventions should be taken for a client who has HIV and diarrhea?
- assess for hypotension
- discourage dietary fate intake
- admin loperamide
- assess perineal skin FREQUENTLY (Q8)
117
what actions should be taken for a client who is HIV positive and reports ongoing drug use?
- needle exchange
- refer to substance abuse
- provide education abt risk of transmitting HIV to others w/needle sharing
- recommend DOT
118
how can the risk of transmission be minimized from mother to baby?
retroviral therapy
119
what tag for a pt w/agonal breaths and head wound?
black tag
120
what is the priority for disaster r/t flash flood at the community level?
safe evacuation
