HNN325 EXAM | 376 QUESTIONS AND ANSWERS |
WITH COPLETE SOLUTION.
iMMEDIATE LIFE THREATENING Answer - - cardiac or resp arrest
- needs code blue activation
immediate risk to airway e.f rr less than 10 or extreme resp distress
- profoudnly hypotensive
-GSC less than 9 or ongoing or prolonged seizures
imminently life threatening Answer - - met call or airway risk
- circulatory compromise (clammy or mottled skin, HR less than 50 or more
than 150, severe blood loss or chest pain
- suspected sepsis
- BGL less than 3
GCS less than 13
- fever with lethargy
- behavioural or psychiatric -> violent of threat to self or others may require
restraints
potentially life threatening Answer - severe hypotension
-mod blood loss
- moderate SOB
-seizures but now alert
,- persistent vomiting
- dehydration
- mod severe pain
-behavioural or psychiatric e.g very distressed. risk to self harm potentially
aggressive
potential serious or situational urgency Answer - - difficulty swallowing
without resp distress
mod pain
- vomiting or diarrhoea
- non-specific abdo pain
-behavioural or pysch under obs or no immediate risk to self or others
Less urgent Answer - Minimal pain
- minor symptoms of existing stable illness
0 identified nursing assessments and interventions that aren't time critical
staple removal indications Answer - wound healed
infection
documented for removal
assessments prior to removing staples Answer - assessing for uniform closure
of wound edges, absence of drainage, redness and swelling
if healed enough
count the number of staples prior to removal
,once removed staples nursing actions required Answer - redress wound,
educate on wound healing, bathing and wound seperation, ambulation,
nutrition and fluids
indications for patient focused cv assessment Answer - effect of symptoms on
ADLs
improvememnt or deterioration in s and s
impact of change on other systems
Assessment of CV system Answer - usually done with periheral assessment
- Inspection: colour, WOB, dizzy, weakness, feeling any pain or tightness, JVT
distension?
- palpation: feel each pulse and work up if cant (bounding, thready, weak,
irregular, fast, slow), BP, apical pulse, ECG
- Auscultation: listen to rate and rhythm of hear -> s1 and s2 sounds are
present and concurrent with radial pulse
subcut meds procedure Answer - check wrist band
education on med and route
check hospital policy on cleaning
, open ampoulse and draw up
hand hygiene and gloves
clean site
45 degrees for SC
Aspirate for IM in case of blood
indications for NGT Answer - stomach decompression or nutritional intake
risks to pt from NGT Answer - tracheal trauma
aspiration
pain
discomfort
steps for NGT Answer - explain to patient and consent
don goggles, gloves and Gown
sit pt up
Bluey under neck
WITH COPLETE SOLUTION.
iMMEDIATE LIFE THREATENING Answer - - cardiac or resp arrest
- needs code blue activation
immediate risk to airway e.f rr less than 10 or extreme resp distress
- profoudnly hypotensive
-GSC less than 9 or ongoing or prolonged seizures
imminently life threatening Answer - - met call or airway risk
- circulatory compromise (clammy or mottled skin, HR less than 50 or more
than 150, severe blood loss or chest pain
- suspected sepsis
- BGL less than 3
GCS less than 13
- fever with lethargy
- behavioural or psychiatric -> violent of threat to self or others may require
restraints
potentially life threatening Answer - severe hypotension
-mod blood loss
- moderate SOB
-seizures but now alert
,- persistent vomiting
- dehydration
- mod severe pain
-behavioural or psychiatric e.g very distressed. risk to self harm potentially
aggressive
potential serious or situational urgency Answer - - difficulty swallowing
without resp distress
mod pain
- vomiting or diarrhoea
- non-specific abdo pain
-behavioural or pysch under obs or no immediate risk to self or others
Less urgent Answer - Minimal pain
- minor symptoms of existing stable illness
0 identified nursing assessments and interventions that aren't time critical
staple removal indications Answer - wound healed
infection
documented for removal
assessments prior to removing staples Answer - assessing for uniform closure
of wound edges, absence of drainage, redness and swelling
if healed enough
count the number of staples prior to removal
,once removed staples nursing actions required Answer - redress wound,
educate on wound healing, bathing and wound seperation, ambulation,
nutrition and fluids
indications for patient focused cv assessment Answer - effect of symptoms on
ADLs
improvememnt or deterioration in s and s
impact of change on other systems
Assessment of CV system Answer - usually done with periheral assessment
- Inspection: colour, WOB, dizzy, weakness, feeling any pain or tightness, JVT
distension?
- palpation: feel each pulse and work up if cant (bounding, thready, weak,
irregular, fast, slow), BP, apical pulse, ECG
- Auscultation: listen to rate and rhythm of hear -> s1 and s2 sounds are
present and concurrent with radial pulse
subcut meds procedure Answer - check wrist band
education on med and route
check hospital policy on cleaning
, open ampoulse and draw up
hand hygiene and gloves
clean site
45 degrees for SC
Aspirate for IM in case of blood
indications for NGT Answer - stomach decompression or nutritional intake
risks to pt from NGT Answer - tracheal trauma
aspiration
pain
discomfort
steps for NGT Answer - explain to patient and consent
don goggles, gloves and Gown
sit pt up
Bluey under neck
