NR 341 final exam
high school student comes to ed with headache, fever, and neck pain Correct Answer: expect
lumbar puncture bc indicative of bacterial meningitis
Status epileptics medication Correct Answer: benzodiazepines (Lorazepam (ativan) is drug of
choice)
When the first line drugs are not effective for status epileptics, given to place pt in induced coma
Correct Answer: phenobarbital
Delirium nursing interventions Correct Answer: quiet environment, reorient, speak slowly, dark
room, maintain consistent routine, identify threats to safety
what to monitor following electrical burns Correct Answer: telemetry for 24 hours
Priority for facial burns Correct Answer: airway/intubate
Patients with burns on face/neck are at risk for what? Correct Answer: airway obstruction
Patient has VS showing infection on burn site - what to do? Correct Answer: get burn and
wound culture
process of getting blood cultures for burns Correct Answer: Do blood cultures before any
antibiotics are given
Burns stress ulcers and prevention Correct Answer: Curling's ulcer; NG tube is the prevention
priority for carbon monoxide burns Correct Answer: oxygen with non rebreather mask
other priority for burns Correct Answer: fluids
superficial burn (1st degree) Correct Answer: like a sunburn (epidermis and maybe small
portion of dermis)
Partial thickness burn (2nd °) Correct Answer: epidermis and most of dermis
Full thickness burn (3rd °) Correct Answer: Same as partial thickness but may extend into
subcutaneous tissue; nerve damage
- Thick, dry leathery appearance
Deep Full thickness burn (4th °) Correct Answer: Destruction of all layers plus muscles, tendons
& bones
- Black with no edema
, Escharectomy Correct Answer: surgical removal of eschar
priority intervention for DKA Correct Answer: fluids
interventions for DKA and HHS Correct Answer: insulin drip w/ regular insulin, *check blood
glucose every hour!! , monitor labs, electrolyte replacement
- fluid replacement:
First use 0.9% NS
Then 0.45% NS
Dextrose added when glucose approaches 200 mg/dL
- electrolyte replacement
Potassium
Maintain between 4-5 mEq/:
Phosphorus (K-phos replacement)
Magnesium
difference between DKA and HHS Correct Answer: DKA → occurs Type 1 DM, BG > 350,
metabolic acidosis, kussmaul's respirations, fruity breath, flushed/dry skin, orthostatic
hypotension, ketones in urine, weight loss
HHS → occurs in Type 2 DM, NO ketoacidosis, BG average > 600, more electrolyte imbalances
and renal dysfunction, higher serum osmolarity than DKA
Insulin drip Correct Answer: monitor glucose every hour, check electrolytes every few hours
for mass causality Correct Answer: greatest good for greatest number of people
who would you give a black tag to in a mass causality Correct Answer: Full cardiac arrest
Open or unresponsive head injury
No pulse
Leg fracture and large bone (large bones like femur and pelvis) - biggest concern Correct
Answer: fat embolism
treatment for fat embolism Correct Answer: extremity immobilization
Long bone leg fx or pelvic fx complications Correct Answer: fat embolism or compartment
syndrome
Rhabdomyolysis Correct Answer: CK lab can show this
Tx → IV fluids to achieve a urine output of 100-200 ml/hr
5 P's Correct Answer: pain, pallor, pulselessness, parasthesia, paralysis
why be wary of SaO2 monitors when pt. has carbon monoxide poisoning Correct Answer:
Cannot distinguish between oxyhemoglobin & carboxyhemoglobin
high school student comes to ed with headache, fever, and neck pain Correct Answer: expect
lumbar puncture bc indicative of bacterial meningitis
Status epileptics medication Correct Answer: benzodiazepines (Lorazepam (ativan) is drug of
choice)
When the first line drugs are not effective for status epileptics, given to place pt in induced coma
Correct Answer: phenobarbital
Delirium nursing interventions Correct Answer: quiet environment, reorient, speak slowly, dark
room, maintain consistent routine, identify threats to safety
what to monitor following electrical burns Correct Answer: telemetry for 24 hours
Priority for facial burns Correct Answer: airway/intubate
Patients with burns on face/neck are at risk for what? Correct Answer: airway obstruction
Patient has VS showing infection on burn site - what to do? Correct Answer: get burn and
wound culture
process of getting blood cultures for burns Correct Answer: Do blood cultures before any
antibiotics are given
Burns stress ulcers and prevention Correct Answer: Curling's ulcer; NG tube is the prevention
priority for carbon monoxide burns Correct Answer: oxygen with non rebreather mask
other priority for burns Correct Answer: fluids
superficial burn (1st degree) Correct Answer: like a sunburn (epidermis and maybe small
portion of dermis)
Partial thickness burn (2nd °) Correct Answer: epidermis and most of dermis
Full thickness burn (3rd °) Correct Answer: Same as partial thickness but may extend into
subcutaneous tissue; nerve damage
- Thick, dry leathery appearance
Deep Full thickness burn (4th °) Correct Answer: Destruction of all layers plus muscles, tendons
& bones
- Black with no edema
, Escharectomy Correct Answer: surgical removal of eschar
priority intervention for DKA Correct Answer: fluids
interventions for DKA and HHS Correct Answer: insulin drip w/ regular insulin, *check blood
glucose every hour!! , monitor labs, electrolyte replacement
- fluid replacement:
First use 0.9% NS
Then 0.45% NS
Dextrose added when glucose approaches 200 mg/dL
- electrolyte replacement
Potassium
Maintain between 4-5 mEq/:
Phosphorus (K-phos replacement)
Magnesium
difference between DKA and HHS Correct Answer: DKA → occurs Type 1 DM, BG > 350,
metabolic acidosis, kussmaul's respirations, fruity breath, flushed/dry skin, orthostatic
hypotension, ketones in urine, weight loss
HHS → occurs in Type 2 DM, NO ketoacidosis, BG average > 600, more electrolyte imbalances
and renal dysfunction, higher serum osmolarity than DKA
Insulin drip Correct Answer: monitor glucose every hour, check electrolytes every few hours
for mass causality Correct Answer: greatest good for greatest number of people
who would you give a black tag to in a mass causality Correct Answer: Full cardiac arrest
Open or unresponsive head injury
No pulse
Leg fracture and large bone (large bones like femur and pelvis) - biggest concern Correct
Answer: fat embolism
treatment for fat embolism Correct Answer: extremity immobilization
Long bone leg fx or pelvic fx complications Correct Answer: fat embolism or compartment
syndrome
Rhabdomyolysis Correct Answer: CK lab can show this
Tx → IV fluids to achieve a urine output of 100-200 ml/hr
5 P's Correct Answer: pain, pallor, pulselessness, parasthesia, paralysis
why be wary of SaO2 monitors when pt. has carbon monoxide poisoning Correct Answer:
Cannot distinguish between oxyhemoglobin & carboxyhemoglobin
