NURBN 3023 Exam Prep Part 2. 2023 with complete solution

List the essential elements in a cardiovascular assessment: Choose one or more. A. Cap refill, Fluid balance, Bowel actions and LOC changes. B. Skin temp and colour, Heart Rhythm, ECG changes, LOC & unusual heart sounds. C. Diet and fluid toleration, Urine output and allergies. D. ECG changes and a rise in white blood cells. B Identify changes in core physiological observations that would warrant a clinical review: Choose all that apply: A. Low urine output for 4 hours. B. Systolic BP 90 & a drop in GCS by 2. C. Threatened airway. D. PR 140BMP or 40. E. RR5BPM & 36BMP. B, C, D & E Core physiological observations include: Select all that apply* A. DRSABCD B. AMPLE C. All vital observations (BP,O2,PR,HR,RR,TEMP,CAP REFILL & LOC). D. EGFH E. GCS A & C Choose the indicators OUTSIDE of core physiological observations that indicate clinical deterioration valid for a MET call: Select all that apply: A. level of pain. B. BGL C. Bleeding (outside of any "normal" bleeding). D. Abdominal pain. E. All of the above. E Which GCS score would indicate deterioration? Select 1 or more. A. 15. B. 11. C. Any drop by 2 points. D. 20. B & C Common assessment findings that are utilised to initiate escalation of care in clinical settings. Choose 1 or more: A. Systolic BP 90, RR 36, PR140BMP, Drop in GCS2. B. Decreased urine output for 4hours. C. LOC. D. Wheeze when breathing. A Assessment findings that are incorporated into the primary assessment ABCD. A. Chin lift/jaw thrust, RR, BP, LOC & AVPU and Skin temp. B. GCS, BGL, PQRST & AMPLE. C. Patient history. D. Give fluid, do an ECG and make patient nill by mouth. A Can a MET call be initiated by a single concerning finding? True/False True Clinical communication includes: A. ISBAR B. Filling out a FBC C. ISBAR and document in pt Hx. A Perception is: A. Having awareness of the events that are going on around them. B. Having awareness of the information being provided from the situation itself. C. Being able to project their thoughts of what may occur to others. A Comprehension is: A. Having awareness of the events that are going on around them. B. Having awareness of the information being provided from the situation itself. C. Being able to project their thoughts of what may occur to others. B Projection is: A. Having awareness of the events that are going on around them. B. Having awareness of the information being provided from the situation itself. C. Being able to project their thoughts of what may occur to others. C What are the HUMAN factors that can affect situation awareness? Select all that apply: A. Stress & Fatigue. B. Hunger. C. Automation & Culture. D. Language barriers. A, C & D Understand the application of the principles of management: A. Recognise when help/escalation is needed. B. Collect more information for handover i.e vitals. C. Prepare the patient i.e IV patency. D. All of the above. D DRSABCD stands for? A. Danger, Reposition, Send for help, Airway, Breathing, Circulation & Defibrillation. B. Danger, Response, Send for help, Airway, Breathing, Circulation & Deflation. C. Danger, Response, Send for help, Airway, Breathing, Circulation & Defibrillation. D. Danger, Response, Send for help, Airway, Breathing, CPR & Defibrillation. D 4H's & 4T's are: A. Hypothermia, Hypovolemia, Hypokalaemia, Hypoxia, Thrombus, Toxins, Tension pneumothorax & Temperature. B. Hypothermia, Hypovolemia, Hypokalaemia, Hypoxia, Thrombus, Toxins, Tension pneumothorax & Tamponade. C. Hypothermia, Hypervolemia, Hypokalaemia, Hypoxia, Thrombus, Toxins, Tension pneumothorax & Temperature. B Shockable Heart Rhythms are: Choose the most correct answer. A. Asystole & PEA. B. Vt & Vf. C. PEA. D. VT, VF, and AF. D Non shockable rhythms are: Choose the most correct answer. A. VT & VF. B. PEA & Asystole. C. EMD, PEA & Asystole. C. Who is a Jaw Thrust not appropriate for? A. Obese patients. B. Patients with spinal precautions. C. Patients with a broken leg. D. Patients with a pace maker. B Advantages of using a pulse oximeter include- Select all that apply: A. Non invasive & Inexpensive. B. Reduced need for invasive procedures such as ABG'S. C. Nail polish. D. Cold hands. E. Immediate result. A, B & E Hypercapnia is: A. Low levels of Carbon Dioxide levels in the blood. B. High levels of Carbon Dioxide levels in the blood. C. High levels of potassium in the blood. D. High levels of calcium in the blood. B PaO2 stands for: A. Partial Arterial pressure in O2. B. Pressure in oxygen. C. Partial Arterial pressure in Carbon Dioxide. A Disadvantages of Pulse Oximetry: Select all that apply. A. Movement & Nail polish. B. No fingers or trauma to the hands. C. Carbon monoxide levels. D. Low peripheral perfusion. A, C & D Indications & nursing considerations for applying a non-rebreather mask: Select 1 or more. A. Patients with COPD that are Co2 retainers. B. Patients with facial hair. C. Facial injuries. D. Patients with a concussion. A & C Fio2 of 21 is: A. Room air. B. 4L/min of o2 via nasal prongs. C. 2L/min of o2 via hudson mask. D. 10L/min of o2 via non-rebreather. A Effective management of a tracheostomy includes: Select one or more: A. Ensure trach equipment is at the patients bedside including a spare trach kit. B. Monitor the patients LOC. C. Ensure the patient has access to their buzzer at all times. D. Ensure suction equipment is set up and at the correct pressure. E. Consider humidification. F. All of the above. F Effective management of chest drains includes: Include all thats relevant. A. Assess fluids, vitals and signs of infection, monitor FBC and perform visual obs hourly. B. Keep patient on fluid restrictions to prevent fluid overloading. C. Ensure drain is below patients chest line at all times. D. Document hourly the amount and quality of fluid in the drain and maintain FBC. E. All of the above. A, C & D Application of Non Invasive Ventilation includes: Choose all that applies. A. Enhances size of each breath. B. Reduces carbon dioxide levels. C. Ensure the mask is properly sized for the patients face. D. Used in type 2 resp failure. A, C & D Type 1 respiratory failure is: A. COPD. B. Pneumonia. C. Asthma/Brain Injury. D. Bronchitis. E. Strep throat. C Type 2 respiratory failure is: A. COPD. B. Pneumonia. C. Asthma/Brain Injury. D. Bronchitis. E. Strep throat. A Describe the differences between HR & PR. A. HR=how many times the valves in the heart close each minute PR=how many pulses are able to be palpated each second. B. HR=how many times the heart beats each minute, PR=how many pulses are palpated in a pulse each minute. B Aortic Stenosis is: The valve is stiff and narrowed, resisting forward blood flow meaning the heart has to work harder to pump blood around the body. Leading to BP increasing in the left ventricle. True/False True Clinical signs you would see in a patient with Mitral Regurgitation: Select one or more. A. Normal heart sounds. B. SOB, Fatigue, Heart palpitations. C. Swollen feet or ankles. D. Muffled heart sounds. B & C P wave in the PQRST complex - Represents electrical activity. The shape and duration of the P wave can indicate Atrial Enlargement. It is the SA node, pacemaker of the heart and Atrial Depolarisation. True/False True PR interval - If this wave is abnormally short or long can indicate a heart issue. True.False True When is a GCS assessment not able to be performed accurately? A. Language barriers, Facial trauma, Hearing & Vision impaired, Aphasia & Intubation. B. Low BGL where patient is incoherent. C. Low levels of consciousness. D. Learning disability. A Disability assessment in ABCDE includes: A. Making a patient use a wheelchair. B. Asking the patient of any pre-exisiting disabilities. C. GCS 2, BGL levels outside of the normal ranges, Pupils being uneven and an unconscious. D. BGL of 4-8. E. Blood in the urine. C Purpose of a "lockout" interval in PCA therapy. A. As the device is locked the patient or family can not accidentally overdose the patient. B. Locking children out of the PCA pump to prevent them overdosing the patient. C. So the patient can not overdose. D. Allowing the patient to only access the medication for a certain time. C If a patient has a PCA set up and becomes un-rousable what is the following treatment? A. Turn the pump up, they are just sleeping. B. Recheck them in 30 minutes. C. Turn the PCA off, count their RR, apply o2 via nasal prongs, alert the DR and administer Naloxone once an order has been written. D. Turn the pump off and give the patient endone instead once they wake up. E. Perform a sternal rub and "shake n shout" the patient. C Nursing management of a patient with a spinal injury includes: A. Only allow the patient to void into bedpans. B. Jaw thrust is ONLY to be used. C. Chin lift is ONLY to be used. D. Only feed the patient soft foods to avoid aspirating. B A patient has a decreased LOC what are your following actions? Choose all that apply: A. Administer a IM injection of glucose. B. ABCD including AVPU, GCS and PEARL. C. Ask them time, place and person. Re-ask in 10minutes to determine brain functionality. D. Place the patient into the recovery position and consider applying oxygen. B & D Advantages of PCA therapy? Keeps the patients pain levels to a minimum allowing the patient to recover easier, medication dose can be lowered or raised depending on demand which allows for better pain management and quicker pain relief. True/False True A sedation score is? A. A scoring system that measures which way the epidural or local anaesthetic is traveling in the body. B. A scale that measures how much someone is effected by sedation. C. Simular to neurovascular observations measures how much sensation someone has or how much their body is sedated. B Secondary survey includes: A. DRSABCD B. FGH, AMPLE, MIST C. GCS D. AVPU, BGL B MIST is an acronym for: A. Medications, Injuries, Symptoms & Trauma. B. Medications, Injuries, Symptoms & Treatment. C. Mechanism of injury, Injuries, Signs (vital) & Treatment. C AMPLE is an acronym for: A. Allergies, Mechanism of injury, Past medical Hx, Last oral intake/LMP for women, Events. B. Allergies, Mechanism of injury, Past medications, Last oral intake/LMP for women, Events. C. Allergies, Mediations, Past medical Hx, Last oral intake/LMP for women, Events. C Cardiac Tamponade is: A build up of fluid fills the pericardial sac, therefore restricting the ability of the heart to both pump effectively and fill to adequate volume reducing the hearts ability to supply adequate oxygen. True/False True Tension pneumothorax is: A shift in the trachea and compression of the great vessels including the superior and inferior vena cava. The mechanism of injury for a tension pneumothorax maybe an open chest trauma, or happen spontaneously. True/False True The correct calculation for fluid resuscitation for a burns patient is: A. 5ml x TBSA% x kg(pt weight) = mls/24hrs (give 1/2 mls in the first 8hrs, 1/2 mls in 16hrs) B. 3-4ml x TBSA% x kg(pt weight) = mls/24hrs (give 1/2 mls in the first 8hrs, 1/2 mls in 16hrs) C. 10ml x TBSA% x kg(pt weight) = mls/24hrs (give 1/2 mls in the first 6hrs, 1/2 mls in 16hrs) D. 2ml x TBSA% x kg(pt weight) = mls/24hrs (give 1/2 mls in the first 4hrs, 1/2 mls in 8hrs) B Initial treatment for a haemorrhage associated for a trauma injury: Choose all that applies: A. Keep the patient cool and calm. B. Ensure there is adequate IV access. C. Observe LOC & skin colour. D. X match for blood transfusion. E. Ultrasound to check for internal bleeding. B, C, D & E