Complex Adult Health Exam 1 (A+ Graded)
Critical Care Environment correct answers Assist client with applying hearing aids/glasses
-Physical environment and sensory deprivation (facilitate your client's ability to see and hear)
Adjust device alarms based on client's condition
-noise (try to limit unnecessary noise around your client)
Speak calmly in audible but quiet voice-noise (try to limit unnecessary noise around your client
-and this intervention also helps to decrease your client's anxiety)
Encourage family to bring objects from home
-Physical environment and sensory deprivation (will provide appropriate stimulation to the
client's senses and may help them feel less anxiety)
Explain procedures in client's primary language (or get assistance of translator)
-sensory deprivation(will provide appropriate stimulation to the client's senses and may help
them feel less anxiety)
Responding to Alarms correct answers Assess the client's level of consciousness
Assess the client's respiratory status
Palpate for a carotid pulse
Check the pulse oximetry alarm and address any issues noted
Check the telemetry alarm and address any issues noted
Assess the client's IV site
Check the infusion pump alarm and address any issues noted
Pharmacological Management of Pain & Anxiety correct answers *Anxiety*
-Benzodiazepines (Midazolam, Lorazepam)
Desired effects/Adverse effects
*Pain*
-Opioids- (Fentanyl, Morphine Sulfate, Hydromorphone)
Desired effects/Adverse effects
ABCDEF Bundle correct answers •Assess, prevent, and manage pain
•Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)
•Choice of analgesia and sedation
•Delirium assessment and management
•Early mobility and exercise
,•Family engagement and empowerment
Barriers to Accessing Health Care correct answers •Income
•Education
•Gender
•Race
•Sexual Orientation
•Disabilities
•Geographic Area
•Immigrant Status
Legal/ Ethical Terms correct answers autonomy- self determination
beneficence- intended to benefit
non-maleficence- do not harm
justice- distributed fairly
veracity- tell the truth
fidelity- faithfulness
confidentiality- protect information
moral distress- ethical dilemma
informed consent- given voluntarily
advocacy- represent for patient
Advance Directives and Do Not Resuscitate
•What are responsibilities of the client/family; health care provider; and nurse with advance
directives and do not resuscitate orders? correct answers Client/Family responsibilities:
•Understand the consequences of refusing resuscitative measures.
•Provide an original, unaltered DNR form for the health care team.
•Accept that if the DNR form is not available and the client cannot confirm their wishes,
resuscitative care will be provided.
•Should an active DNR be discovered during resuscitation efforts, consult with the health care
team to determine how care should proceed.
•Participate in care to the extent able.
Health care provider responsibilities:
•Accept that if the DNR form is not available and the client cannot confirm their wishes,
resuscitative must be provided.
•Should an active DNR be discovered during resuscitation efforts, stop interventions and assess
how to proceed.
•Determine if the client has a terminal condition and the capacity to provide consent.
•Withhold or withdraw resuscitative measures upon finding a valid DNR form.
Nurse responsibilities:
,•Accept that if the DNR form is not available and the client cannot confirm their wishes,
resuscitative must be provided.
•Should an active DNR be discovered during resuscitation efforts, notify the health care provider
and nursing supervisor.
•Confirm the validity of the DNR form and the identity of the client.
•Withhold or withdraw resuscitative measures upon finding a valid DNR form.
•Provide palliative and supportive treatment for the client and family.
Organ Donation
Living Donors correct answers Healthy individuals offer organs to a client with end-organ
disease. Examples of organs donated by living donors are kidneys, lung lobes, part of a pancreas.
•
-Brain Death is one who is pronounced dead by neurologic criteria; cessation of brain function.
Circulatory Death-one who does not meet brain death criteria but has an illness from which no
recovery is expected. The healthcare team notifies an Organ Procurement Organization (OPO) of
the impending death. The OPO will approach the potential donor's family for consent.
Organ Donation
Brain Death or Circulatory Death Donor correct answers Brain Death is one who is pronounced
dead by neurologic criteria; cessation of brain function. Circulatory Death-one who does not
meet brain death criteria but has an illness from which no recovery is expected. The healthcare
team notifies an Organ Procurement Organization (OPO) of the impending death. The OPO will
approach the potential donor's family for consent.
Organ Management correct answers •Potential donors are evaluated on criteria that allows for the
organs to be as viable as possible. They are screened for infections that can be transmitted to
recipient.
•If consent is obtained for organ donation from a brain death or circulatory death client, the OPO
coordinates the direct care of client to preserve organ function. Organ recovery will take place in
the operating room.
•The nursing staff, healthcare team, and OPO collaborate to provide care to provide support to
the grieving family.
Organ Recipient Management correct answers •An interdisciplinary-team approach evaluates
potential organ recipients for physical and psychosocial needs.
•Education of the potential recipient includes the risks and benefits of organ donation.
•The potential complications of organ transplant includes...........................
•Rejection-Reason for use of immunosuppressive medications.
•Infection-Number one cause of morbidity and mortality to organ recipients due to use of
immunosuppressive medications.
•Post-transplant malignancies-Due to suppression of immune system from medications.
, early s/s of respiratory distress correct answers -increased RR
-increased HR
-increased BP (mild)
-anxiety
-restlessness
-pallor
-use of accessory muscles
-confusion
-nasal flaring
-decreased o2
-respiratory alkalosis
-tripod positioning
-agitation
-crackles
-tachypnea
late s/s of respiratory distress correct answers -decreased RR
-decreased HR
-abnormal HR
-decreased BP
-cyanosis
-stupor
-severe consciousness
-adventitious lung sounds
-accessory muscle use
-respiratory acidosis
-death
nursing actions for respiratory distress correct answers -raise head of bed
-purse-lip breathing
-diuresis
-splinted breathing with ABD. pain/incision
-bronchodilators
-supplemental O2
-naloxone/flumazenil
-suction
-bipap-RRT/code blue
FiO2 correct answers -percentage of O2 being delivered-room air FiO2 = 21%-each additional
liter of O2 has an extra 4% FiO2
low flow nasal cannula correct answers 1-6 L/min
24-44%
high flow nasal cannula correct answers 6-15 L/min
Critical Care Environment correct answers Assist client with applying hearing aids/glasses
-Physical environment and sensory deprivation (facilitate your client's ability to see and hear)
Adjust device alarms based on client's condition
-noise (try to limit unnecessary noise around your client)
Speak calmly in audible but quiet voice-noise (try to limit unnecessary noise around your client
-and this intervention also helps to decrease your client's anxiety)
Encourage family to bring objects from home
-Physical environment and sensory deprivation (will provide appropriate stimulation to the
client's senses and may help them feel less anxiety)
Explain procedures in client's primary language (or get assistance of translator)
-sensory deprivation(will provide appropriate stimulation to the client's senses and may help
them feel less anxiety)
Responding to Alarms correct answers Assess the client's level of consciousness
Assess the client's respiratory status
Palpate for a carotid pulse
Check the pulse oximetry alarm and address any issues noted
Check the telemetry alarm and address any issues noted
Assess the client's IV site
Check the infusion pump alarm and address any issues noted
Pharmacological Management of Pain & Anxiety correct answers *Anxiety*
-Benzodiazepines (Midazolam, Lorazepam)
Desired effects/Adverse effects
*Pain*
-Opioids- (Fentanyl, Morphine Sulfate, Hydromorphone)
Desired effects/Adverse effects
ABCDEF Bundle correct answers •Assess, prevent, and manage pain
•Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)
•Choice of analgesia and sedation
•Delirium assessment and management
•Early mobility and exercise
,•Family engagement and empowerment
Barriers to Accessing Health Care correct answers •Income
•Education
•Gender
•Race
•Sexual Orientation
•Disabilities
•Geographic Area
•Immigrant Status
Legal/ Ethical Terms correct answers autonomy- self determination
beneficence- intended to benefit
non-maleficence- do not harm
justice- distributed fairly
veracity- tell the truth
fidelity- faithfulness
confidentiality- protect information
moral distress- ethical dilemma
informed consent- given voluntarily
advocacy- represent for patient
Advance Directives and Do Not Resuscitate
•What are responsibilities of the client/family; health care provider; and nurse with advance
directives and do not resuscitate orders? correct answers Client/Family responsibilities:
•Understand the consequences of refusing resuscitative measures.
•Provide an original, unaltered DNR form for the health care team.
•Accept that if the DNR form is not available and the client cannot confirm their wishes,
resuscitative care will be provided.
•Should an active DNR be discovered during resuscitation efforts, consult with the health care
team to determine how care should proceed.
•Participate in care to the extent able.
Health care provider responsibilities:
•Accept that if the DNR form is not available and the client cannot confirm their wishes,
resuscitative must be provided.
•Should an active DNR be discovered during resuscitation efforts, stop interventions and assess
how to proceed.
•Determine if the client has a terminal condition and the capacity to provide consent.
•Withhold or withdraw resuscitative measures upon finding a valid DNR form.
Nurse responsibilities:
,•Accept that if the DNR form is not available and the client cannot confirm their wishes,
resuscitative must be provided.
•Should an active DNR be discovered during resuscitation efforts, notify the health care provider
and nursing supervisor.
•Confirm the validity of the DNR form and the identity of the client.
•Withhold or withdraw resuscitative measures upon finding a valid DNR form.
•Provide palliative and supportive treatment for the client and family.
Organ Donation
Living Donors correct answers Healthy individuals offer organs to a client with end-organ
disease. Examples of organs donated by living donors are kidneys, lung lobes, part of a pancreas.
•
-Brain Death is one who is pronounced dead by neurologic criteria; cessation of brain function.
Circulatory Death-one who does not meet brain death criteria but has an illness from which no
recovery is expected. The healthcare team notifies an Organ Procurement Organization (OPO) of
the impending death. The OPO will approach the potential donor's family for consent.
Organ Donation
Brain Death or Circulatory Death Donor correct answers Brain Death is one who is pronounced
dead by neurologic criteria; cessation of brain function. Circulatory Death-one who does not
meet brain death criteria but has an illness from which no recovery is expected. The healthcare
team notifies an Organ Procurement Organization (OPO) of the impending death. The OPO will
approach the potential donor's family for consent.
Organ Management correct answers •Potential donors are evaluated on criteria that allows for the
organs to be as viable as possible. They are screened for infections that can be transmitted to
recipient.
•If consent is obtained for organ donation from a brain death or circulatory death client, the OPO
coordinates the direct care of client to preserve organ function. Organ recovery will take place in
the operating room.
•The nursing staff, healthcare team, and OPO collaborate to provide care to provide support to
the grieving family.
Organ Recipient Management correct answers •An interdisciplinary-team approach evaluates
potential organ recipients for physical and psychosocial needs.
•Education of the potential recipient includes the risks and benefits of organ donation.
•The potential complications of organ transplant includes...........................
•Rejection-Reason for use of immunosuppressive medications.
•Infection-Number one cause of morbidity and mortality to organ recipients due to use of
immunosuppressive medications.
•Post-transplant malignancies-Due to suppression of immune system from medications.
, early s/s of respiratory distress correct answers -increased RR
-increased HR
-increased BP (mild)
-anxiety
-restlessness
-pallor
-use of accessory muscles
-confusion
-nasal flaring
-decreased o2
-respiratory alkalosis
-tripod positioning
-agitation
-crackles
-tachypnea
late s/s of respiratory distress correct answers -decreased RR
-decreased HR
-abnormal HR
-decreased BP
-cyanosis
-stupor
-severe consciousness
-adventitious lung sounds
-accessory muscle use
-respiratory acidosis
-death
nursing actions for respiratory distress correct answers -raise head of bed
-purse-lip breathing
-diuresis
-splinted breathing with ABD. pain/incision
-bronchodilators
-supplemental O2
-naloxone/flumazenil
-suction
-bipap-RRT/code blue
FiO2 correct answers -percentage of O2 being delivered-room air FiO2 = 21%-each additional
liter of O2 has an extra 4% FiO2
low flow nasal cannula correct answers 1-6 L/min
24-44%
high flow nasal cannula correct answers 6-15 L/min
