TEST BANK Nur 280 comprehensive review comp 1 comp 2 comp 3 2023

TEST BANK Nur 280 comprehensive review comp 1 comp 2 comp 3 2023 Comp #1 Spinal Cord Injury/Surgery/Procedure - Expected finding: o Decreased reflexes o Numbness/tingling o Inability to urinate (from low spinal cord injury) - Not Expected: o Decreased RR. o Headache (increased ICP) o CSF halo (yellow fluid) - Post-Op: o Airway, circulation o Monitor for ICP, Neuro checks, VS closely - Complication: o Autonomic Dysreflexia. S/S: ▪ Numbness & tingling (expected) ▪ Severe hypotension ▪ Cessation of breathing (not expected). Heparin/Enoxaparin (LMWH) - Anticoagulant that can be give IV or SQ o Labs: ▪ aPTT 30-40 (WNL), while on Heparin should be 1.5-2x the normal value [aPTT on heparin 60-90] ▪ Risk for bleeding (aPTT 70) ▪ Warfarin & Heparin until Warfarin reaches therapeutic INR levels [2-3] ▪ H&H (rule of thumb, hematocrit [37-52] will be 3x the amount of hemoglobin [12-18]) example: HgB 8 = Hct 24, or HgB 10 = Hct 30 ▪ Platelets 1.5-2.5x the normal (want them high not low) • Normal Platelets Range: 150-400 - Antidote: o Protamine Sulfate - Complication o HIT (Heparin Induced Thrombocytopenia) ▪ Due to being on med for longer than a week ▪ Monitor for s/s of bleeding ▪ Lab: low platelet count (150) o Interventions: ▪ Stop heparin ▪ Direct thrombin inhibitor • Lepirudin and Argatroban ▪ Treat active and prevent any new thrombosis - SQ Administration o Don’t aspirate or expel the bubbles out of prefilled syringe Colostomy - Descending colostomy located on LLQ (involves the large intestines) - Stoma should be reddish pink, moist and shiny (Saunders pg. 688) o Call MD if stoma looks: ▪ Pale/ Pink (low h&h levels) ▪ Dark purple/ Black (compromised circulation) ▪ Shrink in size/Dry ▪ Small amount of mucous drain in the bag - Expect liquid stool in the immediate postop period but become mores more solid depending on location o Ascending Colon: liquid o Transverse Colon: loose to semi-formed o Descending Colon: close to normal - Empty pouch when 1/3 full - Monitor for dehydration & electrolyte imbalance - Avoid food that causes excess gas or odor o Give yogurt to help decrease smell - Avoid contact of skin with stool - Should start functioning 2-3 days after surgery Ventilator Associated Pneumonia (VAP) - Prevention o HOB elevated 30 degrees o ulcer prophylaxis (H2 blockers) o preventing aspiration o pulmonary hygiene (chest physiotherapy, postural drainage/percussion and turning/re-positioning Q2hours) o remove water from circuits, and suction PRN. o Vigilant, frequent oral care is key! ▪ brushing teeth Q8hours, antimicrobial rinse and lip moisturizer Q2hours o Cough Sepsis: - Bloodstream infection/UTI, bacteria, fungi, vasodilation o considered a type of distributive shock, prevention is key. - Risk Factors: o cancer patients (highest risk) o malnutrition o immunocompromised o open wounds o DM, CKD, Hepatitis, HIV/AIDS - S/S: o DIC (disseminated intravascular coagulation) o low O2 o tachypnea o decreased/absent urine output o change in LOC o hypoxia o death/dysfunction of organs - Interventions: o Resuscitation oxygen therapy o Blood replacement therapy o Drug therapy - Identify early manifestations of infection o treat with antibiotics o strict aseptic technique o IV fluids o inotropic medications. Septic Shock - Caused by an infection o Medical emergency can happen to anyone who is a patient in the hospital. - Capillaries dilate o Fluid exits the vascular system and enters interstitial spaces. - S/S: Hypotension o Tachycardia o Increased RR o Increased temp o cold and clammy skin. o Changes in LOC (earliest sign) - Treatment: o Fluids ▪ Normal Saline and Lactated Ringers (Bolus) o Broad Spectrum antibiotics o Vasopressors A-Fib - Multiple Rapid impulses - Quivering atria - Irregular heart rhythm - HR 130-150+ - Treatments: o Oxygen o Amiodarone & Digoxin ▪ With rapid ventricular response (RVR) o Calcium Channel Blocker (CCB) ▪ Diltiazem o Beta Blocker (BB) ▪ Metoprolol o Monitor electrolytes ▪ Low potassium (increases risk for dig toxicity) o Anticoagulatory therapy ▪ Warfarin • Prevents blood from clotting due to the quivering of the heart o Synchronized Cardioversion ▪ When symptomatic and non-responsive to med Hyperbilirubinemia pg. 382 - Occurs when there is too much bilirubin in the blood. o Bilirubin is made by the breakdown of RBCs. ▪ Indicates issues with the liver - Lab Value o Bilirubin: 1 ▪ increased with impaired liver function. - S/S: o Jaundice o Poor sucking reflex o Enlarged liver o Lethargy o Poor muscle tone o Elevated bilirubin