NR 341 final exam
high school student comes to ed with headache, fever, and neck pain - ANSWER
expect lumbar puncture bc indicative of bacterial meningitis
Status epileptics medication - 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 - ANSWER phenobarbital
Delirium nursing interventions - ANSWER quiet environment, reorient, speak
slowly, dark room, maintain consistent routine, identify threats to safety
what to monitor following electrical burns - ANSWER telemetry for 24 hours
Priority for facial burns - ANSWER airway/intubate
Patients with burns on face/neck are at risk for what? - ANSWER airway
obstruction
Patient has VS showing infection on burn site - what to do? - ANSWER get burn
and wound culture
process of getting blood cultures for burns - ANSWER Do blood cultures before any
antibiotics are given
Burns stress ulcers and prevention - ANSWER Curling's ulcer; NG tube is the
prevention
priority for carbon monoxide burns - ANSWER oxygen with non rebreather mask
other priority for burns - ANSWER fluids
superficial burn (1st degree) - ANSWER like a sunburn (epidermis and maybe small
portion of dermis)
Partial thickness burn (2nd °) - ANSWER epidermis and most of dermis
Full thickness burn (3rd °) - ANSWER Same as partial thickness but may extend
into subcutaneous tissue; nerve damage
- Thick, dry leathery appearance
Deep Full thickness burn (4th °) - ANSWER Destruction of all layers plus muscles,
tendons & bones
- Black with no edema
, Escharectomy - ANSWER surgical removal of eschar
priority intervention for DKA - ANSWER fluids
interventions for DKA and HHS - 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 - 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 - ANSWER monitor glucose every hour, check electrolytes every few
hours
for mass causality - ANSWER greatest good for greatest number of people
who would you give a black tag to in a mass causality - ANSWER Full cardiac
arrest
Open or unresponsive head injury
No pulse
Leg fracture and large bone (large bones like femur and pelvis) - biggest concern -
ANSWER fat embolism
treatment for fat embolism - ANSWER extremity immobilization
Long bone leg fx or pelvic fx complications - ANSWER fat embolism or
compartment syndrome
Rhabdomyolysis - ANSWER CK lab can show this
Tx → IV fluids to achieve a urine output of 100-200 ml/hr
5 P's - ANSWER pain, pallor, pulselessness, parasthesia, paralysis
why be wary of SaO2 monitors when pt. has carbon monoxide poisoning - ANSWER
Cannot distinguish between oxyhemoglobin & carboxyhemoglobin
Insulin therapy (DKA & HHS) - ANSWER Fluid replacement initiate first; monitor K+
high school student comes to ed with headache, fever, and neck pain - ANSWER
expect lumbar puncture bc indicative of bacterial meningitis
Status epileptics medication - 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 - ANSWER phenobarbital
Delirium nursing interventions - ANSWER quiet environment, reorient, speak
slowly, dark room, maintain consistent routine, identify threats to safety
what to monitor following electrical burns - ANSWER telemetry for 24 hours
Priority for facial burns - ANSWER airway/intubate
Patients with burns on face/neck are at risk for what? - ANSWER airway
obstruction
Patient has VS showing infection on burn site - what to do? - ANSWER get burn
and wound culture
process of getting blood cultures for burns - ANSWER Do blood cultures before any
antibiotics are given
Burns stress ulcers and prevention - ANSWER Curling's ulcer; NG tube is the
prevention
priority for carbon monoxide burns - ANSWER oxygen with non rebreather mask
other priority for burns - ANSWER fluids
superficial burn (1st degree) - ANSWER like a sunburn (epidermis and maybe small
portion of dermis)
Partial thickness burn (2nd °) - ANSWER epidermis and most of dermis
Full thickness burn (3rd °) - ANSWER Same as partial thickness but may extend
into subcutaneous tissue; nerve damage
- Thick, dry leathery appearance
Deep Full thickness burn (4th °) - ANSWER Destruction of all layers plus muscles,
tendons & bones
- Black with no edema
, Escharectomy - ANSWER surgical removal of eschar
priority intervention for DKA - ANSWER fluids
interventions for DKA and HHS - 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 - 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 - ANSWER monitor glucose every hour, check electrolytes every few
hours
for mass causality - ANSWER greatest good for greatest number of people
who would you give a black tag to in a mass causality - ANSWER Full cardiac
arrest
Open or unresponsive head injury
No pulse
Leg fracture and large bone (large bones like femur and pelvis) - biggest concern -
ANSWER fat embolism
treatment for fat embolism - ANSWER extremity immobilization
Long bone leg fx or pelvic fx complications - ANSWER fat embolism or
compartment syndrome
Rhabdomyolysis - ANSWER CK lab can show this
Tx → IV fluids to achieve a urine output of 100-200 ml/hr
5 P's - ANSWER pain, pallor, pulselessness, parasthesia, paralysis
why be wary of SaO2 monitors when pt. has carbon monoxide poisoning - ANSWER
Cannot distinguish between oxyhemoglobin & carboxyhemoglobin
Insulin therapy (DKA & HHS) - ANSWER Fluid replacement initiate first; monitor K+
