NUR356 Exam with complete solutions
2024/2025
Standard 8: Recognising and responding to Clinical Deterioration in Acute Health.
- ANSWER--Recognise failing respiratory, cardiovascular, and neurological
-Allocates points to measure routine vital signs.
-An increased score indicates an increased risk of deterioration and death.
-Purpose of these charts is to support timely recognition of clinical deterioration.
Advanced life support (ALS) - ANSWER-- standardised approach to cardiac arrest
management
-• Nurse to analyses the rhythm and decide if it's a shockable rhythm such as VF
or pulseless VT or to continue with CPR if it's Asystole or PE
ALS Drugs - ANSWER-Adrenaline: Shockable and Non-Shockable
-1mg bolus (10ml of 1:10,000) or (1ml 1:1000)
• Vasoconstriction leads to an increase in coronary and cerebral perfusion
• Increases coronary and cerebral blood flow
Amiodarone: Shockable Only
-300mg bolus diluted in 20ml of 5% dextrose
• Anti-arrhythmic
• Increases the duration of the action potential and refractory period in atrial and
myocardium
• AV conduction is slowed
Shockable - ANSWER-Ventricular Fibrillation (VF) & Ventricular Tachycardia (VT)
,Non-Shockable - ANSWER--Asystole
-Pulseless Electrical Activity (PEA
4 Hs and 4 T's - ANSWER--Hypoxia
-Hypovolaemia
-Hypokalaemia
-Hypothermia
-Tension pneumothorax
-Tamponade
-Toxins
-Thrombosis
Post resus care - ANSWER--Re-evaluate A-E
-12 lead ecg
-Treat precipitating cause
-Aim for Sp02 94-98%
-Targeted temperature management
Endotracheal Tube (ETT) - ANSWER-Indications:
• Upper airway obstruction
• Apnea
• High-risk aspirations
Equipment:
• Suction
• Laryngoscope
• Cuffed ETT tube
• Lubricant
Nursing care of an intubated patient - ANSWER-• Observing the physical signs of
the patient
• Observe Tidal volume and pressure.
• Gas exchange
• Lung auscultation every 2-4hrs for presence of secretions
, • Maintain humidification
• Monitor vital signs
Oral hygiene every 2hrs (Prevent VAP
Central Line Catheter CVC - ANSWER-Benefits:
• Immediate access to the central venous system
• Reduced need for venepuncture
• Allows for continuous and rapid administration of medications and fluids
Risks:
• Increased risk of systemic infection
• Invasiveness of the procedure
positive end-expiratory pressure (PEEP) - ANSWER--It is the the positive pressure
that will remain in the airways at the end of the respiratory cycle through the use
of a peep valve causing resistant/pressure in the lungs which causing lungs not
to fully deflate.
Anaphylaxis - ANSWER--mass release of histamine
-affects two or more system= adrenaline
What are signs of Anaphylaxis? - ANSWER-- Upper respiratory- swelling lips,
hoarse voice (adrenaline)
-Lower respiratory
-Ocular
- GI
A-E (B) - ANSWER-R- respiratory rate
A-Auscultate
T- trachea midline
E- effort of breathing
S- sp02
Pneumonia - ANSWER-• An infection of the lower respiratory tract caused by
bacteria, viruses, fungi, protozoa or parasites.
2024/2025
Standard 8: Recognising and responding to Clinical Deterioration in Acute Health.
- ANSWER--Recognise failing respiratory, cardiovascular, and neurological
-Allocates points to measure routine vital signs.
-An increased score indicates an increased risk of deterioration and death.
-Purpose of these charts is to support timely recognition of clinical deterioration.
Advanced life support (ALS) - ANSWER-- standardised approach to cardiac arrest
management
-• Nurse to analyses the rhythm and decide if it's a shockable rhythm such as VF
or pulseless VT or to continue with CPR if it's Asystole or PE
ALS Drugs - ANSWER-Adrenaline: Shockable and Non-Shockable
-1mg bolus (10ml of 1:10,000) or (1ml 1:1000)
• Vasoconstriction leads to an increase in coronary and cerebral perfusion
• Increases coronary and cerebral blood flow
Amiodarone: Shockable Only
-300mg bolus diluted in 20ml of 5% dextrose
• Anti-arrhythmic
• Increases the duration of the action potential and refractory period in atrial and
myocardium
• AV conduction is slowed
Shockable - ANSWER-Ventricular Fibrillation (VF) & Ventricular Tachycardia (VT)
,Non-Shockable - ANSWER--Asystole
-Pulseless Electrical Activity (PEA
4 Hs and 4 T's - ANSWER--Hypoxia
-Hypovolaemia
-Hypokalaemia
-Hypothermia
-Tension pneumothorax
-Tamponade
-Toxins
-Thrombosis
Post resus care - ANSWER--Re-evaluate A-E
-12 lead ecg
-Treat precipitating cause
-Aim for Sp02 94-98%
-Targeted temperature management
Endotracheal Tube (ETT) - ANSWER-Indications:
• Upper airway obstruction
• Apnea
• High-risk aspirations
Equipment:
• Suction
• Laryngoscope
• Cuffed ETT tube
• Lubricant
Nursing care of an intubated patient - ANSWER-• Observing the physical signs of
the patient
• Observe Tidal volume and pressure.
• Gas exchange
• Lung auscultation every 2-4hrs for presence of secretions
, • Maintain humidification
• Monitor vital signs
Oral hygiene every 2hrs (Prevent VAP
Central Line Catheter CVC - ANSWER-Benefits:
• Immediate access to the central venous system
• Reduced need for venepuncture
• Allows for continuous and rapid administration of medications and fluids
Risks:
• Increased risk of systemic infection
• Invasiveness of the procedure
positive end-expiratory pressure (PEEP) - ANSWER--It is the the positive pressure
that will remain in the airways at the end of the respiratory cycle through the use
of a peep valve causing resistant/pressure in the lungs which causing lungs not
to fully deflate.
Anaphylaxis - ANSWER--mass release of histamine
-affects two or more system= adrenaline
What are signs of Anaphylaxis? - ANSWER-- Upper respiratory- swelling lips,
hoarse voice (adrenaline)
-Lower respiratory
-Ocular
- GI
A-E (B) - ANSWER-R- respiratory rate
A-Auscultate
T- trachea midline
E- effort of breathing
S- sp02
Pneumonia - ANSWER-• An infection of the lower respiratory tract caused by
bacteria, viruses, fungi, protozoa or parasites.
