NUR 2755 Multidimensional Care Iv Final Exam Questions And Answers Verified 100% Correct Rasmussen

NUR 2755 Multidimensional Care Iv Final Exam Questions And Answers Verified 100% Correct Rasmussen When we see a patient passed out/unconscious at home, with cherry red skin color, what do we assume??? - Carbon monoxide poisoning Make sure that if a patient we did Parkland Formula, and still low urine output, what else can we do?? - Increase fluid rate Monitor urine output Check electrolytes Parkland formula - 4 mL x TBSA (%) x body weight (kg). 50% given in first 8 hours, 50% given over the next 16 hours. Patient with a burn, what electrolyte would we typically initially see with 3rd spacing of fluid?? - High potassium What patient would be at high risk for developing a PE?? - Hx of DVT Smoking Oral birth control Pregnancy Immobility Major long bone fracture Hx of falls Post Op patients How would you determine if patient is receiving good ventilation?? - Equal chest rise Stable vitals Skin color Capillary Refill What type of alarm would you hear if patient has mucous plug and needs suctioning?? - High pressure alarm initial phase of shock - MAP decreased by 10 mmHg from baseline. Mild vasoconstriction. Increased heart rate. Vital organ function is NOT disrupted. Indicators of shock are difficult to detect at this stage. THIS STAGE IS STILL REVERSIBLE. Nonprogressive phase of shock - MAP decreases by 10-15 mmHg from baseline. Moderate vasoconstriction. Increased heart rate and decreased pulse pressure. Chemical compensation. Decreased urine output, stimulation of thirst reflex, mild acidosis, mild hyperkalemia. Tissue hypoxia occurs in nonvital organs and in the kidneys but is not great enough to cause permanent damage. Restlessness, tachycardia, increased respiratory rate, falling systolic blood pressure, narrowing pulse pressure, cool extremities, and a 2%-5% change in oxygen saturation. THIS STAGE IS STILL REVERSIBLE. Progressive phase of shock - Decrease of more than 20% MAP. Anoxia of nonvital organs, hypoxia of vital organs. Moderate acidosis, moderate hyperkalemia, tissue ischemia. Some tissues die. Patient may have a sense of impending doom or "something bad". Patient may become confused and thirst increases. Rapid weak pulse, low blood pressure, pallor to cyanosis of oral mucosa and nail beds, cool and moist skin, anuria, and 5%-20% decrease in oxygen saturation. Refractory phase of shock - FINAL PHASE Final stage and also irreversible stage. Occurs when too much cell death and tissue damage has happened. Vital organs have extensive damage and cannot respond effectively to interventions, so shock continues. Severe tissue hypoxia with ischemia and necrosis. Buildup of toxic metabolites. MODS. Death. When patient presents to ER with suspicion of sepsis, what to do in the first few hours?? - Lactic acid Blood cultures Antibiotics AFTER blood cultures How to calculate TBSA? - A&P head: each 4.5% (9% entire head) A&P chest: 18% each A&P arm: 4.5% each side on each arm (9% entire each arm) A&P leg: 9% each side, each leg. (18% entire each leg) Groin: 1% Deep partial thickness burns - Red to white Moderate Edema Yes pain Blisters are rate Yes eschar (its soft and dry) Healing time is 2-6 weeks Grafts can be used in prolonged healing time What happens to a patient that has drowned? - Alveoli are collapsing, and pulmonary edema occurs What kind of scenarios would we see hospital disaster plan activated?? - Large influx of patients Example: explosion Wellness for nurses to prevent burn out and PTSD - Counseling Encourage & Support coworkers Monitor each other's stress levels Take breaks when needed Talk about feelings Drink plenty of water Healthy snacks for energy Keep in touch with family, friends and SO Do not work more than 12 hours