NR 341 final exam with correct answers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
high school student comes to ed with headache, fever, and neck pain - correct answer✔✔expect lumbar
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
puncture bc indicative of bacterial meningitis ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Status epileptics medication - correct 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 - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answer✔✔phenobarbital
Delirium nursing interventions - correct answer✔✔quiet environment, reorient, speak slowly, dark room,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
maintain consistent routine, identify threats to safety
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
what to monitor following electrical burns - correct answer✔✔telemetry for 24 hours
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Priority for facial burns - correct answer✔✔airway/intubate
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Patients with burns on face/neck are at risk for what? - correct answer✔✔airway obstruction
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Patient has VS showing infection on burn site - what to do? - correct answer✔✔get burn and wound
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
culture
process of getting blood cultures for burns - correct answer✔✔Do blood cultures before any antibiotics are
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
given
Burns stress ulcers and prevention - correct answer✔✔Curling's ulcer; NG tube is the prevention
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority for carbon monoxide burns - correct answer✔✔oxygen with non rebreather mask
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
other priority for burns - correct answer✔✔fluids
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
superficial burn (1st degree) - correct answer✔✔like a sunburn (epidermis and maybe small portion of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
dermis)
, Partial thickness burn (2nd °) - correct answer✔✔epidermis and most of dermis
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Full thickness burn (3rd °) - correct answer✔✔Same as partial thickness but may extend into subcutaneous
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
tissue; nerve damage ||\\||\\ ||\\||\\
- Thick, dry leathery appearance
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Deep Full thickness burn (4th °) - correct answer✔✔Destruction of all layers plus muscles, tendons & bones
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
- Black with no edema
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Escharectomy - correct answer✔✔surgical removal of eschar ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority intervention for DKA - correct answer✔✔fluids||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
interventions for DKA and HHS - correct 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 - correct 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 - correct answer✔✔monitor glucose every hour, check electrolytes every few hours
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
high school student comes to ed with headache, fever, and neck pain - correct answer✔✔expect lumbar
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
puncture bc indicative of bacterial meningitis ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Status epileptics medication - correct 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 - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answer✔✔phenobarbital
Delirium nursing interventions - correct answer✔✔quiet environment, reorient, speak slowly, dark room,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
maintain consistent routine, identify threats to safety
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
what to monitor following electrical burns - correct answer✔✔telemetry for 24 hours
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Priority for facial burns - correct answer✔✔airway/intubate
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Patients with burns on face/neck are at risk for what? - correct answer✔✔airway obstruction
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Patient has VS showing infection on burn site - what to do? - correct answer✔✔get burn and wound
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
culture
process of getting blood cultures for burns - correct answer✔✔Do blood cultures before any antibiotics are
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
given
Burns stress ulcers and prevention - correct answer✔✔Curling's ulcer; NG tube is the prevention
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority for carbon monoxide burns - correct answer✔✔oxygen with non rebreather mask
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
other priority for burns - correct answer✔✔fluids
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
superficial burn (1st degree) - correct answer✔✔like a sunburn (epidermis and maybe small portion of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
dermis)
, Partial thickness burn (2nd °) - correct answer✔✔epidermis and most of dermis
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Full thickness burn (3rd °) - correct answer✔✔Same as partial thickness but may extend into subcutaneous
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
tissue; nerve damage ||\\||\\ ||\\||\\
- Thick, dry leathery appearance
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Deep Full thickness burn (4th °) - correct answer✔✔Destruction of all layers plus muscles, tendons & bones
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
- Black with no edema
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Escharectomy - correct answer✔✔surgical removal of eschar ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
priority intervention for DKA - correct answer✔✔fluids||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
interventions for DKA and HHS - correct 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 - correct 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 - correct answer✔✔monitor glucose every hour, check electrolytes every few hours
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
