NUR 265 Exam 4 Questions and Verified Answers Latest Update Graded A+

NUR 265 EXAM 4 QUESTIONS &
VERIFIED ANSWERS; LATEST
UPDATE; GRADED A+


ABCDE - correct answer- A-airway; jaw thrust
maneuver
B-breathing; bag valve mask (not worried about artificial
airway)
C-circulation; cardiac assessment, heart monitor,
pulse..looking for bleeding and hanging fluids
D- disability--GCS
E- exposure--cutting clothes off, preventing hypothermia


Abdominal trauma: bladder - correct answer- -
monitor urine output
-dont remove foley after surgery
-ruptured bladder needs surgical repair


Abdominal trauma: kidney - correct answer- -
injury to flank

,monitor for flank pain, bleeding, and hematuria
REPORT IMMEDIATELY


acute graft rejection - correct answer- fever**
pain**
organ dysfunction**


Acute graft rejection: Heart - correct answer- -
SOA, irregular heart rate,
-fluid gain
-hypotension; new bradycardia


Acute graft rejection: Kidneys - correct answer-
-creatnine is elevated and may or may not be producing
urine
-notify surgeon if HYPOTENSION occurs or excessive
diuresis


Acute graft rejection: Liver - correct answer- -
elevated liver enzymes

,-monitor temp frequently
-RUQ pain
-report increased abdominal pain
-distention, and rigidity


Acute graft rejection: Lung - correct answer-
SOA


acute graft rejection: Pancreas - correct answer-
-blood sugar is high--late sign
-decreased urinary output
-graft tenderness
-fever
-hypertension


albumin - correct answer- 3.5-5.0


allergic reaction - correct answer- stop the
infusion**

, admin epi--impaired airway**
stabbing with epi through clothes on top of thigh; carry 2
epi and call 911**
maintain airway--intubate**


Allergic Reaction Priority - correct answer-
STOP THE INFUSION/ELIMINATE the trigger, then STOP
the immune response


Give Epi
maintain airway


altitude illness - correct answer-
dexamethasone--reduces cerebral edema


Altitude sickness: assess - correct answer- -
respiratory rate--watch for hyperventilation
-exertional dyspnea