CMN 552 EXAM 3 UPDATED EXAM SCRIPT
WITH COMPLETE ANSWERS
◉ Can a UAP measure the drainage of a Hemovac or Jackson-Pratt?
Answer: yes measure the amount of fluid cant assess the drainage
system.
◉ Can a UAP collect specimens?
Answer: yes!!! stool and urine
◉ Can a UAP empty a colostomy bag ?
Answer: yes ! not the wafer.
◉ end of life care
Answer: the support and care given during the time surrounding
death = HOSPICE
◉ hospice care
Answer: comfort measures in the last phases of life
◉ hospice care and family
Answer: - private room
,- encourage the client and family to express feelings
- provide support and advocancy
- provide privacy
- LET THEM TOUCH THE CLIENT AS MUCH AS THEY WANT !
◉ PRIORITY QUESTIONS use what formula?
Answer: SPEC
◉ SPEC stands for ?
Answer: S= stable vs non stable
P= potential vs real
E= expected vs unexpected
C= chronic vs acute
◉ priority patients are?
Answer: - neuro changes ex: GCS LOW 8
- very low values labs ex: DM with 50 BS
- client returning form invasive procedures and a comlication
happens ex: eviceration
- ABC's airway problems and there acid base inbalanced
- client with chest pain and syncope not ecpected
- pt w/ 2-3 rd degree burns
,- client with new onset of infectious disease = TB
- any unexpected events= MI, STROKE, HHS, DKA, ADDISONS CRISIS,
THYROID STORM, MYXEDEMA COMA, HTN CRISIS, PREECLAMPSIA,
STROKE...
◉ Maslow's Hierarchy of Needs
Answer: physiological, safety, love/belonging, esteem, self-
actualization
◉ physiological needs? 1ST NEED
Answer: AIRWAY
RESPIRATORY EFFORT
HR, RHYTHM, CONTRACTIONS STRENGTH
NUTRITION
ELIMINATION
◉ SAFETY AND SECURITY = 2N NEED
Answer: - PROTECT FROM INJURY
- PROMOTE FEELING OF SECURITY
- TRUST IN NURSE CLIENT RELATIONSHIP
◉ TRIAGE RED TAG EXAMPLES? CLASS 1
, Answer: EMERGENT THREAT TO LIFE EX:
CARDIAC TEMPONADE
STROKE
SHOCK
AIRWAY OBSTRUCITON
◉ YELLOW TAG CLASS 2
Answer: Urgent within 30 min to 2 hours- can wait a little
- OPEN FRACTURES W DISTAL PULSES
- LARGE WOUNDS
◉ GREEN TAG CLASS 3
Answer: the walking wounded
- CLOSED FRACTURES
- SPRAINS
- ABRASIONS
- CONTUSION
◉ BLACK TAG CLASS 4
Answer: EXPECTED TO DIE!
- MASSIVE HEAD TRAUMA
- FULL THICK BURNS TO WHOLE BODY
WITH COMPLETE ANSWERS
◉ Can a UAP measure the drainage of a Hemovac or Jackson-Pratt?
Answer: yes measure the amount of fluid cant assess the drainage
system.
◉ Can a UAP collect specimens?
Answer: yes!!! stool and urine
◉ Can a UAP empty a colostomy bag ?
Answer: yes ! not the wafer.
◉ end of life care
Answer: the support and care given during the time surrounding
death = HOSPICE
◉ hospice care
Answer: comfort measures in the last phases of life
◉ hospice care and family
Answer: - private room
,- encourage the client and family to express feelings
- provide support and advocancy
- provide privacy
- LET THEM TOUCH THE CLIENT AS MUCH AS THEY WANT !
◉ PRIORITY QUESTIONS use what formula?
Answer: SPEC
◉ SPEC stands for ?
Answer: S= stable vs non stable
P= potential vs real
E= expected vs unexpected
C= chronic vs acute
◉ priority patients are?
Answer: - neuro changes ex: GCS LOW 8
- very low values labs ex: DM with 50 BS
- client returning form invasive procedures and a comlication
happens ex: eviceration
- ABC's airway problems and there acid base inbalanced
- client with chest pain and syncope not ecpected
- pt w/ 2-3 rd degree burns
,- client with new onset of infectious disease = TB
- any unexpected events= MI, STROKE, HHS, DKA, ADDISONS CRISIS,
THYROID STORM, MYXEDEMA COMA, HTN CRISIS, PREECLAMPSIA,
STROKE...
◉ Maslow's Hierarchy of Needs
Answer: physiological, safety, love/belonging, esteem, self-
actualization
◉ physiological needs? 1ST NEED
Answer: AIRWAY
RESPIRATORY EFFORT
HR, RHYTHM, CONTRACTIONS STRENGTH
NUTRITION
ELIMINATION
◉ SAFETY AND SECURITY = 2N NEED
Answer: - PROTECT FROM INJURY
- PROMOTE FEELING OF SECURITY
- TRUST IN NURSE CLIENT RELATIONSHIP
◉ TRIAGE RED TAG EXAMPLES? CLASS 1
, Answer: EMERGENT THREAT TO LIFE EX:
CARDIAC TEMPONADE
STROKE
SHOCK
AIRWAY OBSTRUCITON
◉ YELLOW TAG CLASS 2
Answer: Urgent within 30 min to 2 hours- can wait a little
- OPEN FRACTURES W DISTAL PULSES
- LARGE WOUNDS
◉ GREEN TAG CLASS 3
Answer: the walking wounded
- CLOSED FRACTURES
- SPRAINS
- ABRASIONS
- CONTUSION
◉ BLACK TAG CLASS 4
Answer: EXPECTED TO DIE!
- MASSIVE HEAD TRAUMA
- FULL THICK BURNS TO WHOLE BODY
