NR 341 Final Exam 2 Questions With Complete Solutions
***Clinical manifestations of Bacterial Meningitis?*** Correct
Answers Subjective:
- headache, nuchal rigidity, photophobia
Red macular rash
Objective:
- Tachycardia, seizures, hyperactive deep tendon reflexes
Fever, chills, N/v, altered LOC
Positive Kernigs & Brudzinskis sign
***How do you calculate how much fluids to give for burn
clients?*** Correct Answers 4 X weight in kg X %TBSA
divide by 2 if looking for first 8 hrs
***What are the clinical manifestations of Autonomic
Dysreflexia?*** Correct Answers - Extreme hypertension,
sudden severe headache, pallor below the level of the spinal
cord's lesion dermatome, blurred vision, diaphoresis,
restlessness, nausea, and piloerection (goosebumps).
- Flushed face and neck above dermatome, diaphoresis
- Nasal stuffiness -***Bladder is full & self-catherization***
***What is included and assessed during Primary Survey?***
Correct Answers ABCDE principle
***Airway/Cervical Spine***
- If the client is unresponsive without suspicion of trauma, the
airway should be opened with a head-tilt/ chin-lift maneuver
,- If the client is unresponsive with suspicion of trauma, the
airway should be opened with a modified jaw thrust maneuver.
- Suction or sweep objects blocking the airway
- Bag valve mask with 100% o2 for clients needed airway
support until an advanced airway is established
- Nonrebreather with 100% o2 for clients w/ spontaneous
breathing
***Breathing***
- Once a patent airway is achieved the nurse should assess the
breathing
- JVD: Trach position: RR: Chest trauma: Sounds
- Manual ventilation if breathing is inadequate
***Circulation***
-HR, BP, Pulses, & Capillary refill
-Shock
- Perform CPR, assess for bleeding, apply pressure to external
bleeding, large bore IV catheter
- Infuse isotoni fluids: LR and 0.9%NaCl & blood products
***Disability***
- Determine LOC using GCS
***Frostbite***
- Warm bath (104-108F {40-42C])
- Administer tetanus toxoid IM
***Exposure***
- Remove clothing
, Brain death management Correct Answers If brain death has
occurred, the family needs support when deciding whether to
donate organs.
***phenylephrine bp <90***
CVP measurement Correct Answers Normal CVP is 2-6mmHg
***best indicator ofvolume status***
***Decreased = hypovolemic shock***
***Increased = cardiogenic shock***
How do we stabilize a suspected neck injury? Correct Answers
- Stabilize cervical spine
- C4 injury can cause tetraplegia
How do you assess an AV graft/ fistula? Correct Answers -
Assess patency:
- presence of bruit, palpable thrill, distal pulses, circulation
-Assess for rejection:
- tachycardia, fever, right upper quadrant pain, change in bile
color or increased jaundice, increased ALT and AST levels.
-Monitor BP:
- hypotension can cause decreased blood flow and hypertension
can cause bleeding
- Report drainage that is not serosanguineous from the drain, or
drainage from the wound to the provider immediately.
-Monitor labs & weight & vascular access
***Clinical manifestations of Bacterial Meningitis?*** Correct
Answers Subjective:
- headache, nuchal rigidity, photophobia
Red macular rash
Objective:
- Tachycardia, seizures, hyperactive deep tendon reflexes
Fever, chills, N/v, altered LOC
Positive Kernigs & Brudzinskis sign
***How do you calculate how much fluids to give for burn
clients?*** Correct Answers 4 X weight in kg X %TBSA
divide by 2 if looking for first 8 hrs
***What are the clinical manifestations of Autonomic
Dysreflexia?*** Correct Answers - Extreme hypertension,
sudden severe headache, pallor below the level of the spinal
cord's lesion dermatome, blurred vision, diaphoresis,
restlessness, nausea, and piloerection (goosebumps).
- Flushed face and neck above dermatome, diaphoresis
- Nasal stuffiness -***Bladder is full & self-catherization***
***What is included and assessed during Primary Survey?***
Correct Answers ABCDE principle
***Airway/Cervical Spine***
- If the client is unresponsive without suspicion of trauma, the
airway should be opened with a head-tilt/ chin-lift maneuver
,- If the client is unresponsive with suspicion of trauma, the
airway should be opened with a modified jaw thrust maneuver.
- Suction or sweep objects blocking the airway
- Bag valve mask with 100% o2 for clients needed airway
support until an advanced airway is established
- Nonrebreather with 100% o2 for clients w/ spontaneous
breathing
***Breathing***
- Once a patent airway is achieved the nurse should assess the
breathing
- JVD: Trach position: RR: Chest trauma: Sounds
- Manual ventilation if breathing is inadequate
***Circulation***
-HR, BP, Pulses, & Capillary refill
-Shock
- Perform CPR, assess for bleeding, apply pressure to external
bleeding, large bore IV catheter
- Infuse isotoni fluids: LR and 0.9%NaCl & blood products
***Disability***
- Determine LOC using GCS
***Frostbite***
- Warm bath (104-108F {40-42C])
- Administer tetanus toxoid IM
***Exposure***
- Remove clothing
, Brain death management Correct Answers If brain death has
occurred, the family needs support when deciding whether to
donate organs.
***phenylephrine bp <90***
CVP measurement Correct Answers Normal CVP is 2-6mmHg
***best indicator ofvolume status***
***Decreased = hypovolemic shock***
***Increased = cardiogenic shock***
How do we stabilize a suspected neck injury? Correct Answers
- Stabilize cervical spine
- C4 injury can cause tetraplegia
How do you assess an AV graft/ fistula? Correct Answers -
Assess patency:
- presence of bruit, palpable thrill, distal pulses, circulation
-Assess for rejection:
- tachycardia, fever, right upper quadrant pain, change in bile
color or increased jaundice, increased ALT and AST levels.
-Monitor BP:
- hypotension can cause decreased blood flow and hypertension
can cause bleeding
- Report drainage that is not serosanguineous from the drain, or
drainage from the wound to the provider immediately.
-Monitor labs & weight & vascular access
