NSG 303 Exam 1 Questions With Complete Solutions

1. Hollow organs - ANSWER Stomach, bowel, bladder 2. Do hollow organs bleed? - ANSWER NO! They PERFORATE OR TEAR and release air and organ contents into the abdomen increasing the risk of infection 3. Solid organs - ANSWER Liver, Spleen, Pancreas, Kidneys 4. Do solid organs bleed? - ANSWER YES! They TEAR, LACERATE, AND BLEED. High risk of hypovolemic shock 5. What do seat belt signs mean? - ANSWER Internal bleeding 6. Assessment of seat belt signs - ANSWER Distended abdomen Absent/diminished bowel sounds Tender abdomen Rebound tenderness Bruising to abdomen/flank area Signs of shock 7. What are the signs of shock? - ANSWER Low BP/MAP, elevated HR/RR, cool clammy skin, decreased SP02, altered mental status 8. Circulation trauma treatment - ANSWER IV access (large gauge in antecubital, forearm, or intraossesous. infusion is warmed NS or LR (1-2L INCLUDING prehospital administration 9. When do you administer blood? - ANSWER When MAP is low after initial NS or LR 10. Is a type and screen done in trauma patients receiving blood? - ANSWER NO! There is an increased risk for reactions 11. What is 1:1:1 ratio? - ANSWER Packed RBC Platelets-fresh frozen plasma then REPEAT 12. Does massive blood transfusion include clotting factors? - ANSWER NO, it contains components. Whole blood is preferred 13. When are vasopressors used in a circulation trauma? - ANSWER Only when hemorrhage is controlled 14. GCS - ANSWER 12+ minor brain injury 9-12 moderate brain injury 8 or less severe injury INTUBATE 15. Assessment for TBI - ANSWER Pupil assessment BEFORE sedating and paralyzing the patient, CT scan 16. Priority interventions for TBI - ANSWER OXYGENATE, ventilate, fluid resuscitation, hemorrhage control/maintain MAP, prevent seizures 17. Symptoms of increased ICP - ANSWER Severe headache Nausea/vomiting Restless, irritability, decreased level of consciousness, Dilated non-reactive pupils Altered breathing patterns (hyperventilation, apnea, cheyne stokes) Posturing 18. Decorticate posturing - ANSWER Arms TOWARD the core, legs internally rotated and extended 19. Decerebrate posturing - ANSWER Arms AWAY from the core, extended, abducted 20. How do you maintain ICP? - ANSWER Calm and quiet environment Control seizures and agitation Control pain Avoid unnecessary procedures Avoid constricting clothing 21. What is Reverse Trendelenburg? - ANSWER Feet DOWN head UP