NSG 270 FINAL Exam and All Correct Answers.

Three ways to check placement of an ET tube? - Answer the measuring on the tube, the X-Ray, and PH How do you prevent PUD in vented patients? - Answer PPIs--- Pepcid and protonix The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided? 1. Reposition the patient every two hours. 2. Position the patient with the head elevated 30 degrees. 3. Suction the airway every two hours per standing orders. 4. Provide continuous oxygen as ordered. - Answer Correct Answer: 3Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP. autonomic dyreflexia can happen in someone with - Answer a SCI at or above T6 normal levels of dilantin - Answer 10-20 what should be the first action of a nurse when they see a patient with a BP of 210/110 and a pulse of 54? - Answer those are signs of autonomic dysreflexia and they should be sat up... then they should be checked for bladder distention C1-C4 injury - Answer will be quadriplegic and need mechanical ventilation What is a positive BNP indicate? - Answer positive for heart failure what is all shock a result of? - Answer poor perfusion How do you see if a BiPap or Cpap are effective? - Answer ABGs will show improved oxygen What is the first sign of shock? - Answer increased heart rate/tachycardia