NUR 445. Exam 3 Review (#4)
Before teaching about ICP- what should the nurse ensure about the patient? - answer
That they are conscious, can't give teaching to an incompetent patient.
What are four assessment findings in a patient with a brain tumor? - answer- Dysphagia
- Papilledema
- Hemiplegia
- Vertigo
What are four teaching points for a patient going home with a brain tumor? - answer-
Sitting at 30 degrees
- S/S of ICP
- Increase fiber and water
- Dressing changes
What is used to monitor ICP? – answer Intraventricular catheter
Before doing a lumbar puncture, what should the nurse make sure patients can do? -
answerLay still.
Name one assessment finding during a neuro exam for a patient with multi organ
failure. - answerChange in LOC
If a patient had pleurodesis and spontaneous pneumo after, what would they complain
of? - answerPain
When a patient has chest tubes removed, what are two teaching points for the nurse to
rely? - answerThey need to have a dressing for two days and may experience pain.
What are two interventions to prevent ventilator complications? - answer- Move the
tubing so they do not get skin breakdown.
- Oral care q2hr
If someone is sedated for an MRI, do they need to be NPO? - answerYes!
Chest tube for a tension pneumo would be placed where? - answerIn the 2nd intercostal
space of midclavicular line.
How do we know if someone is ready to be weaned from the vent? - answer- Cough
reflex
- Start breathing on their own
, Constant peep means what? - answerConstant pressure from vent.
What are five teaching points for ARDS patient's family members? - answer- Prone
positioning
- Suction
- Oral care for vent
- Assess LOC
- Give patient fluids
What are three signs and symptoms of ARDS? - answer- Use of accessory muscles
- Breath sounds diminished
- SPO2 <90
What is the DX test for pulmonary artery hypertension? - answerRight-side cath.
To reduce mortality of ARDS, what non-pharm intervention do we do? - answerPlace
client in a prone position.
How do we know endo trach is placed correctly? - answerEnd tidal CO2 monitor, go for
the gold monitor
Clabsi, def and how do we prevent it? - answer- Central line associated bacterial
infection
- Assess it, clean it
When a patient had a stroke, how would we know they have a central herniation? (Hint:
5 signs) - answer- Positive Babinski reflex
- Cushing triad
- Irregular respirations
- Bradycardia
- Posturing
What reflex is lost if you have doll eyes? - answerOculocephalic
What are early (and late) signs of respiratory distress? - answer- SOB
- Tachycardia
- Restlessness
- Tachypnea
- LOC change (LATE sign)
What are three signs of spinal shock? - answer- Decreased systemic vascular
resistance
- Bradycardia
- Hypotension
Before teaching about ICP- what should the nurse ensure about the patient? - answer
That they are conscious, can't give teaching to an incompetent patient.
What are four assessment findings in a patient with a brain tumor? - answer- Dysphagia
- Papilledema
- Hemiplegia
- Vertigo
What are four teaching points for a patient going home with a brain tumor? - answer-
Sitting at 30 degrees
- S/S of ICP
- Increase fiber and water
- Dressing changes
What is used to monitor ICP? – answer Intraventricular catheter
Before doing a lumbar puncture, what should the nurse make sure patients can do? -
answerLay still.
Name one assessment finding during a neuro exam for a patient with multi organ
failure. - answerChange in LOC
If a patient had pleurodesis and spontaneous pneumo after, what would they complain
of? - answerPain
When a patient has chest tubes removed, what are two teaching points for the nurse to
rely? - answerThey need to have a dressing for two days and may experience pain.
What are two interventions to prevent ventilator complications? - answer- Move the
tubing so they do not get skin breakdown.
- Oral care q2hr
If someone is sedated for an MRI, do they need to be NPO? - answerYes!
Chest tube for a tension pneumo would be placed where? - answerIn the 2nd intercostal
space of midclavicular line.
How do we know if someone is ready to be weaned from the vent? - answer- Cough
reflex
- Start breathing on their own
, Constant peep means what? - answerConstant pressure from vent.
What are five teaching points for ARDS patient's family members? - answer- Prone
positioning
- Suction
- Oral care for vent
- Assess LOC
- Give patient fluids
What are three signs and symptoms of ARDS? - answer- Use of accessory muscles
- Breath sounds diminished
- SPO2 <90
What is the DX test for pulmonary artery hypertension? - answerRight-side cath.
To reduce mortality of ARDS, what non-pharm intervention do we do? - answerPlace
client in a prone position.
How do we know endo trach is placed correctly? - answerEnd tidal CO2 monitor, go for
the gold monitor
Clabsi, def and how do we prevent it? - answer- Central line associated bacterial
infection
- Assess it, clean it
When a patient had a stroke, how would we know they have a central herniation? (Hint:
5 signs) - answer- Positive Babinski reflex
- Cushing triad
- Irregular respirations
- Bradycardia
- Posturing
What reflex is lost if you have doll eyes? - answerOculocephalic
What are early (and late) signs of respiratory distress? - answer- SOB
- Tachycardia
- Restlessness
- Tachypnea
- LOC change (LATE sign)
What are three signs of spinal shock? - answer- Decreased systemic vascular
resistance
- Bradycardia
- Hypotension
