Galen College Nur 283
Comprehensive 1 Exam
1. Priority= ABC’s; safety ; who will die first!!!!
st
a. Triage 1 client w/ multiple compound fractures and reporting chest pain
b. Report to HCP pt who has drainage that has was serosanguineous and has not become
sanguineous
c. See patient first who polycystic fibrosis is bleeding with black tarry stool
d. Pt w/ asthma suddenly stops wheezing
e. Pancreatitis with pain upon inspiration
2. Delegation= LPN vs UAP within scope
a. UAP- change linens, VS NOT NEW ADMIN, REMIND, administer tap water enema (NOT
FLEET). Document drainage, Output
i. UAP turns patient every 2 hours ; or can recheck VS 2 hours after kidney biopsy
b. LPN- Reinforce teaching, enteral feeding , PPN, Meds, PO SQ, IM, IV (isotonic) monitor, 24 hr
post op, wound care
3. Unit assignment= related to nurses skill set if from MedSurg, ortho ect,
a. OB nurse gets appendicitis patient
4. Management – use translator ...speak with eye contact patient NOT translator
5. Nurse suspect child abuse. Nurse should first
a. Assess/ Obtain detail bruising
6. Signs of labor=
a. True labor S/S= bloody show, water breaks, contractions increase freq, duration, intensity,
Cervix dilated 10 cm , effacement 0-100% (cervix thinner shorter)
i. Regular contractions= increase in freq , duration, intensity, DOES NOT decrease
with rest
b. False Labor – Braxton hicks= disappear with walking or position changes
i. Irregular contractions alleviated with rest or position change, no changes to
7. Stage 1 of labor= Active, laten post labor expected ; Normal FHR 110-140
a. Late decelerations tell Dr as priority
nd st
b. Pt is 2 stage of labor FHR decrease = turn patient to the left 1 ( least invasive)
c. Stage 1=contractions=cervix dilation
i. 1. Early/latent phase (early education 0-3 cm, dilation, monitor FHR)
ii. 2. active phase (breathing technique, pain management, cervix 4-7cm, continue,
OXYTOCIN, EPIDURAL, IV narcotics slowly over peak of contractions),
iii. 3. transition phase (8-10cm, 100% effacement, ANXIETY & VOMITY, urge for BM,
Push @ 10cm, BLOODY SHOW assess amniotic fluid, emotional support,
breathing techniques ONLY PUSH @ 10cm)
d. Stage 2 delivery of baby (cervix 100% effaced 10cm dilated, urge to bear down, Fergueson
reflex) position= high fowler's, lithotomy, side-lying (assess- FHR, freq, duration,)
e. Stage 3 delivery of placenta= high risk for infection, uterine inversion (NEVER pull cord), give
PITOCIN
f. Stage 4 postpartum recovery (check bleeding peri pads (report fully saturated in 1 hr, infection
over 100.4 report) 2-4 hours after birth= breastfeeding and skin to skin
st 3 times every 5 mins then every 15 mins
i. Interventions= check fundus 1 , void (every 2-
3hrs) or use cath, Pitocin IV or IM, breast feeding,
ii. Treatment for boggy fundus-fundal massage, void, oxytocin, methergine (increases
BP)
iii. Lochia= Rubra/ dark red 3-4 days; Serosa/ pink brown= 4-10 days; Alba/
white/yellow= 10-28 days
iv. Peri-care- Squeeze peri-bottle with warm water, front to back wipe, blot area,
v. Report bloody fluid should be clear
vi. If FHR is 180 turn mom to left side
vii. Report late deceleration
, 8. Injections time frames
a. Intradermal = can be delegated to LPN, forearm, return to office 48-72 hrs after injection; if
date missed must receive again after 7 days; 25-27 gauge.25-.5 length, 5-15 needle angle;
0.1mL
i. Positive TB induration 10mm Begin Airborne precautions
ii. PPD- not 22 gauge should be 27 gauge
b. SubQ- 26-30 gauge 1.5mL or less, pinch skin 45 degree angle; insulin or heparin ; obese 90
degrees;
i. Insulin best absorbed thru abdomen
c. IM- 22-25 length 0.5-1inches; 90 degrees, 1-2mL (in deltoid)= ventral gluteal, Dorso gluteal,
deltoid; infants 0-12 months vastus lateralis; Z track
d. IV- immediate absorption
9. Ostomy care = bag and wafer; pat skin dry, apply barrier cream only 2cm from stoma; wafer should 1/8
cm larger than stoma; empty pouch 1/3 full; DO NOT empty 30 mins after eating
a. NORMAL Red beefy = fresh new ostomy;OR pink moist normal; REPORT: pale, gray, blue,
dry stoma= no blood flow
b. Teach – ileostomy watery stools;
10. NOT ready for discharge
a. New med, unstable, acute S/S ect,
11. S/S MI = heart attack = unstable angina, chest pain, left substernal pain, sudden, crushing chest pain,
left arm, jaw, heartburn, SOB, N/V abd pain, diaphoresis, dusky skin
a. Risk factors-SODDA= stress, obesity (BMI over 25), Bad diet, Diabetes & HTN, African
American males over 50
i. Is receiving treatment heparin; non-stemi = sent to cath lab
b. Dx- EKG (within 10 mins), TROPONIN over 0.5,
c. Treatment= Oxygen, Aspirin, Nitro (no fils, sublingual, take while sitting), Morphine; CATH
LAB; angioplasty (stent; iodine CONTRAST (feels warm), lie flat/supine after), bypass,
thrombolytics TPA (2-6 hrs of initial MI)
i. Home teaching after angio= NO heavy lifting, NO bath ( can shower), monitor
redness, warm, drainage at incision report ; low Na diet, reduce stress, caffeine,
cholesterol, exercise 5 days a week 30 mins; stop smoking, sex after 2 flight of
stairs without SOB)
ii. Heparin – PTT 46-70 antidote Protamine sulfate
d. ST elevation = NO o2 hyperkalemia; major blockage, treatment: STEMI thrombolytic
e. ST depression aka NON STEMI= low o2= hypokalemia, mild blockage; NEVER
THROMBOLYTIC; NON STEMI = cath LAB
i. If neg for MI = stress test w/ exercise (stop if chest pain or ST changes) or chemical
stress test ( 48-24hrs before caffeine/ decaff, no beta blockers, calcium channel
blocker, theophylline ) no eating or drink 4hrs before and after
12. interventions burn patient-IV lactated ringer or IV 0.9% normal saline; (isotonic); (fluid resuscitation
working if 30mL/hr or more, BP, HR), TPN (increase nutritional intake), prevent infection
( immunocompromised)
a. Labs- high K over 5.0; (tall peaked t wave); low Na below 135, elevated H&H and hematocrit;
dehydration low urine output under 30/ml per hour
b. Rule of 9= front surface head/neck, left arm and right arm= 4.5% each; front surface of chest/
trunk, left leg and right leg 9% each, perineum 1%
st
c. Parkland formula= 4mL x kg X TBSA%= within 1 24 hours ( ½ in 8hrs ; ½ in 16hrs )
d. After burn teaching= water-based lotion, pressure garments, exercise daily ROMs, sunscreen ,
protective clothing
e. Types of burns=
i. 1st degree=superficial- dry blanchable
nd
ii. 2 degree-partial thickness-blisters , red moist, shiny filled vesicles
Comprehensive 1 Exam
1. Priority= ABC’s; safety ; who will die first!!!!
st
a. Triage 1 client w/ multiple compound fractures and reporting chest pain
b. Report to HCP pt who has drainage that has was serosanguineous and has not become
sanguineous
c. See patient first who polycystic fibrosis is bleeding with black tarry stool
d. Pt w/ asthma suddenly stops wheezing
e. Pancreatitis with pain upon inspiration
2. Delegation= LPN vs UAP within scope
a. UAP- change linens, VS NOT NEW ADMIN, REMIND, administer tap water enema (NOT
FLEET). Document drainage, Output
i. UAP turns patient every 2 hours ; or can recheck VS 2 hours after kidney biopsy
b. LPN- Reinforce teaching, enteral feeding , PPN, Meds, PO SQ, IM, IV (isotonic) monitor, 24 hr
post op, wound care
3. Unit assignment= related to nurses skill set if from MedSurg, ortho ect,
a. OB nurse gets appendicitis patient
4. Management – use translator ...speak with eye contact patient NOT translator
5. Nurse suspect child abuse. Nurse should first
a. Assess/ Obtain detail bruising
6. Signs of labor=
a. True labor S/S= bloody show, water breaks, contractions increase freq, duration, intensity,
Cervix dilated 10 cm , effacement 0-100% (cervix thinner shorter)
i. Regular contractions= increase in freq , duration, intensity, DOES NOT decrease
with rest
b. False Labor – Braxton hicks= disappear with walking or position changes
i. Irregular contractions alleviated with rest or position change, no changes to
7. Stage 1 of labor= Active, laten post labor expected ; Normal FHR 110-140
a. Late decelerations tell Dr as priority
nd st
b. Pt is 2 stage of labor FHR decrease = turn patient to the left 1 ( least invasive)
c. Stage 1=contractions=cervix dilation
i. 1. Early/latent phase (early education 0-3 cm, dilation, monitor FHR)
ii. 2. active phase (breathing technique, pain management, cervix 4-7cm, continue,
OXYTOCIN, EPIDURAL, IV narcotics slowly over peak of contractions),
iii. 3. transition phase (8-10cm, 100% effacement, ANXIETY & VOMITY, urge for BM,
Push @ 10cm, BLOODY SHOW assess amniotic fluid, emotional support,
breathing techniques ONLY PUSH @ 10cm)
d. Stage 2 delivery of baby (cervix 100% effaced 10cm dilated, urge to bear down, Fergueson
reflex) position= high fowler's, lithotomy, side-lying (assess- FHR, freq, duration,)
e. Stage 3 delivery of placenta= high risk for infection, uterine inversion (NEVER pull cord), give
PITOCIN
f. Stage 4 postpartum recovery (check bleeding peri pads (report fully saturated in 1 hr, infection
over 100.4 report) 2-4 hours after birth= breastfeeding and skin to skin
st 3 times every 5 mins then every 15 mins
i. Interventions= check fundus 1 , void (every 2-
3hrs) or use cath, Pitocin IV or IM, breast feeding,
ii. Treatment for boggy fundus-fundal massage, void, oxytocin, methergine (increases
BP)
iii. Lochia= Rubra/ dark red 3-4 days; Serosa/ pink brown= 4-10 days; Alba/
white/yellow= 10-28 days
iv. Peri-care- Squeeze peri-bottle with warm water, front to back wipe, blot area,
v. Report bloody fluid should be clear
vi. If FHR is 180 turn mom to left side
vii. Report late deceleration
, 8. Injections time frames
a. Intradermal = can be delegated to LPN, forearm, return to office 48-72 hrs after injection; if
date missed must receive again after 7 days; 25-27 gauge.25-.5 length, 5-15 needle angle;
0.1mL
i. Positive TB induration 10mm Begin Airborne precautions
ii. PPD- not 22 gauge should be 27 gauge
b. SubQ- 26-30 gauge 1.5mL or less, pinch skin 45 degree angle; insulin or heparin ; obese 90
degrees;
i. Insulin best absorbed thru abdomen
c. IM- 22-25 length 0.5-1inches; 90 degrees, 1-2mL (in deltoid)= ventral gluteal, Dorso gluteal,
deltoid; infants 0-12 months vastus lateralis; Z track
d. IV- immediate absorption
9. Ostomy care = bag and wafer; pat skin dry, apply barrier cream only 2cm from stoma; wafer should 1/8
cm larger than stoma; empty pouch 1/3 full; DO NOT empty 30 mins after eating
a. NORMAL Red beefy = fresh new ostomy;OR pink moist normal; REPORT: pale, gray, blue,
dry stoma= no blood flow
b. Teach – ileostomy watery stools;
10. NOT ready for discharge
a. New med, unstable, acute S/S ect,
11. S/S MI = heart attack = unstable angina, chest pain, left substernal pain, sudden, crushing chest pain,
left arm, jaw, heartburn, SOB, N/V abd pain, diaphoresis, dusky skin
a. Risk factors-SODDA= stress, obesity (BMI over 25), Bad diet, Diabetes & HTN, African
American males over 50
i. Is receiving treatment heparin; non-stemi = sent to cath lab
b. Dx- EKG (within 10 mins), TROPONIN over 0.5,
c. Treatment= Oxygen, Aspirin, Nitro (no fils, sublingual, take while sitting), Morphine; CATH
LAB; angioplasty (stent; iodine CONTRAST (feels warm), lie flat/supine after), bypass,
thrombolytics TPA (2-6 hrs of initial MI)
i. Home teaching after angio= NO heavy lifting, NO bath ( can shower), monitor
redness, warm, drainage at incision report ; low Na diet, reduce stress, caffeine,
cholesterol, exercise 5 days a week 30 mins; stop smoking, sex after 2 flight of
stairs without SOB)
ii. Heparin – PTT 46-70 antidote Protamine sulfate
d. ST elevation = NO o2 hyperkalemia; major blockage, treatment: STEMI thrombolytic
e. ST depression aka NON STEMI= low o2= hypokalemia, mild blockage; NEVER
THROMBOLYTIC; NON STEMI = cath LAB
i. If neg for MI = stress test w/ exercise (stop if chest pain or ST changes) or chemical
stress test ( 48-24hrs before caffeine/ decaff, no beta blockers, calcium channel
blocker, theophylline ) no eating or drink 4hrs before and after
12. interventions burn patient-IV lactated ringer or IV 0.9% normal saline; (isotonic); (fluid resuscitation
working if 30mL/hr or more, BP, HR), TPN (increase nutritional intake), prevent infection
( immunocompromised)
a. Labs- high K over 5.0; (tall peaked t wave); low Na below 135, elevated H&H and hematocrit;
dehydration low urine output under 30/ml per hour
b. Rule of 9= front surface head/neck, left arm and right arm= 4.5% each; front surface of chest/
trunk, left leg and right leg 9% each, perineum 1%
st
c. Parkland formula= 4mL x kg X TBSA%= within 1 24 hours ( ½ in 8hrs ; ½ in 16hrs )
d. After burn teaching= water-based lotion, pressure garments, exercise daily ROMs, sunscreen ,
protective clothing
e. Types of burns=
i. 1st degree=superficial- dry blanchable
nd
ii. 2 degree-partial thickness-blisters , red moist, shiny filled vesicles
