K
C
LO
YC
COMP EXAM 3 GALEN 280
D
COLLEGE OF NURSING
U
QUESTIONS WITH CORRECT
ST
SOLUTIONS ALL VERIFIED BY
AN EXPERT A+ GRADED
(LATEST)
,UAP delegation tasks? Name examples... - ANS - vital signs rouitine STABLE PT
- IN & OUT of food and f/c
- ADL'S shower, grooming, shaving etc.
- toileting and walking (not post op who has never walked)
- feeding without aspiration precautions
- positioning
K
Can a UAP measure the drainage of a Hemovac or Jackson-Pratt? - ANS yes measure the
amount of fluid cant assess the drainage system.
C
Can a UAP collect specimens? - ANS yes!!! stool and urine
Can a UAP empty a colostomy bag ? - ANS yes ! not the wafer.
LO
end of life care - ANS the support and care given during the time surrounding death =
HOSPICE
hospice care - ANS comfort measures in the last phases of life
YC
hospice care and family - ANS - private room
- encourage the client and family to express feelings
- provide support and advocancy
- provide privacy
- LET THEM TOUCH THE CLIENT AS MUCH AS THEY WANT !
D
PRIORITY QUESTIONS use what formula? - ANS SPEC
U
SPEC stands for ? - ANS S= stable vs non stable
P= potential vs real
E= expected vs unexpected
ST
C= chronic vs acute
priority patients are? - ANS - neuro changes ex: GCS LOW 8
- very low values labs ex: DM with 50 BS
- client returning form invasive procedures and a comlication happens ex: eviceration
- ABC's airway problems and there acid base inbalanced
- client with chest pain and syncope not ecpected
- pt w/ 2-3 rd degree burns
- client with new onset of infectious disease = TB
- any unexpected events= MI, STROKE, HHS, DKA, ADDISONS CRISIS, THYROID STORM,
MYXEDEMA COMA, HTN CRISIS, PREECLAMPSIA, STROKE...
, Maslow's Hierarchy of Needs - ANS physiological, safety, love/belonging, esteem,
self-actualization
physiological needs? 1ST NEED - ANS AIRWAY
RESPIRATORY EFFORT
HR, RHYTHM, CONTRACTIONS STRENGTH
NUTRITION
ELIMINATION
K
SAFETY AND SECURITY = 2N NEED - ANS - PROTECT FROM INJURY
- PROMOTE FEELING OF SECURITY
- TRUST IN NURSE CLIENT RELATIONSHIP
C
TRIAGE RED TAG EXAMPLES? CLASS 1 - ANS EMERGENT THREAT TO LIFE EX:
CARDIAC TEMPONADE
LO
STROKE
SHOCK
AIRWAY OBSTRUCITON
YELLOW TAG CLASS 2 - ANS Urgent within 30 min to 2 hours- can wait a little
YC
- OPEN FRACTURES W DISTAL PULSES
- LARGE WOUNDS
GREEN TAG CLASS 3 - ANS the walking wounded
- CLOSED FRACTURES
- SPRAINS
D
- ABRASIONS
- CONTUSION
U
BLACK TAG CLASS 4 - ANS EXPECTED TO DIE!
- MASSIVE HEAD TRAUMA
- FULL THICK BURNS TO WHOLE BODY
ST
- HIGH CERVICAL SPINE INJURY REQUIRING MECHANICAL VENTILATION
ABGS NORMAL VALUES - ANS PH = 7.35- 7.45
CO2= 35- 45
HCO3= 21- 28
respiratory acidosis - ANS low pH, high CO2
if you have respiratory acidosis what organ has the problem? - ANS LUNGS =
HYPOVENTILATION
THINK AIRWAY OBSTRUCTION
C
LO
YC
COMP EXAM 3 GALEN 280
D
COLLEGE OF NURSING
U
QUESTIONS WITH CORRECT
ST
SOLUTIONS ALL VERIFIED BY
AN EXPERT A+ GRADED
(LATEST)
,UAP delegation tasks? Name examples... - ANS - vital signs rouitine STABLE PT
- IN & OUT of food and f/c
- ADL'S shower, grooming, shaving etc.
- toileting and walking (not post op who has never walked)
- feeding without aspiration precautions
- positioning
K
Can a UAP measure the drainage of a Hemovac or Jackson-Pratt? - ANS yes measure the
amount of fluid cant assess the drainage system.
C
Can a UAP collect specimens? - ANS yes!!! stool and urine
Can a UAP empty a colostomy bag ? - ANS yes ! not the wafer.
LO
end of life care - ANS the support and care given during the time surrounding death =
HOSPICE
hospice care - ANS comfort measures in the last phases of life
YC
hospice care and family - ANS - private room
- encourage the client and family to express feelings
- provide support and advocancy
- provide privacy
- LET THEM TOUCH THE CLIENT AS MUCH AS THEY WANT !
D
PRIORITY QUESTIONS use what formula? - ANS SPEC
U
SPEC stands for ? - ANS S= stable vs non stable
P= potential vs real
E= expected vs unexpected
ST
C= chronic vs acute
priority patients are? - ANS - neuro changes ex: GCS LOW 8
- very low values labs ex: DM with 50 BS
- client returning form invasive procedures and a comlication happens ex: eviceration
- ABC's airway problems and there acid base inbalanced
- client with chest pain and syncope not ecpected
- pt w/ 2-3 rd degree burns
- client with new onset of infectious disease = TB
- any unexpected events= MI, STROKE, HHS, DKA, ADDISONS CRISIS, THYROID STORM,
MYXEDEMA COMA, HTN CRISIS, PREECLAMPSIA, STROKE...
, Maslow's Hierarchy of Needs - ANS physiological, safety, love/belonging, esteem,
self-actualization
physiological needs? 1ST NEED - ANS AIRWAY
RESPIRATORY EFFORT
HR, RHYTHM, CONTRACTIONS STRENGTH
NUTRITION
ELIMINATION
K
SAFETY AND SECURITY = 2N NEED - ANS - PROTECT FROM INJURY
- PROMOTE FEELING OF SECURITY
- TRUST IN NURSE CLIENT RELATIONSHIP
C
TRIAGE RED TAG EXAMPLES? CLASS 1 - ANS EMERGENT THREAT TO LIFE EX:
CARDIAC TEMPONADE
LO
STROKE
SHOCK
AIRWAY OBSTRUCITON
YELLOW TAG CLASS 2 - ANS Urgent within 30 min to 2 hours- can wait a little
YC
- OPEN FRACTURES W DISTAL PULSES
- LARGE WOUNDS
GREEN TAG CLASS 3 - ANS the walking wounded
- CLOSED FRACTURES
- SPRAINS
D
- ABRASIONS
- CONTUSION
U
BLACK TAG CLASS 4 - ANS EXPECTED TO DIE!
- MASSIVE HEAD TRAUMA
- FULL THICK BURNS TO WHOLE BODY
ST
- HIGH CERVICAL SPINE INJURY REQUIRING MECHANICAL VENTILATION
ABGS NORMAL VALUES - ANS PH = 7.35- 7.45
CO2= 35- 45
HCO3= 21- 28
respiratory acidosis - ANS low pH, high CO2
if you have respiratory acidosis what organ has the problem? - ANS LUNGS =
HYPOVENTILATION
THINK AIRWAY OBSTRUCTION
