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NR 341 Exam #1 with correct answers
pH levels - correct answer -7.35-7. PaCO2 normal range - correct answer -45- PaHCO3 normal range - correct answer -22- PaO2 normal range - correct answer -80- uncompensated - correct answer -normal CO2 or HCO fully compensated - correct answer -pH normal and both CO2 and HCO3 are abnormal Causes of Respiratory acidosis - correct answer -pneumonia, trauma Tx of Respiratory Acidosis - correct answer -vigorous pulmonary toilet, ABX, diuretics, mechanical ventilation Causes of metabolic acidosis - correct answer -renal failure, ASA overdose, ketoacidosis Causes of respiratory alkalosis - correct answer -pain, fever, hyperventilation causes of metabolic alkalosis - correct answer -vomiting, diarrhea, prolonged diuretics -tx: K+ replacement, etc. EKG: tiny box - correct answer -0. EKG: big box - correct answer -0. Big box method - correct answer -measure the R-R interval, count the number of big boxes between & divide into 300 -can only do when regular strip R on T phenomenon - correct answer --leads to lethal dysrythmias -PVC lands on relative refractory period 3 second strip - correct answer -R x 20 P wave - correct answer -atrial depolarization (contraction) PR interval - correct answer --0.12-0. -3-5 small boxes Prolonged PR interval - correct answer -1st degree AV block QRS - correct answer --ventricular depolarization -0.06-0. -narrow = good -wide = deceases perfusion to ventricles QT interval - correct answer --total ventricular activity -0.33-0.
- if over 0.50 = concerning from increased risk of going into cardiac dysrhythmia Meds that prolong QT - correct answer -haloperidol, zofran, anti-dysrhythmics (amiodarone) Absolute Refractory period - correct answer --first half of T wave
-not enough repolarization so no stimulus can happen Relative Refractory Period - correct answer --second half of T wave -enough cells have repolarized so response can happen -R ot T PVC's Causes - correct answer --electrolyte imbalances -ischemia -hypoxia -stimulants -end stage heart failure -medications normal sinus rhythm (NSR) - correct answer -Rate: 60- Regular P wave before each QRS and they all look the same, as soon as you see P wave (have sinus rhythm) PR interval: 0.12 -0.20 seconds QRS: less than 0. QT: 0.33 -0.44 seconds Atrial Fibrillation - correct answer -no p wave, no PR interval, QRS still narrow, QT is normal Enteral Feedings - correct answer --maintains gut integrity (stops the movement of bacteria from leaving the gut) -associated with fewer complications and short hospital stay vs. TPN, also less expensive -can only be used on clients with intact gut -contraindicated in: paralytic ileus, intestinal obstruction, severe diarrhea, GI ischemia, abd. trauma -complications: refeeding syndrome (monitor VS frequently/electrolytes), clogged tubes (give meds 1 at a time flushing in between, NO PEPSI to unclog, dislodged tubes, diarrhea, dumping syndrome Why are oral gastric tubes preferred over NG when a patient is ventilated? - correct answer -decreased risk of secondary sinus infection Verification of duotube - correct answer --aspirate: green (stomach), gold (duodenum) -pH: on initial insertion and must be NPO -gold standard is KUB Xray -ongoing verification by insertion marking CPN - correct answer --requires large vessel such as superior vena cava (central line, port, PICC) -change dressing every 7 days, if dressing is lifting change it, use sterile technique, change central line caps every 72- hours), flush using a push pause method with 10mL NS -increased risk of DVT, monitor -complications: pneumothorax or puncture of artery on insertion of central line, obstruction, air embolism, infection (stat chest xray after insertion), electrolyte imbalance, HHS, fluid overload, refeeding syndrome NI CPN - correct answer --monitor for signs of infection: central line site, fever, chills, WBCs -strict aseptic technique -change fluids and tubing q 24 hours -monitor glucose -notify provider of weight gain -monitor labs as ordered HOB for tube feeding? - correct answer -at least 30 degrees Heparin Preventative - correct answer --5000 units SQ, BID/TID -monitor platelets for HIT Enoxaparin Preventative - correct answer --30-40 mg, daily/BID SQ
increased ICP: cluster or decluster - correct answer -de-cluster care VAP bundle - correct answer --best way to prevent is getting patient off vent ASAP -SBT/SAT daily -HOB 30 degrees -oral care with chlorhexidine -DVT and ulcer prevention -mobility (position frequently or get up in chair, ROM). hyperventilaiton on vent - correct answer -decrease RR, decrease TV hypoxemic respiratory failure - correct answer --low PaO -ARDS -PE hypercapnic respiratory failure - correct answer --PaCO2 high, pH low -COPD, emphysema, neuromuscular diseases First signs of respiratory distress - correct answer -RATT refractory hypoxemia - correct answer -hypoxemia that does not respond to O2 therapy ARDS PEEP - correct answer --will have increased PEEP -normal is 5- -keeps alveoli open hemorrhagic stroke - correct answer --high HTN -worst HA of life -altered LOC -projectile vomiting neurogenic shock - correct answer --massive vasodilation -bradycardia -tx: vasopressors, IV fluids, atropine (anticholinergic that increases HR but also causes dilation of pupils - dont mistake that for patient being brain dead) -if atropine doesnt work then pacemaker -problem with VS spinal shock - correct answer --loss of sensory and motor function below level of injury -lasts for weeks propofol - correct answer --allergies to eggs/soy? -can elevate triglycerides -can decrease BP -hypotension/seizures -watch for green urine -strict sterile technique -1 mL = 1.1 kcal Dexmedetomidine (Precedex) - correct answer --used to treat anxiety and provide sedation, can also help with pain -monitor HR and BP especially in beginning during bolus -alpha properties may cause hypotension and bradycardia -can be left on when extubated ketorolac - correct answer --GI bleed -kidneys - nephrotoxic -NSAID
gabapentin - correct answer --non-opiod -works for neuropathic pain amitriptyline - correct answer --good for neuropathic pain -TCA -very sedating -blocks pain message neuromuscular blockade - correct answer --paralytic -succinylcholine (short onset) -rocuronium -vecuronium -ABC concern is airway -need to be given an analgesic and sedative before -used in RSI -BIS monitoring -TOF (0-4) -can use CPOT, RASS, and CAM, initiate ABCDEF bundle, VAP bundle, prevent stress ulcers, pressure ulcers, and DVT Risk factors for delirium - correct answer -- age > -length of stay in ICU >3 days -mech vent -high acuity -serious illness -major surgery -polypharmacy (especially ativan!) -history of dementia -ETOH or drug use Braden scale <12 - correct answer -high risk for skin breakdown low lung compliance - correct answer --PE, ARDS, P. fibrosis -vent: need higher pressures high lung compliance - correct answer -COPD, emphysema -need lower vent pressures Indications for suctioning - correct answer --visible secretions -increase in RR -decrease in O2 sats -acute respiratory distress -adventitious breath sounds (besides wheezing) -suspected aspiration Complications of Suctioning - correct answer --pain -hypoxia -dysrhythmias -trauma -increase ICP Thick Secretions (Vanilla Pudding) - correct answer --mucolytic -increase fluids (3-4 L/day) -turn patient frequently -humidify -percussion -appropriate ABX -if this doesn't help bronchoscopy
-once lungs reach set pressure, exhale -need a volume alarm -concern is hypoventilation or respiratory acidosis APRV - correct answer --newer setting -time and pressure -allows for inhalation to have one pressure and exhalation to have a lower pressure -can still breathe spontaneously -ARDS Weaning off Ventilator - correct answer --SAT/SBT -if patient responds well then will put on bipap with pressure support and PEEP to assist the patient in breathing, keep here for 30 mins-2 hours -ABG = normal -O2 levels = normal High Pressure Alarm - correct answer --coughing -biting on tubing -kink in tubing -secretions blocking tubing -assess pt. and find problem ASAP, if we cannot quickly solve problem, remove from vent, AMBU bag, call for help Low pressure alarm - correct answer --ET tube and vent tubing disconnect -fix problem or remove from vent, AMBU bag, call for help Apnea Alarm - correct answer --patient not breathing enough /min, machine will be programmed to an automatic RR -if unable to fix, bag patient, and call for help Unplanned Extubation - correct answer --is patient stable or unstable? -stable: apply O2 and continue to monitor -unstable: decrease in O2, gaspin, reintubate Planned Extubation - correct answer --goals met: -mechanics of ventilation (diaphragm strong enough to support ventilation? Control of secretions?) -ABGs (normal) -O2 < or equal to 40% -Mental status: need to be somewhat calm, goal is RASS of -1,0,+ -Secretions -Positive air leak Terminal Weaning - correct answer --family conference -DNR must be on chart -stop propofol, may give high levels of benzos/morphine -notify donor network -extubate when family is ready Post-Extubation - correct answer --set patients up 45-90 degrees -first 1-2 hours are critical -asses for stridor: if stridor is present this is a concern and indicates airway is narrowing (immediate intubation) -NPO for swallow eval -limit talking d/t sore throat and edematous vocal cords -limit pain/anxiety meds for first couple of hours (will suppress respiratory drive) Spinal Cord Injury Assessment - correct answer --airway/breathing -mechanical vent for high cervical injuries -circulation - map 85-
spinal shock - correct answer --electrical silence below level of injury -no motor/sensory/reflex activity -onset within minutes of injury and can last for weeks -secondary injury worsens the primary injury -dexamethasone to reduce inflammatory process Neurogenic shock - correct answer --disruption of autonomic function -no sympathetic response = massive vasodilation -sx: hypotension, bradycardia, hypothermia -tx: vasopressors, atropine, fluids up to 2L, pacemaker Autonomic Dysreflexia - correct answer --excessive, uncontrolled sympathetic response -injuries above T -caused from a stimulus below T -occurs after spinal shock has resolved -cause: distended bladder, constipation, tight clothing, painful sitmuli -sx: severe hypertension, bradycardia, severe HA and blurred vision, flushing above injury, pale below injury, nausea, anxiety -NI: PREVENT, place patient in a sitting position, asses for cause, alleviate cause, treat BP (nifedipine and nitrates), teach patient to recognize and report sx Basilar skull fracture - correct answer --periorbital edema and ecchymosis (raccoon eyes) -postauricular ecchymosis -concern is CSF leak CPP - correct answer -MAP - ICP normal 60- Complication of EVD - correct answer -infection
