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lOMoAR cPSD| 15211230
NUR 436 EXPERIENTIAL LEARNING ADVANCED MIDTERM TEST
PLAN
There will be 50 questions for 35 points for the Midterm exam. You will have 75 minutes to complete the exam. Review Midterm Test Plan info in Course module.
The exam will open at 0730 on Respondus Lockdown Browser w/WEBCAM. Your exam starts once you start the with the exam questions for the 75 minutes.
The test will have Multiple Choice Questions, Multiple Answer Questions and Medication Calculations. The calculator will be available in Respondus. Install ALL computer and Respondus updates before the exam.
CLINICAL JUDGMENT (NURSING PROCESS) (20 QUESTIONS)
● Focused assessment of children and adults related to circulation, airway, breathing and age appropriate normal vital signs. o Adults: Airway, Breathing, Circulation ▪ Vitals: same as adolescent vitals in chart below o Children: Appearance, Work of Breathing, Circulation
● Interpretation of Coder EKG rhythms and treatment of dysrhythmias (asystole, VF, VT, 3rd degree Heart block/pacers, SVT-vagal maneuvers vs med administration).
_Using Codeí as an e ample, when he coded, īhe oídeí goes as follows: V-īach,_**
V- fib, asysīole
o ASYSTOLE:
o VT without a pulse: NO PULSE = CODE BLUE Start CPR, get
the defibrillator, Epi
o Toísades de Poinīes (TdP): Magnesium! CPR, Defibrillate o Identify cause (drugs? electrolytes? hypoxia?)
o 1 ST DEGREE
▪ PR interval consistently long (>0.2) ▪ Interventions : Pacemaker
o 2 ND DEGREE
▪ Type 1 ● PR interval lengthens until P wave not conducted or QRS dropped
(**R to R usually irregular)
● Interventions : Pacemaker, If this patient is symptomatic you can give Atropine.
▪ TYPE 2
● consistent p wave for each ORS until the QRS occasionally drops ● Interventions : *Focus on 2nd degíee o Assess CO- These are likely a SLOW rhythms o May need a 12 lead EKG to diagnose o Identify cause (drugs?) o Pacemaker may be indicated ▪ the best intervention is a temporary pacemaker. ● Aīíopine is noī usually effecīive foí īhis íhyīhm and can acīually be haímfulwd
o 3 RD DEGREE HEART BLOCK:
▪ LETHAL dysrhythmia ▪ QRS wide > 0.12, rhythm 20-40 bpm, there are more p wavesthen QRS's
pacer not sensing pt
intrinsic (own rhythm)
▪ FAILURE TO CAPTURE
● Electrical stimulus sent (pacer spike) but not mechanical action (depolarization) to follow
● Nursing interventions for care of tracheostomy & suctioning, patient management on ventilator (alarms and VAP prevention), arterial lines, IV lines, chest tubes, enteral feedings/G-tube, and restraint use.
o TRACHEOSTOMY & SUCTIONING
▪ Emergency Equipment ● Replacement trach o make sure it is a smaller size ● Obturator ● Sterile hemostat ● Ambu bag ● Suction equipment
▪ SUCTIONING PRESSURES BY AGE
● Infants: 80- mmHg ● Children : 100- mmHg
● ADULTS:
100-150mmHg
▪ NURSING INTERVENTIONS
● Trach care ● Prevent tissue damage ● Air warming and humidification ● Communication ● Nutrition ● Dressing change o Remove old dressing o Clean skin around the stoma with 1/2 H2O o Rinse with NS o Change tiese o Apply trach dressing
● Suctioning documentation o Respiratory assessments before and after o Type and size of trach tube o Frequency and extent of care o Care completed o Client tolerance o Any complications o amount, consistency, color, odor of secretions o Route of suctioning, patient's response to suctioning o condition of stoma
o VENTILATOR (ALARMS & VAP PREVENTION)
▪ Set machine to delivery required tidal volume ▪ Adjust machine to deliver lowest concentration of oxygen to maintain normal PaCO ● Setting may be set high and gradually reduced based on ABGs results ▪ Record peak inspiratory pressure ▪ Set mode (assist/control or SIMV) and rate according to physician order ▪ If pt on assist/control, adjust sensitivity so pt can trigger ventilator with the min. effort (usually 2mmHg negative inspiratory force) ▪ Record minute volume and measure carbon dioxide partial pressure, pH after 20 minutes of ventilation ▪ Adjust FIO2 according to results ▪ AMBU Bag Valve Mask ▪ Pt on controlled ventilation have spontaneous respiration may “fight or buck” the ventilator because they cannot synchronize their own respiration with the machine cycle
o ARTERIAL LINES
▪ Indications ● Frequent ABG's ● Severe hyper or hypotension ● Respiratory Failure ● Meds that significantly affect blood pressure
▪ INSERTION
● 15-30 degrees bevel up ● Use a needle to penetrate the artery
● Monitor hemodynamic waveforms for changes in cardiovascular function.
● COMPARE HEMODYNAMIC PARAMETERS WITH OTHER CLINICAL
SIGNS AND SYMPTOMS.
● Monitor pulmonary artery and systemic arterial waveforms; if dampening occurs, check tubing for kinks or air bubbles, check connections.
● DOCUMENT PULMONARY ARTERY AND SYSTEMIC ARTERIAL WAVEFORMS.
● Monitor peripheral perfusion distal to catheter insertion site
o IV LINES
every 4 hours or as appropriate.
● REFRAIN FROM INFLATING BALLOON MORE FREQUENTLY THAN
EVERY 1 TO 2 HOURS, OR AS APPROPRIATE.
● Maintain sterility of ports.
● PERFORM STERILE DRESSING CHANGES AND SITE CARE, AS APPROPRIATE.
● Inspect insertion site for signs of bleeding or infection.
● CHANGE IV SOLUTION AND TUBING EVERY 24 TO 96 HOURS,
BASED ON PROTOCOL.
● Keep hemodynamic monitoring alarms ON.
▪ NURSING
● Type of solution to be infused. Hypertonic solutions and medications are irritating to vein. ● Condition of vein. Use soft, straight, bouncy vein; if you run your finger down the vein and it feels like a cat’s tail — avoid! Avoid veins near previously infected areas. ● Duration of therapy. Choose a vein that can support IV therapy for 72– 96 hours. ● Catheter size. Hemodilution is important.The gauge of the catheter should be as small as possible. ● Patient age. Elderly and children need additional time for assessment and management of insertion. ● Patient activity. Ambulatory patients using crutches or walker need catheter placement above the wrist. ● Presence of disease or previous surgery. Patients with vascular disease or dehydration may have limited venous access. If a patient has a condition causing poor vascular return (mastectomy, stroke), the affected side must be avoided. ● Presence of shunts or graft. Do not use the arm or hand that has a patent graft or shunt for dialysis. ● Patient receiving anticoagulation therapy. Patients receiving anticoagulant therapy have a propensity to bleed. Local ecchymoses and major hemorrhagic complications can be avoided if the nurse is aware of the anticoagulant therapy. Precautions: Minimal tourniquet pressure; use the smallest catheter that is appropriate for therapy; use care in removing dressing. ● Patient with allergies. Question regarding allergies to medications, foods, animals, and environmental substances. Identify the allergens: ● Iodine. Avoid povidone-iodine as skin preparation
● Nurse’s initials
▪ DOCUMENTATION
● Record the start of the infusion on the client’s chart. ● Include the date and time of the venipuncture ● The gauge and length of the device ● Specific name and location of the accessed vein ● Amount of solution used, including any additives ● Container number ● Flow rate ● Type, length and gauge of the needle or catheter ● Venipuncture site, how many attempts were made and location of each attempt ● The type of dressing applied ● The client’s general response ● Your signature
o CHEST TUBES
▪ A small chest tube is inserted near the second intercostal space to drain the fluid and air. For patients with jeopardized gas exchange, chest tube insertion may be necessary to achieve lung
re-expansion.
▪ The priority is to maintain the airway, breathing, and circulation. The most important interventions focus on reinflating the lung by evacuating the pleural air. ▪ Patients with a primary spontaneous pneumothorax that is small with minimal symptoms
may have spontaneous sealing and lung re-expansion.
o ENTERAL FEEDINGS/G-TUBE
● patient response
● date and time the restraint was initiatives
● Management of patient care situations including resuscitation, arrhythmias, diabetes type 1 (include insulin calculations), palliative/hospice care, bronchiolitis/RSV, asthma, seizures, dehydration & chest pain/MI.
o RESUSCITATION
▪ Cardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest
ADULTS PEDIATRICS
o Arrhythmias
▪ ATRIAL FIBRILLATION &
ATRIAL FLUTTER
