NR 341 FINAL EXAM REVIEW ALREADY GRADED A

NR 341 FINAL EXAM REVIEW ● Burns -- give morphine prior to wound care - side effects - respirations - Zofran for nausea - prochlorperazine ○ Nausea med before morphine ● Bloody Diarrhea - Stool Culture ● Who to see first - A B C s ● Dry mucous membranes - Dehydration ● Vomit Blood Loss - Lactated Ringers ● Trauma - peritoneal lavage - irrigating the abdomen - brown fecal drainage return - perforated bowel - take to OR STAT ● How to Prevent Constipation - Fluid and Fiber - Exercise - Stool Softeners - ● Bowel Movement after Breakfast - YES ● OTC meds cause constipation - YES ● Paracentesis - Ascites - nursing intervention prior - empty the bladder ● Esophageal varices with balloon tamponade - Impaired airway - ● Grave’s Disease - Hyperthyroidism - first treat with PTU - antithyroid medications take several months for full effect ○ Surgery - Hyperparathyroidism - ● Steroid Therapy - DO not discontinue abruptly - monitor glucose and weight and infection ● Green Drainage out NG or JVD - JVD more concerning - Fluid Overload - ● Shock diagnosis - Administer O2 - to do no more harm - make sure they are perfusing O2 ● Anaphylactic Reaction - Administer Epinephrine ● Know Hct 12-14 Plt 150-400 BUN 10-20 ● Crackles in Lungs - Expected with Pneumonia - Look for other abnormalities ● Neurogenic Shock - HR - Brady - Give Atropine - Temp - abnormal - possible Intubation ● SIRS - Postop - Ambulate for prevention - aseptic technique - remove catheters - give antibiotics - do not administer parenteral nutrition ● AKI - vascular access catheter - - bedrest as it may dislodge ● Hemodialysis - cramps in legs - electrolyte imbalance - Normal Saline - ● Know K 3.5-5.0 ● Normal Urine output - 30 mL/hr ● Know GFR - 90-120 ● Pulse ox 85 or weak cough - more concerned about weak cough ● Paradoxical Chest Movement - Uneven - Bad - Might have - Pneumothorax - Insert Chest Tube ● Pneumonia - High Fowler’s ● Femur Fx - Now SOB - PE or Fat Embolism ● RICE Rest -Ice Compression Elevation ● Confusion - Check O2 Frrst ● Know WBC 4-10 ● Compartment Syndrome just from the leg - Yes - Emergency - do not need a cast ● Assess Cap Refill and Pulses with Compartment Syndrome ● Therapeutic Hypothermia - Cooling - Preserve the Heart and other organs ● Exposed to chemical powder - brush it off - wash it off ● Disaster protocols - see First - the Red Tag ● Burn to Face - Airway is major concern ● Electrical Burn - Place on Cardiac Monitor - Heart is most concern ● Fell before Electrical Shock - C-Spine ● Know Na 135-145 ● Burns - worry about potassium ● Ventriculostomy - Ventricle in the Brain - ○ for ICP - Removing Fluid in the Brain ○ Shows Blood Flow to the Brain ● Meningitis - Positive Kernigs sign - nuchal rigidity - low BP is concerning ● ICP - On Steroids - check Glucose ● Decorticate to the Core and Decerebate - celebrate out ● IV Fluids with ICP - Hypertonic Saline -to shrink the cells 0.5% ● Autonomic Hyperreflexia - Spinal Cord injury - overreaction - Causes - Bladder and Bowel ● Neurogenic Shock - Hypotension - Extremities Warm ● Cauda Equina Syndrome - Herniation in Spinal Column - Incontinent of Bowel and Bladder ○ Prevention - Log Roll - ○ Stabilize the Neck when Repositioning ○ **Foley Catheter** ● High Calorie - High Protein Foods - Chicken - ● Peg Tube Care - TLC Residual - check every 4-6 hours ● Parenteral Nutrition - Check BG Q 4-6 HR