NSG233 ;NSG 233 Final Exam (Latest
Update): Medical-Surgical Nursing III | Questions and
Verified Answers | 100% Correct | Grade A+
Alcoholic- first assessment
✓ Priority: look for head injury, hypoglycemia (which mimics intoxication), and other
health problems.
Actions: detoxification, recovery, rehab
Ask if patient if they have gone through withdrawal before and had seizures
when was there last drink?
Benzos: sedative
Let them sleep if they calm-
not calm- benzo's
Non-fatal drowning **
✓ Priority: manage hypoxia, acidosis and hypothermia > airway, oxygen
Management: CPR, core temp (rectal) rewarming procedures during CPR,
trach/PEEP, O2
Risks: ARDS> hypoxia, hypercarbia and respiratory acidosis can occur
Hypothermia> metabolic acidosis
NGT> decompress stomach and prevent aspirating gastric contents.
Monitor: ECG, ICP, serial chest xray, I/O
Labs: serum electrolytes
Highest risk: <5 yo, >85 yo
Freshwater: loss of surfactant- inability to expand lungs
Saltwater: pulmonary edema
Observe pt for 23 + hours
Serum Electrolytes
✓ Mg+ 1.5-2.5
* Phos 2.5-4.5
* K+ 3.5-5
, * Ca 8.5-10.9
* Chl 95-105
Bite Priority
✓ Animal: rabies prophylaxis
Snakebite: lie down, removing constrictive items, providing warmth, cleansing the
wound, covering the wound with a light sterile dressing, and immobilizing the
injured body part below the level of the heart.
CABs (Circulation, Airway Breathing)
NO: Ice, incision and suction, or a tourniquet
Tetanus and analgesia should be given as necessary.
Meds: FabAV or CroFAb: no limit on how much to give
S&S: necrosis, edema, ecchymosis
Tick: remove with tweezers, straight up pull, (try to get close to skin as possible)
S&S: bulls eye rash
Poisoning in the house
✓ Carbon Monoxide: 100% O2 Atmospheric/hyperbaric chamber
Ingested Poison: ABC, Call poison control, try to describe what was ingested
Charcoal: most effective, Do not use if heavy metals were ingested. Corrosives: give
water/milk
Cathartics: sorbitol: give w/ 1st dose of charcoal
syrup ipecac: Induces vomiting, only give to alert patients-and NO patients who
ingested a corrosive agent
Gastric emptying: intubate before lavage ( if -LOC/-gag reflex) with in 1 hour of
ingestion.
MODS- OD
01.04.03 **
✓ Find out what Patient OD'd on. Give antidote if there is one
Treatment goals for a patient with a drug overdose are to support the respiratory
, and cardiovascular functions, to enhance clearance of the agent, and to provide for
safety of the patient and staff.
Abuse- interpersonal violence
✓ Priority: ask questions IN PRIVATE, separate from person who is abusive/neglectful
referral to shelter
adults are free to accept or refuse help
safety plans should be explored
Mandatory report: children and elderly abuse - only need to suspect abuse, do not
need to prove it
PTSD- rape and stabbing 01.04.06??
✓ Keep patient comfortable
Offer therapeutic communication -listen
Avoid triggers
Chest-Blunt trauma complications **
✓ Flail chest: paradoxical chest movement, hypoxemia, resp acidosis
Pulmonary contusion: abnormal accumulation of fluid,
SATA: - lung sounds, cough, frank blood, mucus, chest pain, atelectasis, -BP, resp
acidosis
Monitor: fluid intake, fluid replacement and pain
Managment: airway, O2, treat pain, bronchoscopy
Meds: morphine
Medical Management• ABC-oxygen, possible endotracheal intubation, ventilatory
support• Replace fluid volume• Restore negative intrapleural pressure if needed•
Needle decompression• Chest tube if needed• Hemothorax• Pneumothorax• Hemo-
pneumothorax
Crush injuries and trauma
✓ Hypovolemic shock
Spinal Cord Injury
Fractures
