NR 341 Final Exam: Questions & Verified Solutions
High school student comes to ed with headache, fever, and neck pain Right
Ans - expect lumbar puncture bc indicative of bacterial meningitis
Status epileptics medication Right Ans - benzodiazepines (Lorazepam
(ativan) is drug of choice)
When the first line drugs are not effective for status epileptics, given to place
pt in induced coma Right Ans - phenobarbital
Delirium nursing interventions Right Ans - quiet environment, reorient,
speak slowly, dark room, maintain consistent routine, identify threats to
safety
What to monitor following electrical burns Right Ans - telemetry for 24
hours
Priority for facial burns Right Ans - airway/intubate
Patients with burns on face/neck are at risk for what? Right Ans - airway
obstruction
Patient has VS showing infection on burn site - what to do? Right Ans - get
burn and wound culture
process of getting blood cultures for burns Right Ans - Do blood cultures
before any antibiotics are given
Burns stress ulcers and prevention Right Ans - Curling's ulcer; NG tube is
the prevention
priority for carbon monoxide burns Right Ans - oxygen with non
rebreather mask
other priority for burns Right Ans - fluids
superficial burn (1st degree) Right Ans - like a sunburn (epidermis and
maybe small portion of dermis)
, Partial thickness burn (2nd °) Right Ans - epidermis and most of dermis
Full thickness burn (3rd °) Right Ans - Same as partial thickness but may
extend into subcutaneous tissue; nerve damage
- Thick, dry leathery appearance
Deep Full thickness burn (4th °) Right Ans - Destruction of all layers plus
muscles, tendons & bones
- Black with no edema
Escharectomy Right Ans - surgical removal of eschar
priority intervention for DKA Right Ans - fluids
interventions for DKA and HHS Right Ans - insulin drip w/ regular insulin,
*check blood glucose every hour!! , monitor labs, electrolyte replacement
- fluid replacement:
First use 0.9% NS
Then 0.45% NS
Dextrose added when glucose approaches 200 mg/dL
- electrolyte replacement
Potassium
Maintain between 4-5 mEq/:
Phosphorus (K-phos replacement)
Magnesium
difference between DKA and HHS Right Ans - DKA → occurs Type 1 DM, BG
> 350, metabolic acidosis, kussmaul's respirations, fruity breath, flushed/dry
skin, orthostatic hypotension, ketones in urine, weight loss
HHS → occurs in Type 2 DM, NO ketoacidosis, BG average > 600, more
electrolyte imbalances and renal dysfunction, higher serum osmolarity than
DKA
Insulin drip Right Ans - monitor glucose every hour, check electrolytes
every few hours
for mass causality Right Ans - greatest good for greatest number of people
High school student comes to ed with headache, fever, and neck pain Right
Ans - expect lumbar puncture bc indicative of bacterial meningitis
Status epileptics medication Right Ans - benzodiazepines (Lorazepam
(ativan) is drug of choice)
When the first line drugs are not effective for status epileptics, given to place
pt in induced coma Right Ans - phenobarbital
Delirium nursing interventions Right Ans - quiet environment, reorient,
speak slowly, dark room, maintain consistent routine, identify threats to
safety
What to monitor following electrical burns Right Ans - telemetry for 24
hours
Priority for facial burns Right Ans - airway/intubate
Patients with burns on face/neck are at risk for what? Right Ans - airway
obstruction
Patient has VS showing infection on burn site - what to do? Right Ans - get
burn and wound culture
process of getting blood cultures for burns Right Ans - Do blood cultures
before any antibiotics are given
Burns stress ulcers and prevention Right Ans - Curling's ulcer; NG tube is
the prevention
priority for carbon monoxide burns Right Ans - oxygen with non
rebreather mask
other priority for burns Right Ans - fluids
superficial burn (1st degree) Right Ans - like a sunburn (epidermis and
maybe small portion of dermis)
, Partial thickness burn (2nd °) Right Ans - epidermis and most of dermis
Full thickness burn (3rd °) Right Ans - Same as partial thickness but may
extend into subcutaneous tissue; nerve damage
- Thick, dry leathery appearance
Deep Full thickness burn (4th °) Right Ans - Destruction of all layers plus
muscles, tendons & bones
- Black with no edema
Escharectomy Right Ans - surgical removal of eschar
priority intervention for DKA Right Ans - fluids
interventions for DKA and HHS Right Ans - insulin drip w/ regular insulin,
*check blood glucose every hour!! , monitor labs, electrolyte replacement
- fluid replacement:
First use 0.9% NS
Then 0.45% NS
Dextrose added when glucose approaches 200 mg/dL
- electrolyte replacement
Potassium
Maintain between 4-5 mEq/:
Phosphorus (K-phos replacement)
Magnesium
difference between DKA and HHS Right Ans - DKA → occurs Type 1 DM, BG
> 350, metabolic acidosis, kussmaul's respirations, fruity breath, flushed/dry
skin, orthostatic hypotension, ketones in urine, weight loss
HHS → occurs in Type 2 DM, NO ketoacidosis, BG average > 600, more
electrolyte imbalances and renal dysfunction, higher serum osmolarity than
DKA
Insulin drip Right Ans - monitor glucose every hour, check electrolytes
every few hours
for mass causality Right Ans - greatest good for greatest number of people
