MDC 4 Exam 2 Rasmussen (All Correct)
A patient comes to the ED having diminished breath sounds on his left lung and asymmetrical chest expansion when asked to breathe. The nurse feels the patient's trachea has deviated to the right side of the throat. What is the patient suffering from? correct answers Pneumothorax
A provider tells the nurse that a patient is having a simple pneumothorax. What treatment might be prescribed for the patient? correct answers Chest Tube
A provider tells the nurse that a patient is having a tension pneumothorax. What could the nurse anticipate about how this will be treated? correct answers With a needle decompression thoracotomy
A nurse sees a patient coming into the trauma bay with paradoxical chest movement. What might
the patient be having? correct answers Flail Chest
A provider tells the ED nurse that the patient has a flail chest. What does the nurse anticipate will
happen next for the patient? correct answers Intubation and mechanical ventilation
What is an early manifestation of hypovolemic shock? correct answers Decreased urine output
A nurse is caring for a patient who is critically ill and has a fever, low BP and yellowish mucus coming from the nose. What type of shock is occurring with this patient? correct answers Septic Shock
What is the main nursing issues revolving around rib fractures? correct answers Pain! Puncturing
vasculature or organs.
What can the nurse teach the patient who has had a rib fracture to decrease pain? correct answers
Splint when coughing
A nurse is caring for a patient with ARDS in the ICU. What manifestations might she see? correct answers Low oxygen levels that do not get better with 100% oxygen applied, bilateral pulmonary edema that is not cardiac related, broken glass lung appearance on the X-ray.
A client ate peanuts and has an allergy to peanuts and tree nuts. What manifestations might the nurse see upon client arrival related to anaphylactic shock? correct answers Stridor and angioedema
A client is having anaphylactic shock due to a bee sting. What medication should be given to treat this? correct answers Epinephrine
A nurse is caring for a patient with ARDS. What treatment orders might the nurse see from the provider for the patient? correct answers Place them prone and on PEEP
What are complications of PEEP? correct answers Pneumothorax Low BP
What is ventilator associated pneumonia? correct answers Infection from being on the ventilator for a long time
A nurse is learning about ARDS. What are the causes of ARDS? correct answers Sepsis, Infection, burns, near drowning, trauma, shock.
A client with a bone infection is getting information on ensuring his infection does not progress into sepsis or septic shock. What might be some risk factors of the conditions? correct answers Infection risks, chancer, chemo, immunocompromised states, immunosuppressants, HIV
A nurse will be preparing to care for a newly intubated patient. What are some things she must prepare and remember while caring for the patient? correct answers Place ambu bag at bedside, suction PRN, switch tube once a shift, assess respiratory status every 2 hrs, oral and mouth care every 2 hrs, wash hands, expect orders for PPI or H2RB,
A patient is suspected to have a PE while in the ED. What might be some manifestations of this occurring? correct answers Low o2 saturation, low BP, sudden severe SOB, chest pain, LOC changes, petechiae, lung edema , ascites.
A client was recently just extubated and now is showing signs of stridor and low oxygen levels. What might of occurred and who should be called? correct answers Irritation fo the throat form the tube. Call RRT
What are clinical manifestations of hypovolemic shock? correct answers weak and thready pulse,
decreased BP, increased HR, altered LOC, shallow and fast respiration, long capillary refill, decreased H/H, low urine output.
A client has fluid volume excess due to heart failure. What are some of the important cardiac findings for this condition? correct answers Bounding pulse, JVD, central venous pressure is high, wedge pressure is high
What must the nurse do immediately when a patient presents with an inhalation injury? correct answers Intubate to assume an airway, assess respiratory status.
A burn patient presents to the ED. What are some of the signs they may present with leading to an inhalation injury? correct answers SOB, soot around nose, singed facial hairs, drooling, not swallowing, black membranes.
What things could cause an elevated wedge pressure? correct answers FVE, left ventricular failure
What are the components of DIC? correct answers Inappropriate clotting that uses up all the clotting factors and bleeding due to not having enough clotting factors bath the same time.
