NSG 233 - Medical -Surgical Nursing III Exam 1 Question: Triage patients in the ED Answer: Use ESI (emergency severity index) tool Responsibilities of triage nurse: Assess, reassess, initiate treatment, manage and communicate, educate, sort patients, transport them Question: Meds for managing sexual assault Answer: Prophylaxis for gonorrhea Ceftriaxone + 1% lidocaine Prophylaxis for syphilis and chlamydia: Single d ose metronidazole Single dose azithromycin 7-day oral regimen doxycycline Anti -pregnancy: Levonorgestrel and ethinyl estradiol Give within 12 -24 hours, no more than 72 hours post -intercourse Antiemetic for side effects Question: Tension pneumothorax care Answer: Immediate needle decompression Followed by chest tube insertion S/S: chest pain, dyspnea, tachycardia, anxiety, air hunger, increased use of accessory muscles, decreased/absent breath sounds on affected side, deviated trac hea to unaffected side Question: Subcutaneous emphysema care Answer: Leaked air pockets under skin, feels like "rice crispies" Part of spontaneous pneumothorax Not usually serious Report to provider Monitor airway Absorbs once pneumothorax is treated Question: Intra -abdominal injury care Answer: Risk for hemorrhage - monitor for shock Liver - right shoulder pain Spleen - left shoulder pain If stable --> CT If unstable --> FAST exam (focused assessment with sonography for trauma) Management: ABCs, C -spine precautions, NPO, antibiotics/tetanus, monitoring, surgery PRN Question: Pneumothorax assessment Answer: Tracheal alignment - midline (simple pneumothorax) Chest expansion - decreased Breath sounds - diminished/absent Chest percussion - normal/hyper -resonant Question: Pneumothorax care Answer: Goal: to evacuate air/blood from pleural space A small chest tube (28 Fr) is inserted near second intercostal space If hemothorax, large tube (32 Fr or greater) is inserted in f ourth or fifth intercostal space Suction is applied Pleural cavity is decompressed (drainage of air/blood) Question: Patient -controlled analgesia (PCA) Answer: Has programmable settings Delivers morphine at a preset bolus Can program a lockout period (co ntrol frequency) HCP gives loading dose to attain therapeutic blood levels quickly (with continuous IV infusion) Assess pain scores after initiation, after any change in pump setting, and periodically
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