HESI PN MED SURGE PROCTORED EXAM

HESI PN MED SURGE PROCTORED EXAM

VERSION 9

CHAPTER 2

• What are the five level system of triage?

a. Level 1: Resuscitation

b. Level 2: Emergent

c. Level 3: Urgent

d. Level 4: Less urgent

e. Level 5: Nonurgent

40.Resuscitation requires what?

• Immediate treatment to prevent death
• What is required for nonurgent triage (level 5)?
• Non life threatening condition requiring simple evaluation and care management

42.What is the standard precaution for primary survey during triage?

• Gloves
• Gowns
• Eye protection
• Face masks
• Shoe covers
• ABCDE guides the primary survey

43.What is the ABCDE principle?

• Airway/Cervical Spine brain injury/death = 3-5 min. if airway not patent.
• Breathing assess presence & effectiveness of breathing.
• Circulation
• Disability
• Exposure
• How to implement airway for patients who is unresponsive without suspicious of trauma?
• Airway opened head tilt, chin lift maneuver
• How to implement airway for patients who is unresponsive WITH suspicious trauma?
• Airway opened modified jaw thrust maneuver

46.How is the modified jaw thrust maneuver performed?

• Nurse place both hands on either side of the client’s head. Locate the connection

between maxilla and mandible. Lift the jaw superiorly while maintaining alignment of the cervical spine.

• During triage, what mask is given to patient who are spontaneously breathing?
• Non-breather mask with 100% O2 source

48.What does the breathing assessment include?

• Auscultation of breath sounds
• Observation of chest expansion and respiratory effort
• Notation of rate and depth of respiration
• Identification of chest trauma
• Assessment of tracheal position
• Assessment of JVD

49.How to assess for circulation?

• Nurse assess HR, BP, peripheral pulses, and capillary refill for adequate perfusion. 1 / 3

50.What are the precursor to shock that nurses need to be aware of?

• Cardiac arrest
• Myocardial dysfunction
• Hemorrhage
• What are some interventions that is geared toward restoring effective circulation?
• CPR
• Assess for external bleeding.
• Hemorrhage control
• Obtain IV access using large-bore IV catheters inserted into the antecubital fossa of

both arms, unless there is obvious injury to the extremity.

• Infuse isotonic IV fluids such as Lactated Ringer’s & 0.9% NaCl &/or Blood

products.

• What is shock?
• Body response to inadequate tissue perfusion and oxygenation. It manifests with an

increase HR, hypotension and result in tissue ischemia and necrosis.

• What are some intervention that can alleviate shock?
• Administer oxygen
• Apply pressure to obvious bleeding
• Elevate lower extremities to shunt blood to vital organs
• Administer IV fluids and blood products
• Monitor VS
• Remain with client and provide reassurance and support for anxiety.

54.What is the D portion of the ABCDE protocol during triage?

• Disability quick assessment to determine clients LOC

b. Ex: AVPU (Alert, Response to Voice, Responsive to pain, Unresponsive), GCS

• What is the E portion of the ABCDE protocol during triage?
• Exposure
• What is the primary concern during the exposure phase during triage?
• Hypothermia pt. core temperature 35 degree Celsius (95-degree F.) or less.
• Why hypothermia for trauma patients? Exposure, un-warmed oxygen, cold IV

fluids

• What can hypothermia eventually lead to?
• Coma, hypoxemia, and acidosis
• What is a contraindication in the first 6-8 hours after the bite (poisoning)?
• Ice
• Tourniquets
• Heparin
• Corticosteroids

59.Antivenom is effective when?

• Within 4-12 hour and is based on type and severity of a snake bite

60.What is considered cardiac emergency?

• Cardiac arrest
• V. Fib
• Pulseless V. tach.
• V. Asystole
• Pulseless electrical activity (PEA)

61.What is a cardiac arrest?

• Sudden cessation of cardiac function causes most commonly by V. fib. or V. sys.

62.What is Ventricular fibrillation? 2 / 3

5 H’s:

• Hypovolemia
• Hypoxia
• H+ ion accumulation

acidosis

• Hyperkalemia/hypokalemia
• Hypothermia

5 T’s:

• Toxins
• Tamponade
• Tension pneumothorax
• Thrombosis (coronary)
• Thrombosis (pulmonary)
• Fluttering of the ventricles causing LOC, pulselessness, no breathing. Requires

collaborative care to defibrillate immediately using ACLS protocol.

• What is pulseless V. tach.?
• Irritable firing of ectopic ventricular beats at a rate of 140 to 180/min.
• Pt. overtime become unconscious and deteriorate into V. fib.
• What is v. asystole?
• Complete absence of electrical activity and ventricular mvmt of heart.
• Pt. complete cardiac arrest requires implementation of BLS/ACLS protocol.

65.What is pulseless electrical activity (PEA)?

• Rhythm appears to have electrical activity but is not sufficient to stimulate effective

cardiac contractions and requires implementation of BLS/ACLS protocol

• What are the most common causes of pulseless electrical activity?

• What is an Alpha-1 Receptor site?
• Activation of receptors in the arterioles of skin, viscera, mucous membranes, veins

vasoconstriction 68.What is Beta-1 Receptor site?

• Heart stimulation leads to increased HR, increased myocardial contractility,

increased rate of conduction through the AV node

• Activation of receptors in the kidney release of renin

69.What is a Beta-2 receptor site?

• Bronchial stimulation bronchodilation
• Activation of receptors in uterine smooth muscle relaxation
• Activation of receptors in the liver breakdown of glycogen into glucose
• Skeletal muscle receptor activation muscle contraction tremors

70.What is a dopamine receptor site?

• Activation of receptors in the kidney renal blood vessels to dilate.71.What

is the AHA ACLS protocol for VF or pulseless VT?

• Initiate CPR BLS
• Defibrillate
• IV access
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