NUR 2755 Multidimensional Care IV
MDC4 Exam 3
Patient education for halo device
Correct Answer:
Wash skin daily, use a straw for drinking, advise that the device can alter balance
Wound infection signs
Correct Answer:
red hard skin, purulent drainage, warm tender skin
Clinical manifestation PACU nurse should be concerned with
Correct Answer:
Respiratory rate 12 or below elevated BP Increased pain that is not resolved with pain medication
What are protonix used for?
Correct Answer:
prophylactic treatment for stomach ulcers 1 / 4
Who can sign a consent for a confused client?
Correct Answer:
Spouse, POA
When would a hospital disaster plan be activated?
Correct Answer:
Factory Explosion
When should a patient carry an epi pen?
Correct Answer:
if they have had previous anaphylaxis to wasp or bee’s stings
Prioritize patient treatment:
#1 21 year old dazedwith laceration to face.#2 infant with fever, petechia and nucheal rigidy #3 25 year old with broken ankle and pulse #4 50 year old woman with abdominal pain
Correct Answer:
2,1,43
Priority treatment: for patient with left sided chest pain and following vital
signs; BP 140/90, RR 16, P90, O2 88%
Correct Answer:
Oxygen 2 / 4
Priority Action by nurse:
Patient arrives with heat stroke, patient vitals are : 104.4, 88/50, p112, O2
88%
Correct Answer:
Oxygen->Start Iv->Administer IV fluids->Insert rectal themometor
Patient arrives to ER with temperature of 104 after working on the roof, what is the diagnosis and how do you treat?
Correct Answer:
Heat stroke- Do not give fluids by mouth or medications- remember heat stroke is similar to thrombolytic stroke they may be disoriented and unable to drink, also, this is a medical emergency. You would take prompt action to decrease body temperature.
Mass Casualty Incident (MCI)
Correct Answer:
An incident where the number and severity of casualties exceeds the capability of the responder's initial resources
Mass-Causalty incident triage
Correct Answer:
Emergent- treat first,Red Triage Tag ("Immediate" or T1 or Priority 1): Patients whose lives are in immediate danger and who require immediate treatment Urgent- Yellow Triage Tag ("Delayed" or T2 or Priority 2): Patients whose lives are not in immediate danger and who will require urgent, not immediate, medical care; Non-Urgent- Green Triage Tag ("Minimal" or T3 or Priority 3): Patients with minor injuries who will eventually require treatment; 3 / 4
Expectant-Black Triage Tag ("Expectant" or No Priority): Patients who are either dead or have such extensive injuries can not be saved with the limited resources available.
Treatment for inhalation burn, ( brassy cough)
Correct Answer:
Oxygen
Priority action:
You find your patient has received multiple doses of their medication. What do you do?
Correct Answer:
Assess the patient for condition change->administer care-> call the physician
Your client is post surgical and you notice a declining cognition. What do you do ?
Correct Answer:
Call a rapid response
Latex allergy
Correct Answer:
- Must use latex-free gloves;
- Label O.R. as "latex free";
- clients w/latex allergy usually have an allergy to foods such as bananas,
- / 4
kiwis, and avocados, strawberries.