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 dose metronidazole 1 / 4
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 trachea to unaffected side
Question:
Subcutaneous emphysema care
Answer:
Leaked air pockets under skin, feels like "rice crispies" Part of spontaneous pneumothorax Not usually serious 2 / 4
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
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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 fourth 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 (control 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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