NUR 2755 / NUR2755 Exam 3: Multidimensional Care IV / MDC 4 Exam 3, Answered-A patient comes to the ED having diminished breath sounds on his left lung
... [Show More] 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?
- Pneumothorax
A provider tells the nurse that a patient is having a simple pneumothorax. What treatment might be prescribed for the patient?
- 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?
- 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?
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?
- Intubation and mechanical ventilation
What is an early manifestation of hypovolemic shock?
- 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?
- Septic Shock
What is the main nursing issues revolving around rib fractures?
- Pain! Puncturing vasculature or organs.
What can the nurse teach the patient who has had a rib fracture to decrease pain?
- Splint when coughing
A nurse is caring for a patient with ARDS in the ICU. What manifestations might she see?
- 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?
- Stridor and angioedema
A client is having anaphylactic shock due to a bee sting. What medication should be given to treat this?
- Epinephrine
A nurse is caring for a patient with ARDS. What treatment orders might the nurse see from the provider for the patient?
- Place them prone and on PEEP
What are complications of PEEP?
- Pneumothorax
Low BP
What is ventilator associated pneumonia?
- Infection from being on the ventilator for a long time
A nurse is learning about ARDS. What are the causes of ARDS?
- 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?
- 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?
- 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?
- 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?
- Irritation fo the throat form the tube. Call RRT
What are clinical manifestations of hypovolemic shock?
- 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?
- 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?
- 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?
- SOB, soot around nose, singed facial hairs, drooling, not swallowing, black membranes.
What things could cause an elevated wedge pressure?
- FVE, left ventricular failure
What are the components of DIC? [Show Less]