NCLEX Critical Care

An adult client sustains partial-and full thickness burns of the left thigh and left arm. Using the Lund-Browder chart, the nurse calculates the percentage of total body surface area burned. Which percentage will the nurse record?

16.5%

Which is the minimum length of time victims of a large scale near drowning incident brought to the emergency department would be kept under observation in the hospital?

23 hours

A client weighing 132 pounds (60 kilograms) with burns over 35% of the body arrives at the hospital an hour after being rescued from a fire. Which amount of lactated ringer solution would the nurse anticipate being infused in the next 8 hours?

4200 ml

What do we provide a client first with multiple injuries

A bag-valve-mask ventilation to ensure effective breathing

Sheehan Syndrome

A pituitary infarction caused by postpartum hemorrhaging

Allograft

A temporary measure. It is expected to come off

Which clinical manifestation would the nurse associate with successful fluid replacement therapy?

A trended urinary output of at least 30 ml/h

Shrapnel injury

Abdomen is a type of penetrating injury

Decerebrate Posturing

Abnormal extension Arms and legs straight out Toes pointed downwards Neck and head arched back Rigid muscles Indicated worse, more extensive damage

Decorticate Posturing

Abnormal flexion Arms pulled in towards the center Clenched fists Rigid muscles Arms shaped like C's moving towards spinal cord

For which complication is a client with gestational hypertension at risk?

Abruptio Placentae

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding?

Absence of breath sounds on auscultation

Inotropes

Act by increasing the force of myocardial contractility

Adrenergic Receptors

Alpha 1 Beta 1 Beta 2

Schwartz-Bartter Syndrome

Also known as SIADH

Tidal Volume (TV)

Amount of air inhaled during one respiratory cycle

Cardiac Output

Amount of blood heart pumps through the circulatory system in a minute

Preload

Amount of blood returning to the right side of the heart

Positive End Expiratory Pressure (PEEP)

Amount of pressure in the alveoli at the end of the expiration

What is a tracheostomy tube?

An artificial airway used for long-term needs. This is an last resort and we used to if we can get an endotracheal tube in due to obstruction, edema or a block

A client in her 36th week of gestation is admitted with vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. For which intervention would the nurse prepare?

An immediate cesarean birth

When the fetal head begins to crown during an emergency precipitous birth, how would the nurse respond

Applying gentle perineal pressure

What should the nurse do after an endotracheal tube is placed?

Assess for equal breath sounds bilaterally. (Auscultate)

Hospital Incident Commander

Assumes overall leadership for implementing the emergency plan

Antidote for nerve agent poisoning

Atropine

Mean Arterial Pressure (MAP)

Average arterial pressure throughout one cardiac cycle - systole and diastole Normal: 70-100 mmHg

What treatments can cause hypothermia

Blood infusion Neuromuscular blocking agents

Example of crush injury

Blunt trauma to the head

Causes of decreased cardiac output

Bradycardia Arrhythmias (Pulseless V-tach; V-fib; Asystole; SVT) Hypotension Myocardial Infarction Cardiac muscle disease

Assessment findings of a client with electrical burns

Burn odor Leathery skin Cardiac arrest

Cardiac Index (CI)

Cardiac output per body surface area Normal: 2.5-4.0 L/min

Myocardial necrosis

Causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days

Full-thickness burn

Charred, white, leathery, and black

The ventilator alarm is beeping persistently for low pressure despite the fact the client is calm and has stable vitals. What should the nurse do?

Check the tubing for holes

How do we verify the placement of an endotracheal tube?

Chest X-Ray (Gold Standard)

Causes for HIGH Ventilator Alarm

Client coughing Gagging Bronchospasm Fighting the ventilator ETT occlusion Kink in the tubing Increased secretions Thick secretions Water in the ventilator circuit

Middle ear injury

Common type of blast injury that results from the supersonic over pressurization shock wave caused by the explosion

Which nursing intervention is the most effective in preventing a seizure in a client with severe preeclampsia?

Controlling external stimuli

Assessment findings associated with inhalational injuries

Coughing Smoky breath

Which is more worse: Decorticate or Decerebrate Posturing?

Decerebrate Posturing

Manifestations of Lower Airway Injury

Dyspnea Wheezing

Manifestations of upper airway damage

Edema Stridor Blisters

Beta 1 receptors

Found in heart & intestinal smooth muscle Increased contractility Increase Stroke Volume, Heart Rate, Cardiac Output

Alpha 1 receptors

Found in vascular smooth muscle Peripheral vasoconstriction Increased Systemic Vascular Resistance

Medication used to treat cerebral edema or to decrease free water in clients with submersion injuries

Furosemide Mannitol

Which is the facility-level organizational model for disaster management used by the hospital or long-term care facility

Hospital Incident Command System (HICS)

Compliance

How easily the heart muscle expands when filled with blood

Fraction of Inspired Oxygen (FiO2)

How much oxygen the client is getting 21-100%

Addison Disease Manifestations

Hyperkalemia Hypotension Hypoglycemia

What does moderate hypothermia cause

Hypovolemia Metabolic acidosis Respiratory acidosis

What to do if a client has abruptio placenta

Immediate C-section

Causes of increased cardiac output

Increased blood volume Tachycardia Medications (ACE inhibitors; ARBS; Nitrates ; Inotropes)

Deep partial thickness burns

Injury to the epidermis and dermis Characterized by pain and red-to-white tissue color.

Medication of choice to control shivering in victims of heatstroke

Intravenous chlorpromazine

If a Glasgow Coma Scale (GCS) is less than 8, what do you do?

Intubate

What is an endotracheal tube?

Invasive, artifical airway used when the client is unable to protect their own airway. It keeps the airway open

What happens if an endotracheal tube is placed incorrectly?

It should be removed and replaced

Schwartz-Bartter Syndrome (SIADH) Manifestations

Loss of appetite Nausea Vomiting

Central Venous Pressure (CVP)

Measure of pressure in the superior vena cava Normal: 2-8 mmHg

Sodium Bicarbonate Indications

Metabolic acidosis during cardiac arrest, tricyclic antidepressant, aspirin, and phenobarbital overdose, hyperkalemia, crush injuries.

Vasopressors

Mimic sympathetic nervous system to cause vasoconstriction

Cushing Syndrome Manifestations

Moon face Truncal Obesity Hypertension

Glasgow Coma Scale: Motor Response Score

Obey Commands - 6 Localizing - 5 Normal flexion - 4 Abnormal flexion - 3 Extension - 2 None - 1

Which collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehydration, a heart rate of 100 beats/minute, and blood pressure of 104/62 mmHg?

Offer frequent oral fluids for several hours

Glasgow Coma Scale: Verbal Response Score

Oriented - 5 Confused - 4 Words - 3 Sound - 2 None - 1

Signs of cardiogenic shock

Pale skin (pallor) Agitation Tachycardia Narrow pulse pressure

Superficial partial-thickness burns

Pinkish and tender

Biological agents of terrorism that can be treated effectively with antibiotics

Plague Anthrax Tularemia

Afterload

Pressure against which the left ventricle must pump to eject blood

Ventilator Alarms: HIGH

Pressure in the circuit is too high

Ventilator Alarms: LOW

Pressure in the circuit is too low

What interventions are the priorities of care to promote client safety directly after esophagogastroduodenoscopy (EGD)?

Preventing aspiration Monitoring for signs of perforation

Beta 2 Receptor

Primarily found in bronchial vasculature Bronchodilation Coronary artery vasodilation

Which is the priority nursing intervention for a client with severe preeclampsia?

Protecting her against extraneous stimuli since the client is at risk for seizures

Yellow or tenacious sputum is indicative of what

Respiratory infection

Medical command physician

Responsible for identifying the need for and calling in specialty trained providers in emergencies

Triage officers

Responsible for rapidly evaluating each client to determine priorities for treatment

Public Information officer

Serves as liaison between the health care facility and the media

Which potential life-threatening conditions would be considered during the primary survey for a client admitted after a fire accident?

Shock Inhalation Injury Direct Cardiac Injury

A client with severe hyperkalemia develops acidosis. Immediate administration of which medication can help prevent a life-threatening crisis

Sodium bicarbonate

Sputum of a client with a burn injury

Sooty

Glasgow Coma Scale: Eye Opening Score

Spontaneous - 4 To sound - 3 To pressure - 2 None - 1

Phencyclidine

Street drug that is considered to be a risk factor for heat related emergencies

Contractility

Strength of contraction of the heart muscle

Cardiac Output Formula

Stroke Volume x Heart Rate

Room Air (RA)

The atmospheric air we breathe under normal circumstances (it has an FiO2 of 21%)

Peak Inspiratory Pressure (PIP)

The highest level of pressure in the lungs during inhalation

Pressure-controlled

The lungs are inflated to a certain pressure

Infection Prevention of Endotracheal or Tracheostomy Tubes

The natural defenses of the nose and mouth are bypassed - higher risk for infection Daily trach care Suctioning

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. How would the nurse's behavior be interpreted?

The nurse is negligent and can be sued for malpractice

End-Tidal Carbon Dioxide (ETCO2)

The partial pressure of CO2 detected at the end of exhalation

Systemic Vascular Resistance (SVR)

The resistance exerted on circulating blood by the vasculature of the body Normal: 800-1200 dymes/sec/cm

Volume-controlled

There is a certain volume of air delivered to the patient with each breath

Continuous Positive Airway Pressure (CPAP)

There is continuous positive airway pressure while the patient controls their respiratory rates and volumes

Bilevel Positive Airway Pressure (BiPAP)

There is positive airway pressure, set at different pressures for inspiration and expiration

Cardiac Output

Total volume of blood pumped by the heart per min Normal: 4-8 L/min

Causes for a LOW Ventilator Alarm

Tubing is disconnected Loose connections Leak Extubation Cuffed ETT is trach is deflated Poorly fitting CPAP/BiPAP mask

Within minutes of giving birth to a healthy infant, a client displays symptoms of respiratory distress and an amniotic fluid embolism is suspected. For which other complication would the nurse assess this client?

Uncontrolled Bleeding

Milrionone

Used in patients with cardiogenic shock, decreased cardiac output, congenital/acquired heart defects

Thallium Imaging

Used to assess myocardial ischemia or necrotic muscle tissue related to angina or myocardial infarction

Which would the nurse expect to find when assessing a client suspected of having abruptio placentae?

Uterine tenderness and increased fetal activity

Signs of Abruptio Placenta

Vaginal bleeding Severe Abdominal Pain Rigid Fundus Signs of Impending Shock

Stroke Volume

Volume of blood pumped out of the ventricles with each contraction

Safety of Endotracheal or Tracheostomy Tubes

You must keep two back up trachs at the bedside in case of emergency

"ABC"

airway, breathing, circulation

Pinpoint red spots

petechiae

Frothy sputum is indicative of what

pulmonary edema