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
