Module 1 practice

What is the cardiac output of a client with a HR 50, Cl 2.5, SV 60, CVP 8

3000ml/min HR 50 X SV 60

The blood pressure in a patient diagnosed with heart failure is 130/80 mmHg. What is the mean arterial pressure (MAP) in the patient? Round to two decimal places

96.66

A priority for an immobilized MVC brought to the ED with multiple injuries, bleeding, & extreme disorientation is A. Assess the respiratory pattern and ensure the airway is patent. B. Check the patient's responsiveness by using the Glasgow Coma Scale. C. Assess for loss of sensation and function in the lower extremities. D. Observe and palpate the abdomen for bleeding and tenderness.

A

What is the primary purpose of an arterial catheter/line? A. Internal measure of blood pressure B. Vasoactive drug administration C. Administer nutritional support D. Monitor coagulation status

A

The nurse is performing an assessment on a patient who had severe blood loss during a surgical procedure. Which assessment finding indicates a decrease in preload? A. Increased pulse rate B. Increased bp C. Presence of peripheral edema D. Presence of crackle sounds on auscultation

A Cardiac output involves the volume of circulating blood, hr, and vascular contractions. Loss of blood may indicate a decrease in the fluid volume, which may result in increased pulse rate. All the other choices indicate signs of fluid overload

The nurse is teaching about blunt trauma. Which statement indicates the need for further teaching? A. Blunt trauma is when the energy transference does not cause disruption to the skin. B. Injuries caused by blunt trauma can easily be seen with the naked eye C. Shearing occurs when the skin or tissue slide in opposite parallel directions D. Deceleration occurs when a moving body comes to an abrupt stop

B Injuries caused by blunt trauma are difficult to see with the naked eye

What does the pulmonary artery occlusive pressure (wedge) tell the nurse about the client? A. Right ventricular preload B. Right ventricular afterload C. Left ventricular preload D. Left ventricular after load

C

A client arrives in the ED with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? A. Level of consciousness and pupil size B. Characteristics of pain and blood pressure C. Quality of respirations and presence of pulses D. Observation of abdominal contusions and other wounds

C Assessing breathing and circulation are the priorities in trauma management; basic life functions must be maintained or reestablished (ABCs: airway, breathing, circulation). Level of consciousness and pupil size are assessments associated with head injury; in this situation these follow determination of respiratory and circulatory status, which are the priorities. Although blood pressure is an important assessment associated with adequacy of circulation, it is obtained after assessments associated with patency of airway and breathing;a clients pain is addressed after ABC needs are assessed and interventions implemented to support life. Assessment for abdominal injury and other wounds follows determination of respiratory and circulatory status, which are the priorities

What should the nurse assess immediately after a central venous catheter is inserted? A. Heart sounds B. Glasgow coma score C. Pulses D. Breath sounds

D

Which of the following is not a safety concern from a pulmonary artery catheter? A. Dysrhytmias B. Pulmonary Artery infarction C. Infection D. Hypotension

D

Which prescription should the nurse anticipate for a low systemic vascular resistance (SVR)? A. Lopressor B. Crystalloid C. Nitroglycerine D. Norepinephrine

D

Pressure in the arteries during a single cardiac cycle

Mean arterial pressure

Care that improves the quality of life of patients and families the problem of life-threatening illnesses

Palliative Care

Stabbings, firearms, and impalements are what type of trauma?

Penetrating

In clinical practice you would level the arterial line transducer to the ......

Phlebostatic axis

In the trauma assessment when is the C-collar placed?

Primary assessment during Airway

The secondary survey consists of

Vitals/family, labs, monitor(ECG), naso/orogastric tube, oxygenation/ventilation, pain, history

At least 3 interventions to treat high preload

furosemide, morphine, hydralazine, nitroglycerin

The three sites for central line placement

subclavian, femoral, and internal jugular

What is the priority for the nurse to monitor while the healthcare provider inserts a pulmonary artery catheter? A. Heart rhythm B. Temperature C. Wave forms D. Bleeding

A

What position should the client be placed in to remove a central venous catheter? A. Supine B. Left Lateral C. Semi- fowlers D. Reverse Trendelenburg

A

The charge nurse is monitoring the care of several critically ill patients in the ICU. Which patient requires immediate intervention by the provider? A. The patient with a PA catheter remaining in the wedge position B. The patient with an SvO2 of 55% C. The patient with an SVR of 1,300 D. The patient with a CO of 3.2

A Rationale: All of the above patient situations are slightly abnormal, requiring attention, but a pulmonary artery catheter that remains in a wedge position may indicate the possibility of pulmonary artery occlusion requiring repositioning or discontinuation of the catheter. Decreased mixed venous oxygen saturation and cardiac output may indicate the need for volume or inotropic support. The slightly increased systemic vascular resistance would need to be evaluated for cause, such as hypovolemia, and treated as necessary.

The nurse is caring for a family that was admitted to the emergency department following a car acci- dent. The car was traveling at 40 miles an hour and was struck on the driver's front side. Which of the following family members should receive immediate attention? A. The 40-year-old female driver who is having difficulty breathing B. The 21-year-old female front seat passenger who is complaining of chest pain C. The 16-year-old female who was a rear seat passenger and is complaining of abdominal pain D. The 18-year-old male who was a rear seat passenger with a laceration to the right eyebrow

A Rationale: The driver took the main impact of the crash and difficulty breathing is the priority. The patient with chest pain should be assessed next (ABCs), followed by the patient with abdominal pain, and then the patient with the facial laceration. Remember ABCs—airway and breathing come first.

The trauma nurse anticipates which of the following complications when treating an intoxicated homeless patient after he was hit by a car in the snow? The patient is in C-spine immobilization, has an open femur fracture, a pelvic fracture, abdominal tenderness, and a GCS of 12. (Select all that apply.) A. Decreased hemoglobin and hematocrit B. Decreased SpO2 C. Tension pneumothorax D. Sepsis E. Decreased PaCO2

A, B, and D Rationale: The patient is at huge risk of having a bleed- ing complication due to having both a femur fracture and a pelvic fracture. Abdominal tenderness indicates potential liver or spleen injury furthering the risk for bleeding. The patient is homeless and was hit in the snow, placing the patient at a much higher risk of hypothermia, which can cause coagulopathies that increases the bleeding risk further. Both the alcohol and the bleeding can easily cause the patient to vomit, putting the patient at greater risk for aspiration and decreased SpO2. The patient's low GCS score puts the patient at further airway risk since it is unknown if the GCS is alcohol induced or secondary to head trauma. Respiratory depression may be present, potentially resulting in an increased PaCO2. Sepsis may be a potential eventual complication for this patient second- ary to the open femur fracture that allows for a source of infection. There is no mechanism of injury that would indicate a tension pneumthorax.

List all (A-E) parts of the primary trauma assessment in order

A- Airway/apply C-collar/AVPU B- assess Breathing C- assess Circulation/Control bleeding D- Disability (GCS) E- Exposure/Environment

Which client conditions if selected by the student nurse as lowest priorities of care would indicate effective understanding of prioritizing care for clients with different conditions in an ED? SATA A. Cystitis B. Cold symptoms C. Closed fracture D. Intubation trauma E. Moderate abdominal pain

AB Care for clients with cystitis and cold symptoms can be delayed because these conditions may be stable when compared with conditions of other clients and these are not life threatening conditions. Client with closed fractures can be cared for within an hour. The client with intubation trauma should be given immediate care because the clients condition with trauma may not be stable. The client with moderate abdominal pain can wait for some time to receive care.

Based on the ABCDES of trauma resuscitation, the flight nurse will perform which intervention during the assessment and immediate care of a patient with gunshot wounds? Select all that apply. One, some, or all responses may be correct. A. Check the pupils. B. Apply a cervical collar. C. Assess tissue integrity. D. Initiate intravenous access. E. Determine ventilation needs.

ABCDE The Advanced Trauma Life Support (ATLS) primary survey, which is performed upon initial contact with the patient, is based on the ABCDES of trauma resuscitation: Airway maintenance with cervical spine protection, Breathing and ventilation, Circulation with hemorrhage control, Disability (neurologic status), and Exposure or environmental control. Therefore the flight nurse will check the pupils (Disability; neurologic status), apply a cervical collar (Airway maintenance with cervical spine protection), assess tissue integrity (Exposure), initiate intravenous access (Circulation with hemorrhage control), and determine ventilation needs (Breathing and. ventilation).

Which are the priority emergency assessments with the nurse will perform for a client with bomb blast injuries? SATA A. Airway B. Breathing C. Circulation D. Giving comfort measures E. Facilitating family presence F. Exposure or environmental control

ABCF The primary survey focuses on ABCDE.

Which action will the nurse take to address the needs of family members of a patient who has experienced a traumatic injury? Select all that apply. One, some, or all responses may be correct. A. Allow the family members to express their emotions. B. Bring family members together with other families of trauma patients in support groups. C. Schedule a visit from a chaplain. D. Encourage family members to participate in the care of the loved one. E. Provide information about available hospital resources.

ABDE The effect of traumatic injury can be devastating for patients, family members, and significant others. Trauma can precipitate a crisis within the family. The family is often faced with an unexpected situation for which the members have had little time to prepare. A helpful action by the nurse is to allow them to express their emotions. Another valuable intervention is to bring families of trauma patients together in support groups. Trauma family support groups can offer sharing of experiences, mutual support, and sharing of coping strategies. Although it may be challenging, family members should be encouraged, to the extent that they are able and wish to do so, to participate in patient care while maintaining the comfort and safety of the patient. The nurse should help them learn about resources available via the hospital and community. The nurse should not assume that a visit from a chaplain will be helpful; the nurse would need to assess the family's spiritual needs first.

What is a major safety concern for the care of arterial lines? A. No risk for bleeding B. Never administer meds though the line C. Never turn the alarms on D. Use the vamp to draw blood from the line

B

The nurse is caring for a number of patients who have arrived to the emergency department following an explosion at a local food treatment plant. Which of the following orders should the nurse implement first? A. Administer 5 mg of oxycodone to a patient with a deformed ankle. B. Administer an albuterol nebulizer to a patient with difficulty breathing due to inhalation of debris. C. Assess orthostatic vital signs on a patient who is experiencing dizziness. D. Apply a wound dressing to a patient with a laceration to the forearm.

B Rationale: All are important but remember ABCs— airway and breathing come first

The nurse is managing the care of a patient with an arterial line. Which assessment finding warrants immediate intervention by the nurse? A. An overdamped waveform on the monitor B. Tubing disconnected from the arterial line C. IV medications being infused into an arterial line D. Redness at the arterial line insertion site

B Rationale: All of the findings indicate a problem, but disconnected tubing may result in hemorrhage requir- ing immediate intervention. Intravenous medications through the arterial line should be stopped as soon as possible. A dampened or flat waveform requires assess- ment of positioning or air in the line. Redness at the site indicates possible inflation and may require the line be discontinued.

A 30-year-old female driver who was in a front-end, high-speed MVC is admitted to the ED. She had a seatbelt on, but the car did not have any air bags. There was severe front-end damage with spidering of the windshield in front of the driver's seat and a bent steering wheel. The nurse caring for this patient should anticipate and monitor for which injuries? A. Sternal/rib, T-spine, pelvic fracture injuries B. Head, cervical-spine (C-spine), sternal/rib, cardiac contusion, hollow abdominal organ injuries C. Head, C-spine, solid abdominal organ injuries D. Sternal/rib, collarbone fracture, pelvic fracture, facial fracture injuries

B Rationale: Sternal and rib fractures would be expected due to the force of impact the patient's body had with the steering wheel. The force was great enough to bend the steering wheel, making there be a very high index of suspicion for a sternal fracture and rib fractures. With such a high force chest wall injury, a cardiac con- tusion must also be suspected and the patient will need to be monitored for cardiac dysrhythmias. Spidering of the windshield takes great force, and with it being di- rectly in front of the driver seat, the cause of the spider- ing is most likely the driver's head and therefore, there should be a high index of suspicion for a head/brain injury. This also puts the patient at great risk for a c-spine injury due to the deceleration/ "whiplash" forces. Anytime there is a high force head/brain injury, C-spine injury must be suspected. The patient was wearing a seatbelt in a high force accident. Abdominal organ injuries should be highly suspected due to the high force and deceleration forces in coordination with the seatbelt sign. T-spine injuries could potentially hap- pen but not as high of an index of suspicion as would C-spine. The same is true of pelvic fractures. Due to the seatbelt sign, it is not just solid abdominal organs that are at risk but also the hollow organs. Facial fractures can happen, but most of the impact is farther up the head and not the nose area.

Which parameters would the nurse consider for proper rapid baseline assessment using a disability mnemonic (AVPU) in a client prescribed with drug abuse? SATA A. Level of anxiety B. Reaction to pain C. Response to voice D. Body temperature E. Evidence of assault

BC The disability examination provides a rapid baseline assessment of neurological status. It helps evaluate level of consciousness by the AVPU mnemonic, which also helps assess for the responsiveness to pain and voice. Level of anxiety is not assessed by a disability mnemonic. Body temperature and evidence of assault are assessed in a primary survey of exposure

The patient with a PA catheter has a low pulmonary artery occlusive pressure. On the basis of this information, what intervention should the nurse anticipate? A. A diuretic to help decrease fluid volume overload B. A vasoactive drip to help increase blood pressure C. A fluid bolus to help increase preload D. An afterload reducer to help decrease SV

C Rationale: A low PAOP indicates decreased preload in the left heart typically requiring volume. A vasoactive drip would increase blood pressure but not affect volume. An afterload reducer will decrease blood pressure. A diuretic would further decrease the PAOP.

The nurse is caring for a patient coming into the ED unconscious after taking an overdose of an unknown substance approximately 1 hour ago. Which of the following actions should the nurse take first? A. Initiate gastric lavage B. Insert two large-bore IVs C. Assess vital signs with pulse oximetry D. Insert nasogastric tube

C Rationale: Weak or absent respirations or low oxygen levels require immediate intervention before initiating interventions directed at the overdose.

Which action would the nurse perform as the highest priority for a client with trauma in the emergency unit? A. Applying dry dressing B. Evaluating chest expansion C. Providing adequate oxygen O2 supply D. Applying direct pressure on a bleeding site

C The nurse would prioritize care while caring for a client with trauma in the emergency department. Evaluation of chest expansion and respiratory effort, as well as evidence of chest wall trauma, helps assess breathing, a primary survey. The highest priority intervention is to establish a patent airway by providing adequate O2 supply, thereby reducing the brain injury and progression to anoxic brain death. Direct application of pressure on the bleeding site with thick, dry dressing material helps reduce external hemorrhage.

The most important aspect of a secondary survey is to A. Check circulatory status B. Insert a urinary catheter C. Check electrolyte profile D. Obtain patient history

D

Which consideration is correct for opening the airway of an unresponsive trauma patient in the ED? A. Hyperextension of the neck is the only acceptable technique. B. Airway patency is priority over cervical spine immobilization. C. Flexion of the neck protects the patient from further injury. D. Airway assessment must incorporate cervical spine immobilization.

D

Which emergency assessment has been performed on the client when an emergency management team is removing foreign bodies and performing criciothyriodotomy on a client postburn injury? A. Breathing B. Circulation C. Exposure and environmental control D. Airway with simultaneous cervical spine stabilization

D Emergency assessment of the airway with simultaneous cervical spine stabilization involves removing foreign bodies and performing cricothyroidotomy. It is done in a primary survey to assess patency, respiratory distress, and bleeding. Assessment of breathing is done to check ventilation and respiratory rate and may require ventilating with bag-valve-mask with 100% oxygen or using needle thoracostomy. Circulation assessment is performed to check capillary refill or measure blood pressure and may require initiating cardiopulmonary resuscitation and advanced life-support measures. Exposure and environmental assessment is done to check the entire body for injuries; it involves removing all clothing and using warm blankets or warmed intravenous fluids to prevent hypothermia

The nurse understands priority prehospital interventions include which of the following? A. Transporting the patient as quickly as possible to the nearest trauma center B. Treating all injuries found and then transporting the patient C. Notifying the local hospital of the transportof a trauma patient and transporting the patient quickly D. Assessing the patient using ABCs, treating life- threatening conditions, then transport to the hospital

D Rationale: A prehospital provider's priority is to quickly assess using ABCs and stabilize/treat the life- threatening conditions and quickly transport to the appropriate facility. The appropriate facility most likely is the nearest trauma center; however, if the patient is too unstable, the closest local emergency department may be the most appropriate facility in order to further stabilize the patient, then transport to a trauma center. Prehospital providers should not be treating all injuries found, only immediate life- threatening injuries.

Which statement will the nurse make to explain the golden hour to the family of a patient? A. It is the time frame from the preinjury activities to the time of the traumatic event. B. It is the 60 minutes that immediately follow a traumatic event. C. It is the hour that begins after a trauma patient has been brought to the hospital. D. It is the time frame from activation of emergency medical services to the provision of critical care

D The golden hour of trauma resuscitation is often viewed as a critical time frame in which the injured patient will die unless definitive care is delivered. However, the golden hour should not be considered a time frame but rather a guideline for all trauma care providers. Components of the golden hour incorporate activation of emergency medical services, stabilization and transport, triage, initial resuscitation, early surgical consultation, and provision of critical care. For a critically injured trauma patient, the primary goal is to minimize the time from injury to definitive care. The golden hour is not the patient activities preceding a traumatic event, the 60 minutes that immediately follow a traumatic event, or the hour that begins when a. trauma patient is brought to the hospital.

Which client response indicates to the nurse that a vasodilator medication is effective? A. Absence of adventitious breath sounds B. Increase in the daily amount of urine produced C. Pulse rate decreases from 110 to beats/minute D. Blood pressure changes from 154/90 to 126/72 mmHg

D Vasodilation will lower the blood pressure. The pulse rate is not decreased is not decreased and may increase. Breath sounds are not directly affected by vasodilation, although vasodilator medications can decrease preload and afterload, which could indirectly affect breath sounds in heart failure. The urine output is not affected immediately, although control of blood pressure can help preserve renal function over time

At least 3 interventions for helping family

Family satisfaction, explain information, honest information, understanding of why things are happening, notify family, delivery of care is courteous

What is the priority significance for hemodynamic line calibration? A. So waveform appears dampened B. To ensure accuracy of readings C. So blood does not back up into the line D. To identify air bubbles in the line

B

What should the nurse assess immediately after a central venous catheter is removed? A. Pulses B. Heart sounds C. Breath sounds D. Glasgow coma score

B

Which medication is prescribed to enhance contractility of the heart muscle in patients suffering from a low cardiac output? A. Beta blockers B. Angiotensin receptor blockers (ARBs) C. Cardiac glycosides D. Venous vasodilators

C Cardiac glycosides are usually administered to patients to increase contractility of the heart muscle. This medication acts as a positive inotrope agent.

Name the components of primary survey

Airway/alertness/c-spine Breathing/ventilation Circulation Disability Exposure/enviroment

The nurse has just received report on assigned patients. Which of the following patients should be assessed first? A. Patient A with an admission diagnosis of snake bite to the left forearm who has been treated with antivenin 24 hours ago B. Patient B, who just arrived to the unit with an admission diagnosis of allergic reaction and tongue swelling, recently complained of hoarseness. C. Patient C, who was admitted with a spider bite, has been treated with antibiotics and is ready to be discharged. D. Patient D, who was admitted yesterday with heat exhaustion and has recent stable vitals

B Rationale: Patient B is at risk for respiratory compromise due to the allergic reaction. Allergic reactions are sudden onset and require a prompt response.