2650 Exam 2
First on the scene says...
"If you can walk this way, walk this way"
How long is the incubation for Anthrax?
1-7 days
What is flail chest?
2 or more ribs broken in 2 or more places. Intubate the person until the ribs heal
What is the incubation period for rabies?
4-8 weeks
____ broken bones means that there has been blood loss
6
If RR ______ then intubate
<8
What is the core body temperature for Hypothermia?
<95 Severe is <89.6 Death is 78
What is delegation in nursing
A licensed nurse transfers responsibility to a person who is competent to complete a task
The registered nurse delegates the tasks related to caring for a client who has undergone surgery. What are the benefits of delegation in this situation? Select all that apply. A. Increased efficiency B. Improved quality of client care C. Improved supervision by the licensed practical nurse D. Increased delegation authority by the licensed vocational nurse E. Increased professional skills of the unlicensed assistive personnel
A, B, E
What are the purposes of applying the four elements of safety, critical thinking, stability, and time in delegation? Select all that apply. A. Encouraging effective delegation decisions B. Ensuring effectiveness in performing elements of care C. Determining the level of readiness according to Hersey D. Developing the expectations of individuals to accomplish safety E. Assessing the ability of unlicensed nursing personnel (UNP) to perform the task
A, B, E
A client who works in the leather industry reports bloody discharge and persistent pain after the treatment of sinusitis. The client has a history of smoking. The nurse suspects a tumor of the nasal cavity and suggests the client consult a primary health care provider immediately. Which type of leadership does the nurse exhibit? A. Adaptive leadership B. Transactional leadership C. Transformational leadership D. Transgenerational leadership
A. Adaptive Leadership
The healthcare team is caring for clients in a mass casualty event. Which clients should be given the least priority of care? A. Client reporting leg sprain B. Client reporting hip fracture C. Client reporting renal colic pain D. Client reporting substernal chest pain
A. Client reporting leg sprain
The registered nurse (RN) is delegating a task to an unlicensed nursing professional (UNP). Which client care is appropriate for the UNP to achieve a proper outcome in the care? A. Oral care and personnel hygiene assistance for neutropenia patient B. Catheter drainage monitoring for bladder irrigation patient C. Wound care for ulcers for a patient with Chronic venous insufficiency D. Tracheostomy care for a patient with a tracheostomy
A. Oral care and personnel hygiene assistance for neutropenia patient
While receiving an adrenergic beta 2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action? A. Withhold the drug and notify the healthcare provider. B. Tell the client not to worry; these are expected side effects from the medicine. C. Give instructions to breathe slowly and deeply for several minutes. D. Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.
A. Withhold the drug and notify the HCP
What is the Universal recipient?
AB+
Treatment for Acute Radiation Syndrome
ABC's Trauma Wound and burn care Type and Screen Possible bone marrow transplantation Epogen to Stimulate RBC production
What is the terminal event of anthrax infection?
ARDS
As a RN you are still _________________ and ________________ for the task getting done correctly
Accountable, responsible
Nerve agents inhibit _____
Ach
Types of Delegation
Active, Passive
What medication can you give to help with symptoms of Smallpox?
Acyclovir
Complications related to delegate
Age, gender, ethnicity
What does a chest tube remove?
Air or blood
What resources can aid the nurse in delegation?
American Nurses Association, NCSBN, Nurse Practice Act, Standards of Practice, State Board of Nursing, Job Descriptions
What medications do you give for cyanide poisoning?
Amyl Nitrite Sodium Nitrite Sodium Thiosulfate
Passive Delegation
Approved listing of activities as outlined in policies and procedures
The registered nurse is delegating a task for unlicensed assistive personnel l (UAP). Which client's care would be suitable for delegation to the UAP? A. Monitor for discharge from fistula site post-removal of anal fistula B. Monitor hourly temperature for patient with severe malarial fever C. Monitor for Abdominal pain in a patient who underwent appendectomy and hospitalized D. Monitor respiratory rate for a respiratory infection
B. Monitor hourly temperature for patient with severe malarial fever
While working with a delegatee, the registered nurse says to the delegate, "It's easy; you can do the procedure tomorrow after watching me do it today. Just follow the steps I have demonstrated." What is the behavior of the registered nurse in this situation? A. Telling B. Selling C. Delegating D. Participating
B. Selling
What do you give for ETOH poisoning?
Banana bag for Vitamin B deficiencies
Why do basilar skull fractures not have increased ICP?
Because CSF comes out of the eyes/ears with this injury
What do you use to sedate for rapid intubation?
Benzos - Midazolam, Sublimaze
What signs and symptoms warrant intubation?
Blocked airway, Cervical spine damage and unable to breathe on own, Possible smoke inhalation
What body fluids is ebola present in?
Blood vomit urine feces sweat semen spit other -- ALL Body Fluids
What is most important among damages from radiation?
Bone Marrow
What is the primary concern of Sulfur mustard?
Bone marrow damage and suppression in 3-5 days
Treatment for pulmonary Agents
Bronchodilators Ventilators with PEEP IVF Steroids Monitor for bacterial infection
A nurse is preparing medications. Which client's health problem motivates the nurse to question a prescription for a beta blocker? A. Coronary artery disease B. Essential hypertension C. Acute heart failure D. Sinus tachycardia
C. Acute Heart Failure
If uncontrolled external hemorrhage s noted, reprioritize to:
CAB Circulation Airway Breathing
Difference between Smallpox and Chickenpox
CP: seldom on soles or palms Always begins on trunk No fever prior to rash
What lab do you monitor for rhabdomyolysis?
CPK
How can you tell if a colon or bladder is ruptured?
CT scan
What is the #1 action when faced with poison exposure?
Call poison control
What is the basis of EMTALA?
Can't turn away patients Transition of care for patients: Must have an accepting MD,, available bed and resources, Appropriate mode of transportation
How to assess circulation
Check carotid or femoral pulse Palpate pulse for quality and rate Assess skin color, temp, and moisture Check Capillary refill
Reportable situations
Child Abuse Elderly abuse GSW/Stabbing Suspicious deaths Intimate partner violence Death within 24 hours of admission
For extremity injuries what do you check first?
Circulation Movement Sensation
Assess Airway by _______________
Clearing Airway
______________ Involves a joint responsibility for patient outcomes
Collaboration
Breach of Duty
Commission or omission falls below the standard of care
Damages
Compensation given to patient
Signed consent
Covers evaluation and treatment. Does not cover invasive or surgical procedures
A client with pulmonary edema is provided care according to the functional model of nursing. The registered nurse (RN) who is in charge of providing intravenous medication every hour went on a break. Which activity performed by the RN would be most appropriate in this situation? A. Delegating the work to the nursing manager B. Informing the associate nurse before taking a break C. Delegating the work to the licensed practical nurse (LPN) D. Reporting the client's condition to a charge nurse before taking a break
D
Upon assessment the nurse discovers a client with heart failure has crackles in lower lung fields and dyspnea. Upon notifying the primary healthcare provider, the provider prescribes intravenous (IV) normal saline at 200 mL/hr and furosemide 120 mg orally stat. Which action should the nurse take next? A. Place the normal saline on an infusion pump to control the amount, and give the furosemide. B. Ask the healthcare provider why so much intravenous fluid is to be given to an older adult client, and give the furosemide as prescribed. C. Decline to give the intravenous fluid, saying it could cause circulatory overload, and give the furosemide as prescribed. D. Question the choice of solution, the amount to be given, and the dose of furosemide that has been prescribed.
D
The registered nurse is evaluating the statements of the student nurse after teaching about delegation. Which statement made by the student nurse indicates a need for correction? A. "Delegation is merely sharing a set of functions." B. "Delegation ensures quality client care outcomes." C. "Professional aspects of care can also be delegated." D. "The final accountability of a task remains with the delegator."
D. "Professional aspects of care can also be delegated."
The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing? A. Bradypnea B. Bradycardia C. Hypotension D. Hypothermia
D. hypothermia
Role of RN
Delegates to LPN and UAP and can do all the duties of UAP and LPN. Assigned to complex and critical and post op patients, discharge teaching. Comprehensive assessment, gives all meds, Blood transfusions, invasive procedures (central lines, etc.). Develops care plan and uses critical thinking. Collaborate with other members of the healthcare team
What are the four most important factors for assessing acute radiation syndrome?
Dose Dose Rate Amount of body exposure Penetrating radiation
What are the complications of hypothermia?
Drop in BMR Hypoglycemia V Fib
__________ symptoms are an indication of the severity of the radiation dose
Early
What is the effect f acute radiation syndrome on CNS?
Edema Increased ICP Death within hours Irreversible injury Symptoms of shock develop quickly
EMTALA
Emergency medical treatment and Active Labor Act
Duty
Establishes a relationship
Intrapersonal characteristics of the nurse
Ethical grounding, sense of importance, Trustworthiness, developmental maturity in thought and knowing processes, formulates opinions and values, skill in using various ways of knowing
What do you use for anesthesia/induction for rapid intubation?
Etomidate, Propofol
How often do you need tetanus/Diphtheria vaccine?
Every 10 years
Chlorhexidine bathing is an example of
Evidence Based Approach
Gray
Expected not to survive given the circumstances NOT ALREADY DEAD Can be later triaged and re-classified
What are the primary signs and symptoms of Anthrax?
Flu like symptoms that can turn into ARDS
Early Symptoms of Ebola
Flu-Like: Fever Headache V/D Stomach Pain Unexplained bleeding or bruising Muscle Pain
How do you treat heat cramps?
Fluids with electrolyte replacement. May need to give IV because may vomit up if given PO Rest and stay out of heat for 12 hours
How to do you provide the right supervision?
Follow up on the task and ensure it was completed properly
Why would an RN delegate?
Frees up RN to care for critical patients and complete other tasks
Where does Botulism start to appear on the body?
From the head down
Informed consent
Full understanding of risks and benefits, not under the influence
How much atropine do you give to treat a nerve agent reaction?
Give 2mg to start with and then give as much as needed until secretions are drying or dry.
How do you treat OD?
Give activated charcoal to bind drug and then give cathartic antidotes
What is the antidote for Nerve agents?
Give atropine! This has anticholinergic effects
How do you reheat a patient with hypothermia?
Gradual
__________ is the last color that you use resources (personnel and equipment) on.
Gray
Examples of Yellow tagged patients
Gunshot wounds to abdomen with stable VS Major fractures requiring ORIF SCI with acceptable VS
How long does it take for Biological Damage to occur (cells, tissues, whole animals)?
Hours to years
What is the Golden Hour Triad?***
Hypothermia Acidosis Coagulopathy
Under what terms could anthrax be passed from person to person?
If it forms a pustule on the infected person and that pustule bursts
What patient circumstance is the right circumstance for a UAP/LPN to be delegated to?
If the patient is stable
What is Kehr's sign?
If you hit a person in the bottom of the left foot and they have pain in the left shoulder.....
Red
Immediate treatment needed. Patients are critically injured and require immediate intervention
Cause in fact
Injury would not have occurred but for the action of the nurse
Factors that influence noticing
Intrapersonal characteristics of the nurse, Theoretical and experiential knowledge of the nurse, Knowing the patient, context or environment of care
How does Zika affect the patient?
It attacks their brain. Can cause microcephaly, GBS, and other neurological disorders
What do you do with a tooth that gets knocked out?
Keep it in milk
What do you do when you obtain a sample?
Keep it with you until you can transfer it to a higher authority. Do not transfer laterally
Knowing the patient
Knowing the range of patient's pattern of response, Knowing the patient as a person, including preferences and desires
Developing clinical Judgment
Knowledge or deep understanding, learn to recognize patterns, apply concepts to nursing practice, Skillful responding, Reflective Practice
Who can RN delegate to?
LPN or UAP
A Level 3 comes to emergency room with chest pain. Vital signs look good and EKG looks ok. 10 minutes later the patient is experiencing ST changes. What is the new triage tier?
Level 1
What do you use to premedicate for rapid intubation?
Lidocaine
Treat ____________________ injuries first
Life-threatening
When someone OD's on acetaminophen, what do you monitor?
Liver function tests
What are the signs and symptoms of nerve agents?
Loss of consciousness Seizures Apnea Death after large amount
What does a CXR for Anthrax infection show?
Mediastinal widening
Types of Nurse-Nurse Collaboration
Mentoring, Shared governance
How is zika spread?
Mosquitoes - Most concerning during hurricanes
What are the effects of acute radiation syndrome on the GI system?
N/V within first 2-4 hours Diarrhea Associated with sepsis or opportunistic infections Bloody diarrhea at 10 days Damage to epithelial cells lining small intestine Death within 9-13 days
Symptoms of Ricin ingestion
N/v/d (Leads to hypovolemia -- Give Fluids) Vascular collapse death
What is the hallmark sign and symptom of radiation damage?
Nausea and vomiting
Classes of Chemical Agents
Nerve agents Vesicants Cyanide Pulmonary
Can the UAP redelegate a task?
No Role of UAP:Supervised by RN, Can't delegate. Completes ADL's (ambulating, turning, bathing, I's & O's, mouth care, toileting, linen change, feeding (not aspiration), Stable vitals, weights, Does not give meds.
What PPE is supposed to be worn for anthrax?
Normal PPE
Theoretical and Experiential Knowledge of the Nurse
Novice and less experienced nurses use deductive reasoning, rules, and comparisons of the patient with the textbook. Expert nurses look at the whole picture and use pattern recognition and intuition
Types of Collaboration
Nurse-Patient Collaboration, Nurse-Nurse Collaboration, Interprofessional Collaboration, Interorganizational Collaboration
The licensed nurse cannot delegate _________________________ or any activity that involves _____________________________
Nursing Judgment; critical decision making
Never delegate
Nursing process - Assessment, diagnosis, planning, implementation, and evaluation
What is the universal donor?
O
Who removes motorcycle helmets?
Only qualified people
When does ebola spread?
Only when people are sick
Why does metabolic acidosis develop with Cyanide poisoning?
Organs begin to die because of decreased perfusion
How to treat Ricin
Oxygen, fluids, diuretics (depending on situation)
What is the patho for burns?
Pain Swelling Infection
When collecting evidence, what is an acceptable receptacle?
Paper bags. NOT PLASTIC
Black
Patient is deceased
Telephone Triage
People are calling ER or you and the response is to have the patient come in and be seen since they "seem concerned"
How is smallpox transmitted?
Person to person Airborne Direct Contact Highly transmissible Fever and Malaise 2-4 days prior to rash
There are no documented cases of ______________________________ transmission of inhalational anthrax has ever occurred.
Person-to-Person
What is the process for rapid intubation?
Premedicate Sedate Anesthesia/Induction Neuromuscular blocking agent
If a patient is post-op day 1, who gets the patient up to ambulate?
RN
If a patient has a new ostomy placed, who changes it first?
RN because patient is postop and has risk
How is bone marrow damaged with radiation?
Rapid cells can not produce. Risk for infection, anemia, and bleeding
What are the signs of smallpox?
Rash progressing from extremities and face to trunk. Palms and soles
You have to be able to do something within a few minutes to change the outcome of this color triage patient
Red
How do you manage Cyanide poisoning?
Remove cyanide from the cell with amyl nitrate/sodium nitrite Add Sodium Thiosulfate to detoxify cyanide Give O2, hyperventilate, bicarb, and fluids
Signs and Symptoms of cyanide poisoning
Respiratory distress with normal O2 sats Metabolic acidosis Cyanide concentrations High O2 content of venous blood
Plague treatment
Respiratory isolation for the first 48 hours Otherwise, only supportive care Tetracycline or doxycycline as prophylaxis
What does Kehr's sign indicate?
Ruptured spleen
SLUDGE
Salivate Lacrimate Urinate Defecate GI Emesis
Treatment for Nerve Agents
Self-protection Decontamination ABC's Antidote Diazepam Charcoal (if ingested)
Shared Governance
Set of committees inside the hospital that meet and help make big decisions
Treatment for Smallpox
Should be quarantines for 17 days post-exposure or post-vaccine (or until scab falls off)
How can anthrax be transmitted?
Skin Exposure Inhalation Ingestion
Where does anthrax live?
Soil
Who do you ask to delegate something to?
Someone that has competency and experience to do the task you are asking them to do
SALT - Mass casualty Algorithm
Sort Assess Lifesaving Interventions Treatment/Transport * Developed by the CDC
Components of Clinical Judgment
Standards Based Approach, Evidence Based Approach, Interpretivist Approach
Yellow
Still have serious medical problems, but are suspected to survive until definitive care can be rendered later
What Neuromuscular blocking agents are used for rapid intubation?
Succinylcholine Pancuronium Vecuronium Rocuronium
Role of LPN
Supervised by RN, duties depend on state and facilities. Can perform all duties of UAP and delegate to UAP. Give most stable patient assignment with chronic and predictable outcomes. Do not get new admissions. Does not give education. Does not get post-op patients or patients being discharging. Can gather data to help contribute to assessment. Can not interpret data, can only collect and report to RN. Can give meds that are NOT IV or blood transfusions.
What is the acute treatment of Anthrax?
Support ABC's Ciprofloxacin PCN Doxycycline Vaccinate
Treatment for radiation exposure is primarily ____________.
Supportive
compartment syndrome
Swelling in a confined space that produces dangerous pressure; may cut off blood flow or damage sensitive tissue.
Examples of Gray tagged patients
TBI with exposed brain 90% TBSA burns
What are the 5 rights of nursing delegation?
Task, Circumstance, Person, Direction/Communication, Supervision
TAPE
Teaching, Assessment, Planning, Evaluation
What do you use to determine if a task can be delegated to other people?
Teaching, Assessment, Planning, Evaluation, State and facilities protocol, 5 Rights of Nursing Delegation
What is the Golden Hour?
The first hour after injury for major abdominal surgery, thoracic surgery, progression of intracranial hemorrhage Time before the onset of the triad.
Proximate cause
The nurse should have seen that injury would occur
What is the antidote for Radiation exposure?
There is none
What is the main concern for human bites?
They can cause infection easily
With acute cyanide poisoning, it is almost impossible to treat because....
They often die before they get to the hospital
Why do you give people Potassium iodide for thyroid?
This can protect the thyroid from radiation
What is the Type and Screen for HLA typing?
This determines if a bone marrow transplant can happen. It identifies antigens on the WBC to determine tissue compatibility
What do you do when there is air collecting in the pleura space and you can't repair immediately?
This is a tension pneumothorax and you should put dressing on and close 3 sides of the dressing
Radiation protection principles
Time Distance Shielding
Delegation
Transfer of the responsibility for a task, but not the accountability
Effective delegation skills
Understand the nurse practice acts of their states, understand delegation standard related to individual job descriptions, understand the policies of the healthcare facility, function within their state's regulatory guidelines
Orange
Used when victims have been contaminated with hazardous material. Tags removed after decontamination and box on tag is checked
Active Delegation
Verbal direction by RN
Best tasks for a UAP
Very straight forward task that doesn't require TAPE and is very easy to understand
Green
Walking Wounded
Symptoms of Ricin inhalation
Weakness, fever, cough, pulmonary edema ARDS Death from hypoxemia in 36-72 hours
When do you NOT intubate a patient?
When they have major facial trauma
When should you never insert a NG tube?
When you suspect a facial facture
When do you use Jaw Thrust maneuver?
When you suspect c-spine injury
Criteria to determine if acceptable care was given
Written or unwritten (ex. Job description, professional organizations, State board of nursing)
Care can wait for up to 12 hours in this color triage patient
Yellow
Is there a vaccine for Anthrax?
Yes
How do you stop bleeding in the abdomen?
You can't.
MCI refers to
a man-made or natural event or disaster that overwhelms a community's ability to respond Always require assistance from outside resources
Authority
ability to perform a duty for a specific role
Clinical Reasoning is defined as
an iterative process of noticing, interpreting, and responding - reasoning in transition with a fine attunement to the patient and how the patient responds to the nurse's actions
Examples of Green tagged patients
ankle sprains closed fractures of small bones
Clinical Judgment requires the nurse to
apply knowledge, both tacit and explicit, to the unique patient situation to make sense of it and respond
When should you get smallpox vaccine?
at least 4 days prior to expected exposure or within 3 days after exposure
Vesicants appear as _______
burns
Effects of nerve agents at muscarinic sites
cholinergic effects Smooth muscle contractions (eyes, airways, GI)
Collaboration
development of partnerships to achieve best possible outcomes that reflect the particular needs of the patient, family, or community, requiring an understanding of what others have to offer
Cathartic antidotes cause ___________
diarrhea
Good Samaritan Act
established to protect doctors and nurses who stop to render aid to victims. Law prevents malpractice Differs from state to state
National Disaster medical System
expands the nation's medical response capability by organizing and training volunteer disaster medical assistance teams
Influences of Clinical Judgment
experience, environment, theoretical knowledge, expertise
Improper follow through with Delegator
failure to provide clear and concise directions related to assigned task/activity
Improper follow through with delegate
failure to report results/findings related to assigned tasks
Right Directions and Communication
follow up and give clear instructions so the delegate knows what the goal is
Organizational Accountability
having adequate resources and appropriate nurse to patient ratios
Interpretivist Approach
holistic view of patient situation. Takes into account patient's culture, your culture, values, and individual experiences
Examples of Red Tagged individuals
inhalation burns neurologically decompensating TBI Pericardial tamponade Pneumothorax patients
Key Attributes of Care Coordination
interorganizational and interprofessional team that includes the patient, communication and information exchange, proactive plan of care with goals, targeted set of purposeful activities, outcomes and proactive follow up
Clinical Judgment
interpretation or conclusion about a patient's needs, concerns, or health problems and/or the decision to take action, use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response
Right Circumstance
is this patient stable or unstable
Right Task
is this task appropriate for this personnel to perform
Right Person
is this the right person to delegate to
What could be an outcome of vomiting an diarrhea from radiation exposure?
loss of fluids, electrolyte imbalance, and opportunistic infections
What do you do if internal organs are exposed?
never poke it back in. Put moist, sterile dressing over it and send to surgery
Tanner's Model of Clinical judgment
noticing, interpreting, responding, and reflecting
Supervision
oversight of delegated task
Standard's based approach
patient guidelines and protocols in the hospital
Delegation factors
patient's condition, complexity of the task to be performed, predictability of outcomes
The combination of ________________ and ___________ is the most reliable presentation of nerve agent (organophosphate) poisoning
pinpoint pupils seizures
Implied Consent
presumptive treatment if the patient could consent
What is the primary concept for treatment of nerve agents?
protect yourself first
Pneumonic Plague
secondary transmission is possible and likely airborne droplets
How long does it take for chemical damage from free radicals to occur?
seconds
How long does it take for Biological molecular damage to occur?
seconds to hours
Care Coordination
set of activities purposefully organized by a team of personnel that includes the patient to facilitate the appropriate delivery of the necessary services and information to support optimal health and care across settings and over time
Context or Environment of Care
setting in which the nurse interacts with the patient
__________ Doesn't indicate a fracture
swelling
Greater exposure means....
symptoms appear quicker
What is the primary concern with anthrax?
that it may lead to untreated skin infection
Clinical Reasoning is
the thinking process by which a nurse reaches a clinical judgment.
Evidence Based Approach
things that evidence has said that we should do
Assign
transfer both the responsibility and Accountability to another person who is already authorized to do so
NEVER delegate a patient who is __________
unstable
Initial triage assessment when a disaster hits: Can you _______________? Can you _______________? or _______________________
walk this way Wave to me Can't do anything at all
Reasoning and Interpretation
what is going on with the patient, deciding what kind of care they need, interpreting lab values
Process Orientation
what the patient needs, their background, etc
Nurse-Patient Collaboration
working together when the patient for a common goal such as history taking, medication and therapy history, medication compliance. Making a contract with patient so they will stay in the bed. Patient education.
Accountability
you are accepting ownership of that activity. If you delegate a task as RN to a UAP, the RN is still accountable for that action