Exam 2: NUR2755/ NUR 2755 (New 2023 / 2024) Multidimensional Care IV |Complete Guide with Questions and Verified Answers| 100% Correct – Rasmussen
Exam 2: NUR2755/ NUR 2755 (New 2023 /
2024) Multidimensional Care IV |Complete
Guide with Questions and Verified Answers|
100% Correct – Rasmussen
QUESTION
Nurses priority for assessing for shock
Answer:
ABC
QUESTION
When should the patient receive emergency treatment for burns
Answer:
When the burn covers more than 25% of the body
QUESTION
septic shock
Answer:
a serious condition that occurs when an overwhelming infection affects the body. signs of septic
shock- elevated temperature
QUESTION
anaphalactic shock
Answer:
severe allergic reaction system release of histamines
massive vasodilation
decreases BP- Treat with epinephrine IM or INH.
QUESTION
Neurogenic shock
Answer:
a state of shock (hypoperfusion) caused by nerve paralysis that sometimes develops from spinal
cord injuries,
QUESTION
Neurogenic shock treatment
Answer:
General treatment & Atropine for bradycardia &
stabilize C-spine & methylprednisolone within 8 hours of injury
QUESTION
Septic shock treatment
Answer:
Blood cultures, IVF, vasopressors: Norepinephrine is first line of defense, dopamine,
dobutamine can be used; abx within 1 hour
QUESTION
endotracheal intubation
Answer:
placement of a endotracheal tube through the mouth into the pharynx, larynx, and trachea to
establish an airway
QUESTION
flail chest
Answer:
Paradoxical chest wall movement—”sucking inward” of loose chest area during inspiration,
“puffing out” of same area during expiration
QUESTION
Signs of neurogenic shock.
Answer:
Hypertension
Bradycardia
Warm, dry skin (cushings triad)
QUESTION
Distributive shock occurs when:
Answer:
widespread dilation of the blood vessels causes blood to pool in the vascular beds.
QUESTION
What does nor-epinephrine do?
Answer:
Increases map without changing intravascu- lar volume
QUESTION
Types of shock
Answer:
Hypovolemic, Cardiogenic, Obstructive, & Distributive
QUESTION
Burn shock is caused by :
Answer:
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How do you treat an airway blockage?
Log roll patient into recovery position use suction equipment to remove fluids or other obstructions
What can be used as a suction device in the back country?
syringe
How do you assess an airway?
Look at the airway with a flashlight and see if there are visible obstructions
Listen to see if you can hear gurgling, wheezing, or snoring
Feel the air move in and out of the airway.
recovery position
A side-lying position used to maintain a clear airway in unconscious patients without injuries who are breathing adequately.
nasopharyngeal airway
a flexible breathing tube inserted through the patient’s nostril into the pharynx to help maintain an open airway
How do you size a nasopharyngeal airway?
tip of patients earlobe to the corner of their mouth plus one inch
oropharyngeal airway
a curved device inserted through the patient’s mouth into the pharynx to help maintain an open airway
how do you measure a oropharyngeal airway?
tip of patients earlobe to the corner of their mouth
Arteriosclerosis
hardening of the arteries
Atherosclerosis
hardening of the arteries due to cholesterol-lipid-calcium deposits
coronary artery disease
atherosclerosis of the coronary arteries that reduces the blood supply to the heart muscle
Angina Pectoris
chest pain that results when the heart does not get enough blood supply to the heart muscle
myocardial infarction
the occlusion of one or more coronary arteries caused by plaque buildup (heart attack)
respiratory arrest
when breathing completely stops
stroke
Damage to the brain from interruption of its blood supply.
aneurism
Artery/vein breaks in the head
sudden cardiac death
when the heartbeat stops abruptly and unexpectedly
Causes of sudden death
-electrocution
-drowning and near-drowning
-anaphylaxis
-shock
-MI
-severe trauma
Risk Factors for cardiovascular disease that cannot be changed
Hereditary
Sex
Age
Race
Risk Factors for cardiovascular disease that can be changed
Cholesterol
Diet and Obesity
Inactivity
Smoking
Diabetes
Hypertension
Alcohol and Recreational drugs
Heart Attack
Acute myocardial infarction or Angina Pectoris
treat all chest pain as though it were a heart attack
Signs and symptoms of Acute Myocardial Infarction
Pain: Substantial chest pain, back pain, pain may radiate to jaw, neck, or left arm
They may be denying anything is wron
Increased anxiety
Shortness of breath
Weakness
Nausea
Indigestion
Vital Signs that indicate cardiogenic shock
LOC: Anxious
Skin: Pale, cool, clammy
Pulse: Rapid, weak
Respirations: Rapid and Shallow
BP: Steady then falling
Pupils: PERRL
Treatments for heart attacks
Maintain ABC’s
Reassure
Place in a position of comfort
Encourage rest
Encourage Sublingual Nitroglycerin if the patient has a prescription
Encourage them to chew aspirin (325 mg)
Monitor
Evacuate
cardiopulmonary resuscitation (CPR)
increases the time between clinical death and biological death by oxygenating the brain
Best results from a combination of CPR and early defibrillation
Complications to CPR
Aspiration of Vomit
Fractured ribs
Punctured Heart/Lungs
Lacerated Liver
Do not begin CPR if
Street:
Scene is unsafe
Rigor Mortis is present
Dependent lividity is present (pooling of blood)
Injuries incompatible with life
DNR orders present
Wilderness:
All the street protocols plus:
Frozen/incompressible chest
Hypothermic patient
Putrefaction (rot) is evident
When to stop CPR
Scene becomes unsafe
Patient returns to life
Rescuer is relieved by equally or more highly trained personnel
Patient is declared dead by MD, DO, or Medical Examiner
Rescuer is unable to continue efforts
Wilderness:
all street protocols plus
may stop CPR after 30 continuous minutes without patient exhibiting any signs of life
automated external defibrillator (AED)
A device that detects treatable life-threatening cardiac arrhythmias (ventricular fibrillation and ventricular tachycardia) and delivers the appropriate electrical shock to the patient.
Ideal time before shock is delivered
6 minutes
process of events before defibrillation
Perform primary survey
Begin CPR
Place the device on the left side of patients head when available
Bare the patients chest (If the chest is wet quickly wipe it dry)
Remove the backing from the first pad and place it adhesive side down on the upper right chest
Remove the backing of the second pad and place it on the skin below and left of the left nipple
Tightly connect the lead cables from the AED to the pad
Follow defibrillators prompts (Stop CPR, Stand Back, Shock, Check Breathing and Pulse)
If a pulse is present after defibrillation
leave the machine attached to monitor the condiiton
Maintain an open airway and continue life-support procedures
Assist with ventilations if needed
If no pulse is present after defibrillation
leave the machine attached
continue CPR
after two minutes the AED will prompt you to stop CPR and will analyze if an additional shock is needed
If defibrillator pads are no in full contact
Make sure patients chest is dry and free of anything in contact with its surface
remove all dressings and nitro patches on placement site
wipe off nitropaste
Shave the pad placement area if necessary
decompensatory shock
stage of shock in which he body’s compensatory mechanisms are no longer able to maintain a blood pressure and perfusion of the vital organs.
Signs of decompensatory shock
LOC decreases
HR increases
RR increases
SCTM white, ashen, cold
BP decreases
PERRL slow to react
hypovolemic shock
shock resulting from blood or fluid loss
cardiogenic shock
Shock caused by inadequate function of the heart, or pump failure.
neurogenic shock
a state of shock (hypoperfusion) caused by nerve paralysis that sometimes develops from spinal cord injuries
signs and symptoms of shock
Moist, pale, cold, clammy skin
Weak rapid pulse, increasing shallow respiration decreased blood pressure
Urinary retention and fecal incontinence
Irritability or excitement, and potentially thirst
Care and treatment of shock
ABCDE
find and treat underlying cause of injuries
get them warm-theyll be cold
Anatomy of the skin
epidermis, dermis, hypodermis
Principles of treating soft tissue injuries
Maintain BSI
Control Bleeding
Prevent infection and promote healing
Control bleeding what do you do?
Direct pressure
Elevation
Digital Pressure
Pressure dressings
contusion
bruise
Contusion treatment
Rest
Ice
Compress
Elevate
Abrasion
Scrapes: May be painful, dirty, and can easily become infected
Abrasion treatment
Scrub thoroughly with soap and water and allow to air dry before bandaging
Consider antibiotic ointment for comfort
Lacerations and Incisions
Smooth or jagged cutting or tearing of skin
may bleed profusely
Treatment of Lacerations and Incisions
Control bleeding
proper wound cleaning and long term care
Flap Avulsion
Three sided tear, one side still attached
Flap Avulsion Treatment
Control bleeding
If possible, place flap in proper anatomical position
Proper wound cleaning
Rinse under flap with sterile irrigation, and bandage it in its proper anatomical position
Amputation
partial or complete removal of a limb
Treatment for amputation
IRRIGATE, BANDAGE, GET THEM OUT
Control bleeding, clean wound site
Wrap the severed par tin a moist sterile dressing and seal in plastic bag
Immerse the bag in cold water and evacuate both the patient and the part
impaled objects
Objects that penetrate the skin but remain in place.
Impaled object treatment
Remove object if it comes out easily
Stabilize object in place and evacuate if: it is in the head, neck, chest, abdomen, or pelvis if difficult to remove
puncture
a small penetrating wound to the skin
Puncture Treatment
gently irrigate to cause some bleeding to flush out the wound, monitor for infection
sources;
https://www.gcu.edu/
https://yaveni.com/
https://www.rasmussen.edu/