Exam Study

Question 1

Is an artificial airway needed for an unconscious person who is breathing spontaneously with an O2 Sat of 95% in RA?

Answer 1

Yes - Pt unconscious. Requires Guedel airway

Question 2

Is an artificial airway needed for a person with a burn injury to 50% of their body after being trapped in a house fire?

Answer 2

Yes - risk of shock. Requires bag and mask and ETT.

Question 3

Is an artificial airway needed for an unconscious 10 yr old boy post-operative inguinal hernia repair being cared for in recovery?

Answer 3

Yes - Pt unconscious. Requires Guedel airway.

Question 4

Is an artificial airway needed for an unconscious person who is breathing shallow with an oxygen sat of 82% in RA?

Answer 4

Yes - Pt unconscious and has poor oxygen sats. Suctioning, Guedel airway and recovery position.

Question 5

Is an artificial airway needed for a person with a burn injury to their hands as a result of spillage of boiling water?

Answer 5

No.

Question 6

Is an artificial airway needed for a person who is unconscious and not breathing?

Answer 6

Yes - Pt unconscious and not breathing. Suctioning, guedel airway and bag and mask. Need to protect airway.

Question 7

Is an artificial airway needed for someone who is unconscious, breathing spontaneously but has an O2 Sat of 88%?

Answer 7

Yes - Pt unconscious, low oxygen sats, spontaneous breathing. Suctioning, guedel airway or Nasal airway plus Hudson mask with oxygen at 6/Lpm Oxygen saturation monitoring is essential, recovery position, monitor. Need to protect airway.

Question 8

Chest tubes or intercostal catheters are inserted in the pleural space to remove air or fluid. Principles in the safe management of the person with a closed chest drainage system include:

Answer 8

• preparation of the person for the procedure, • maintenance of standard precautions throughout to prevent infection, • observation of the chest tube drainage system for: - patency. - security of connection. - the chest tube drainage system is below the level of the chest. - fluctuations or bubbling in the water-seal bottle (if water system used). • assessment of the: - insertion site and the dressing. - colour and volume of drainage. • ensuring the sterile water bottle is readily available. • Encouraging the person to undertake deep breathing and coughing exercises.

Question 9

What are the indications for an intercostal catheter?

Answer 9

Pneumothorax, haemothorax, lung requiring re-expansion

Question 10

Gravity is usually sufficient to drain …… and …… from the pleural space.

Answer 10

Air and Fluid

Question 11

The connections of the intercostal catheter and drainage bottle should be checked for

Answer 11

Leaks and security

Question 12

List safety issues relevant to the nursing care of a person with an intercostal catheter

Answer 12

Check connections tights; if water in drainage system keep bottles below level of chest; have normal saline bottle at bed side in case of accidental disconnection – ICC end can be placed in bottle of Normal Saline so no air enters pleural space. RN then has time to replace drainage system if needed; Check dressing for ooze and change as per hospital policy.

Question 13

What medications can be used to reduce BP?

Answer 13

Ramipril 5mg – ACE inhibitor – reduce BP Metoprolol 100mg, - ß-Blocker – reduce BP

Question 14

What is Frusemide?

Answer 14

Loop diuretic – used to reduce circulating fluid. Removes water and Na+ and K+. Risk of electrolyte imbalance

Question 15

What is Esomeprazole sodium 20 used for?

Answer 15

H2-antagonistic drugs – reduces gastric secretions

Question 16

What does Atorvastatin 40mg do?

Answer 16

Reduces cholesterol

Question 17

When taking blood from a CVL or intra-arterial line what safety issues need to be considered by the nurse?

Answer 17

-PPE at all times -Closed system so maintenance of aseptic technique required in all manipulations of the tube. -Check line connections secure -Check limb for discolouration, sensation during procedure

Question 18

When assessing respiratory assessment, what should you be LOOKING for?

Answer 18

Equal rise and fall of the chest

Question 19

Identify the landmarks on the chest which help to identify the right position to listen to breath sounds

Answer 19

Midclavicular, 2nd intercostal, midclavicular line, 4th intercostal, 6th intercostal, 8th intercostal, (all anterior). Posterior - 1st, 3rd, 5th, 7th, 9th intercostal Lateral - 6th, 8th, 9th intercostal

Question 20

If HCO-3 is out (compensating), what does that usually signify?

Answer 20

An underlying chronic condition

Question 21

What does Primary Assessment include?

Answer 21

Airway - is airway patent? Breathing - is the person breathing spontaneously? Are the lungs clear with equal air entry? SPO2 levels and respirations? Circulation - skin colour and warmth, temperature, BP, pulse, capillary refill Disability - Is the person conscious/unconscious? PEARL? Pupil size?

Question 22

What key points need to be considered when assessing the patency of a person’s airway?

Answer 22

a) The work of breathing (recession, respiratory rate, depth, effort including the use of accessory muscle use). b) The effectiveness of breathing (oxygen saturation, chest expansion, breath sounds). c) Chest wall movement and any chest injury. d) Whether the client can talk. Is the client breathless when talking? Are they able to talk in sentences or only single words? e) If there is any pain being experienced by the client on inspiration or expiration f) Position of trachea (midline or is deviation noted). g) Auscultate for bilateral breath sounds including the lung peripheries. h) That the stomach is not being ventilated and count respiratory rate. A nasogastric tube maybe required to be inserted to treat and prevent gastric dilatation. i) The effects of inadequate respiration (heart rate, mental state)

Question 23

Why is important to monitor the vital signs of a person with suspected airway compromise?

Answer 23

An assessment of the vital signs provides essential physiological information about patients. Impending critical illness and respiratory compromise can alter these signs. Monitoring of vital signs will identify deterioration in the person condition.

Question 24

When would the nurse insert a Guedel’s airway (oropharangeal airway)?

Answer 24

When the spontaneously breathing person is unconscious or unable to maintain the patency of their own airway.

Question 25

In what circumstances would a LMA be used?

Answer 25

Indicated as an alternative to the face mask for achieving and maintaining control of an airway, and has proved to be a valuable tool in the emergency management of a failed intubation, as it helps establish and maintain an airway

Question 26

What is the nursing role following endotracheal tube intubation?

Answer 26

The nurse should check that the ET tube is in the correct place. this is done by watching for both equal and bilateral chest movements and listening for air entry. The nurse should secure the ET tube once it is in place to prevent it from moving

Question 27

List the nursing responsibilities when caring for a person with a tracheostomy tube insitu?

Answer 27

It is vital that the cuff pressure is checked regularly and that the cuff is deflated and reinflated at appropriate intervals to prevent the effects of pressure on the internal wall of the trachea. Suction should be applied above the cuff prior to deflation to remove any secretions. • Pre-oxygenation of person may be needed prior to suctions. • Need to treat suctioning and dressing changes a clean – aspetic procedures – needed to assist in reducing risk of resp infection

Question 28

What is the purpose of artificial airway suctioning?

Answer 28

To remove secretions from the airways. Tracheostomy suctioning may improve the patency of the airway, oxygenation and gaseous exchange

Question 29

What are the possible consequences of inaccurate chest electrode placement in ECG?

Answer 29

Inaccurate ECG reading and as a result in accurate diagnosis of client condition

Question 30

List your initial actions when a person is not breathing

Answer 30

Check airway and clear if obstruction found

Question 31

What is the most appropriate action to clear a person’s obstructed airway?

Answer 31

Turn head to side and scope out debrie or use suction – wall suction and yankur sucker

Question 32

If the person is not breathing, what is the best way to determine if the heart is beating?

Answer 32

Listen with stethoscope for an apex beat

Question 33

How many minutes following cessation of breathing and heartbeat does it takes for brain damage to occur?

Answer 33

6 minutes

Question 34

What is the rate and ratio of compressions to breaths for a one person resuscitation of an adult person?

Answer 34

Rate 100 compressions per minute with a ratio of 30 compressions to 2 rescue breaths.

Question 35

What is the most reliable way for the resuscitator to determine that breathing is inflating the person’s lungs?

Answer 35

Rise and fall of the patients chest

Question 36

Identify the appropriate endotrachela tube size for a female and male.

Answer 36

Female—size 8 Male—size 9

Question 37

List the clinical signs that indicate resuscitation has been successful

Answer 37

Breathing and heart rate have returned. Cardiac output is present

Question 38

List the observations that should be made post resuscitation

Answer 38

Vital signs, connect client to cardiac monitor and observe rate and rhythm, monitor urine output as indicator of cardiac function, record oxygen requirements and oxygen saturations

Question 39

1) What is the heart rate?
2) Heart Rhythm?
3) Is there a P wave?
4) Is there a PRI complex?
5) QRS complex?
6) What is the rhythm?
7) Is this a shockable rhythm?

Answer 39

1) 80 bpm
2) Regular
3) Yes - present
4) Present
5) Present and alike
6) Normal Sinus Rhythm
7) No

Question 40

Define triage?

Answer 40

Assessment of client and the allocation of the appropriate triage score to enable the prioritising of clients to ensure those with the most life threatening injuries will be seen first by medical personnel.

Question 41

Why is the triage nursing role important?

Answer 41

Accurate assessment of clients health status is essential to ensure those with the most life threatening conditions are treated first. The Triage nurse is often the first point of contact for the client and as such requires well-developed assessment skills to ensure accurate triaging of clients

Question 42

Identify the various types of central venous access devices

Answer 42

Central venous catheters, portacath, PICC line, Jugular vein catheters, etc

Question 43

List the complications of central venous access devices

Answer 43

Safety, correct measurement, information about procedures, prevent complications such as haemorrhage, leakage, disconnection, dislodgement of tube, etc

Question 44

Central venus catheter placement is checked by?

Answer 44

Chest x-ray

Question 45

CVP is a reflection of?

Answer 45

pre-load of right ventricule

Question 46

What are the indications for CVP monitoring?

Answer 46

Decreased cardiac output/post-op, shock, use of inotropic drugs, etc

Question 47

How is the zero point established to enable the measurement the central venous pressure (CVP)?

Answer 47

Level of right atrium

Question 48

Why is it important to ensure the CVP reading is taken with the client is the same position each time?

Answer 48

Enable accurate measurements to be obtained and results compared with previous findings to enable adequate assessment of client fluid status.

Question 49

Normal range for mean arterial pressure is?

Answer 49

70-105 mm/Hg

Question 50

What are the main nursing responsibilities when caring for a person with an arterial line insitu?

Question 51

What criteria needs to be met to recognise brain death?

Answer 51

Absent reflex and motor movement
Pupils fixed and dilated
No spontaneous respiration
Flat EEG - no circulation
Absent ocular movement
Persistence of manifestations for 30 min to 1 hr.

Question 52

What are the nursing responsibilities of a pt that presents with chest pain?

Answer 52

ECG, pain management, observations, blood tests, provide reassurance, where is the pain, how long has it been going on, does it radiate, MO review

Question 53

Legal and ethical - duty of care.
A patient is owed a duty of care when they present to hospital. What does the hospital’s duty of care involve?

Answer 53

They have a duty to maintain records and equipment etc. They also have a duty of care to their employees and patients, privacy and confidentiality and appointing competent staff. Ensuring accurate advice and treatment is given.