prioritization/CPR/ventilation

Question 1

prioritize during rapid response

Answer 1

what to prioritize
if a client falls and u shout their name and they don’t respond, check their pulse, call for help & do cpr and you don’t know their code status, do CPR. unknown code is CPR. don’t check bracelet, do cpr first

if doc suspect pt has severe acute resp syndrome, #1: put client on contact and airborne precautions before giving meds or taking cultures or saline. you have to protect yourself and other clients in the facility.

Question 2

bag valve mask

Answer 2

the mask that’s use to give breaths during ressussitation.
it’s also kept at the bedside in a pt receiving mechanical ventilation, in case there’s a power failure or significant difficulty with mechanical ventilation

Question 3

pt on mechanical ventilation

Answer 3

Ensure that the bag-valve-mask device and suction equipment are at the bedside at all times.
Collect vital signs every four hours and obtain arterial blood gasses (ABGs) as directed.
Assess the placement of the ET tube.
Assess breath sounds.
Maintain the head of the bed at least 30 degrees to prevent ventilator-acquired pneumonia.
Suction the mouth and ET tube, as clinically indicated.
Provide oral care frequently.
Ensure that alarms are enabled on the ventilator.
Empty ventilator tubings when moisture collects.

Question 3

giving breaths during cpr

Answer 3

1 breaths every 5 or 6 seconds or every 3-5 seconds for a baby

Question 3

if a toddler accidently swaller a small toy and is having trouble breathing, whats the 1st thing to do?

Answer 3

perform abdominal thrust (also known as the heimlich maneuver (which can be perform on the abdomen or chest: above the belly button or below the ribcage, repeat up to 5x) depending on the situation.

if this client has trouble breathing, this indicates choking.

Question 4

carbon monoxide poisoning, what oxygenation to use

Answer 4

use FIO2 of 100%
the only one is nonrebreather

Question 5

ventilation just read

Answer 5

nasal cannula: 1-6L/min at 24 - 44% fio2
venturi mask 4-10L/min at 24 - 55% fio2
simple face mask: 5 - 8L/min at 45 - 60% fio2

Question 6

what to do in a fire

Answer 6

RACE
R: rescue the people
Activate the fire alarm
Confine the fire
E: extinguish or evacuate

Question 7

LPN can collect medical history
true or false

Answer 7

true

Question 8

what to prioritize post surgery

Answer 8

bleeding, risk of hemorrhage
not incentive spirometry, this helps expand their lungs so that they breathe better, but hemorrhage untreated may lead to death.

Question 9

when is compression stockings (Ted hose)

Answer 9

may aggravate ischemia, so when someone has blood disorders, circulation disorders, etc..

Answer 10

position for liver biopsy: supine
position following a liver biopsy: right side, put pressure on where the liver is to reduce bleeding

Question 11

careful with which require follow vs which require immediate follow up
I read wrong and lost a question like that
they ask which require follow up and I got 3/8 b/c in my head i’m thinking immediate follow up

which requires follow means, eventually or now those require follow up, anything from now till 2 days from now
so which requires follow up?
hypoactive bowels in all 4 quadrants (yes, for RFU, depending on the situation. if the patient had surgery 1-4 days ago, it does not require follow up b/c that’s common with surgery***)
alert and oriented x 1 (yes for requires follow up & requires IMMEDIATE follow up)
non-blanchable redness (yes for RFU)
2/5 strength (yes for RFU: requires follow up)

Question 12

are drawing labs medium or high-medium-low priority?
client pull out IV high or low or medium priority?

Answer 12

drawing labs are medium priority

depending on the IV med but either ways medium

Question 13

fire acronym

Answer 13

RACE
R: REMOVE
ACTIVATE ALARM
CONFINE FIRE
E USE EXTINGUISHER

Question 14

if right foot is cooler what to do? dependent position? heart level? tell provider

Answer 14

heart level and tell provider

dependent position: incorrect

Question 15

air embolism

Answer 15

caused by central venous catheter insertion or removal.
best position: left trendelunberg

apply occlusive dressing over the insertion site to prevent more air from coming in
occlusive dressing: an air & water tight trauma dressing

Question 16

ST elevation means

Answer 16

ST elevation or STEMI: segment elevation myocardial infarction: total blockage. immediate percutaneous intervention (stent in) or thrombolytics.

Question 17

explain first degree, 2nd degree, and 3rd degree block

Answer 17

first degree heart block is associated w/ prolong PR interval, they’re usually asymptomatic and does not require immediate intervention

2nd degree can lead to complete heart block if left untreated

3rd degree heart block: is life threatening and a serious emergency.

Question 18

s/s for hyperkalemia

Answer 18

everything is high except heart rate is low (bradycardia) and urine output is low.
but everything else is high

in death penalties, they give the pt a high dose of potassium, their heart rate keeps going down and it becomes 0 and they die.

Question 19

defribrillation

Answer 19

only for pulseless vtach and vfib

Question 20

Vtach vs Vfib ekg

Answer 20

Vfib is more similar to asystole in largeur. asystole is a line, Vfib has small zigzags along that line

vtach takes a good chunk of space in the cardiac rhythm. hr can be as high as 300 - 400 beats per minute. in Vfib you can barely count hr.

Question 21

atrial flutter

Answer 21

heart Chambers beat too frequently. palpitations, shortness of breath, dizziness

Question 22

unilateral chest expansion and diminished breath sounds indicate

Answer 22

pneumothorax

unilateral chest expansion and diminished breath sounds indicates the presence of air or open in the pleural space.

Question 23

if patient was receiving mechanical ventilation and all of a sudden, they cough and it comes off, what’s your first intervention
1. assess
or
2. give breaths

Answer 23

if a client is receiving mechanical ventilation this means not they cannot breath on their own. first thing to do is give breaths immediately with the bag valve mask at their bedside.

using the head tilt chin lift and the jaw thrust maneuver

sedation significantly depressess respiration. this should not be delayed. accidental extubation is a medical emergency

Question 24

does preeclampsia cause epigastric pain

Answer 24

yes, epigastric pain or right upper quadrant pain due to hepatic damage and swelling

headache, blurred vision due to nervous system irritability
hypertension 140/90 twice at least 4hrs apart.
protein in urine, but preeclampsia DOES NOT CAUSE FREQUENT URINATION

Question 25

what can cause PVC (premature ventricular contractions)

Answer 25

caffeine, alcohol, nicotine or electrolyte imbalances.

extra heart beats: PVC: pulse extra
common in older adults and people with prior heart condition. not a concern unless the person has a fam hx of heart diseases.

Question 26

SVT (supraventricular tachycardia)

Answer 26

usually not serious, but some people may need treatment

Question 27

colostomy
when to change bag
when to drain stool
how much fluid to drink
what foods to avoid

Answer 27

change bag every 5-10 days
drain stool when its 1/3 to 1/2 full
colostomy may cause fluid loss (due to semi liquid stool) so drink 3L of fluid is recommended
avoid gas forming foods like broccoli, cauliflower, onions, beans

Question 28

`is using a wood burning stove in the home as heat concerning?

Answer 28

yes, this is a fire hazard.
can cause physiological damage from inhaling smoke.

Question 29

what to do when client ask to be present during cpr

Answer 29

accept their request and let them stay, that helps them cope w/ the situation

Question 30

do you notify the provider first or the nurse manager first about a medication error?

Answer 30

notify the provider first so that he/she could prescribe the appropriate interventions.

Question 31

car seats safety for children 5 rules

Answer 31

keep car seat at a 45 degree angle
age
0 - 2: rear facing car seat

2 - 7: forward facing car seat

4 - 12: booster seat

8+: seat belt in back seat
14: can sit in front

Question 32

mechanical valve replacement
how long they need to take warfarin for?

Answer 32

patients w/ mechanical valve replacement are at an inc. risk for thromboembolic events. they will need to be on warfarin for the rest of their lives.
like apixaban, warfarin, etc..

Question 33

cardiac tamponate s/s

Answer 33

fluid filled in pericardium
do pericardiocentesis to treat, and give IV fluids during or after pericardiocentesis
s/s: tachycardia, low blood pressure, decrease oxygen saturation (administer oxygen), muffled heart sounds, jugular vein distention, pulse paraxodous

cardiac tamponade is life threatening.

may show Decrease systolic blood pressure during inspiration

Question 34

treating pericarditis

what does ecg show?
what are the lab values?

what do you hear when you auscultate the heart?

what worsens the pain? what makes it better?

Answer 34

inflammation caused by infection of pericardium. wbc >10,000.
interventions: colcichine (med for gout but can also help treat pericarditis)
nitroglycerin: to reduce chest pain that comes with pericarditis

administer nsaids (high dose aspirin to reduce inflammation)
hob >30 degrees
frequent use of incentive spirometer is not indicated

in pericarditis:
ecg shows ST elevation (due to the inflammation)
you hear grating, squeaky sound upon heart auscultation
the chest pain worsens with deep breathing and is relieved by leaning forward

Question 35

MI pain
what worsens it and what makes it better?

Answer 35

MI pain can be worsened if untreated. it can be relieved by nitroglycerin but also not completely. you can give that in an MI, but you’ll need more interventions. it won’t go away completely, you’ll need clot busters, etc..

it doesn’t get better by changing positions, deep breathing doesn’t make it worst

Question 36

pulmonary embolism affects which body system?

Answer 36

PE affects the lungs, it also causes chest pain. but you will not hear heart sounds upon heart auscultation. but in lungs you may hear crackles (small fluid in airway), wheezing

pain is worst with deep breathing

Question 37

moderate Alzheimer’s disease
-fortgetfullness, esp short term memories. may remember long term memories
so telling client activities so that they plan the day wouldn’t work b/c they have issues remembering what you tell them

Question 38

heart attack (anterior myocardial infarction) 2 days ago, now heart murmur what to do?

ignore the word anterior, don’t let it trick you

Answer 38

EKG won’t show heart murmur
arterial blood gas only shows oxygenative, acidosis, alkalosis, won’t help

vital signs or evaluate heart sounds while the client is leaning forward.
no, not familiar w. that ans. i’ll get a set of vitals

Question 39

ooze blood means

Answer 39

bleeding heavily
so if client ooze blood after surgery or anytime, you would wanna apply pressure to stop the bleeding. remember, be a SAFE NURSE. you don’t want them to continue bleeding.

Question 40

PVC rhytm

Answer 40

go on Google to see what they look like
if its one PVC, the beat that’s PVC goes all the way up. if there’s 6 pvcs in a row or 6 PVCs in a minute, that’s concerning

no need to contact hcp or call rapid response if it’s just 1 pvc
just assess the client for changes in rhytm

Question 41

if client had an MI and now has 8 PVCs in 1 minute on cardiac monitor, what do you do?

Answer 41

call the healthcare provider for 6 or more PVCs in 1 minute.

inc. o2 from 2 - 4l is wrong b/c questions doesn’t say anything about hypoxic or showing o2 stat, we don’t know that at all.

Question 42

if patient is having PVCs every other beats, what to do first?
a. rapid response
b. assess orientation and vital signs
c. call healthcare provider
d. administer lidocaine

Answer 42

in the question they didn’t tell us if the patient is unstable. so we would assess orientation and vital signs. if we call doc or rapid response, they’re going to ask are they alert? what’s their skin color? we won’t know these answers b/c we didn’t assess.

if they’re not alert, pulse under 60 and no breathing or pulse under 30 and breathing, that’s a different story

Question 43

who’s most at risk? count +1 for each risk factors
ex: most risk factors for coronary artery disease
over 50, add +1, obese: add +1, mitral valve prolapse: +1, etc..

Answer 43

65yr old female who’s obese with ldl of 188
3 risk factors: age, weight, LDL value

32 yr old w/ mitral valve prolapse only has 1 risk (mitral valve prolapse
total cholesterol normal: less than 200

Question 44

what requires IMMEDIATE action?
any new onset. check around for that
what’s unexpected after cardiac procedure? murmur might be normal after that, they might have it before. spo2; 93% or higher is normal

more somnolent? means more drowsy or sleepy? not normal b/c they had a procedure, not a surgery, they should be alert. not more difficult to arouse.

you don’t have to know everything, just use good nursing judgements

Question 45

best nursing action to prevent infections

Answer 45

hand hygiene, washing hands. it’s never a wrong answer

sterile dressing is usually not used

Question 46

BP 80/40 and spo2 90% on 50% face mask (90% not very low but not terrible)
a. begin chest compression? no b/c they have a blood pressure
b. remove family from the room (no)
c. call the rapid response team
d. ventilate the client w/ a bag mask device

when you call the RRT: it means that the patient is unstable and you’re not sure what to do?
and: is call rapid response team
they might say let’s ventilate them, let’s get an ABG, etc..

you need some advice on what to do

Question 47

chest tube insertion
normal drainage?

Answer 47

no more than 100ml/hr
but it should be serous or serisanguineous (little blood), but if it is sanguineous or red drainage, than that’s an hemorrhage. the drainage should not be red, it should be clear like

Question 48

Maslow: objective, physiological problem
2. psychological, pain (subjective, so its for comfort)

potential infection (cephalozin, not yet b/c its to prevent infection

Question 49

when you have four patients and are prioritizing, see UNSTABLE PATIENT first

IF 2 patient are unstable and 1 of them are hospice, I won’t prioritize the hospice pt b/c there’s a reason why they’re hospice.

Answer 49

rescue asthma drug
end in rol
salmeterol, albuterol

Albuterol is better, short acting.

salmeterol is long acting but also rescue, albuterol always best for asthma exacerbation

Question 50

recommended water intake, 2-3L, both correct on NCLEX unless the person has heart failure, kidney failure, fluid overload, etc..

Answer 50

status asthmaticus: asthma that has not resolved after an inhaler and gets wrost
if someone has status asthmaticus and all of a sudden they stopped wheezing, it means that their airway is closed, so you have to activate RAPID REPSONSE team
status asthmaticus + absence of wheezing: pt not getting air in lungs and you need to secure the airway,

Question 51

assess when you don’t have enough data, if you have enough data, you don’t have to assess first