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critical care > unit 5 > Flashcards

unit 5 Flashcards

1
Q

in a chest tube acts as a one way valve

air goes out - none in

A

water seal chamber

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2
Q

in a chest tube, the drainage system should be kept __

and the insertion site should be _____-

A

always be kept below the level of the chest

insertion site covered with air tight dressing

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3
Q

most common mechanism of injury. Injuries may not be easily noted; requires expert clinical judgment to diagnose.

A

Blunt trauma-

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4
Q

first 60 mins where a critically injured trauma patient must recieve life saving care

A

golden hour

when primary survey is done

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5
Q

3 interventions for problems with disability

A

Spinal stabilization
Monitor for neurogenic shock
Maintain perfusion

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6
Q

musculoskeletal injuries what 5 things

A 
Bone 
Soft tissue 
Muscle 
Nerves 
Surrounding blood vessles
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7
Q

cardiac tamponade is diagnosed by _____

A

fast ultrasound

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8
Q

with a blood transfusion it is important to remember to remain with client for _______

A

Remain with patient 1t 15-30 miN

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9
Q

in the fluid remobilization phase:

H&H:
Na:
K:
WBC:
glucose: 
ABG's:
protein & albumin:
A 
H&H: decreased 
Na: decreased 
K: decreased 
WBC: decreased 
glucose: elevated 
ABG's: met.acidosis 
protein & albumin: decreased
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10
Q

5 P’s

A 
pain - early sign 
pallor 
pulse -late sign 
paraesthesia - early sign 
paralysis
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11
Q

Fat globules from the long bones are released into the circulation and may lodge in the pulmonary system resulting in severe hypoxemia

May occur from fracture to the long bones and pelvis.

A

fat embolism

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12
Q

in a disaster situationclients that: have life threatening injuries that need immediate care

pneumothorax - tracheal deviation
chest bruising - flail chest
paradoxical breathing

A

Emergent

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13
Q

Crush injuries to the pelvis and/or both lower extremities or a prolonged entrapment often require

A

amputation

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14
Q

with a burn phase: begins with injury and continues for 24 to 48 hrs.

A

Resuscitative phase

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15
Q

Occurs when air escapes from injured lung into the pleural space, resulting in partial or complete collapse of the lung.

A

Pneumothorax

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16
Q

in the Resuscitative phase 6 things to remember with treatment

A 
Stop the burning process 
Take off jewlery (nonadherant)
Cool water - no ice or cold water
Brush off chemical 
Prophalatic intubation
FIO2 100%
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17
Q

Findings are usually mild and include itching, urticaria, and flushing.

The client can develop an anaphylactic transfusion reaction resulting in bronchospasm, laryngeal edema, and shock.

A

allergic blood transfusion reaction

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18
Q

5 interventions to remember with the acute phase of burns

A 
Pain management - IV opioids 
Promote wound healing 
Prevent infection (protective isolation)
Parental or TPN feedings 
Physical therapy
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19
Q

3 interventions for problems with circulation

A

2 large gauge IV with isotonic solution

Transfusion of blood - warm blood

Fast scan - small ultrasound machiene for no missed bleeding

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20
Q

3 nursing interventions for a bacterial blood transfusion reaction

A

Stop the transfusion.

Administer antibiotics and an IV infusion of 0.9% sodium chloride using new tubing.

Send a blood culture specimen to the lab for analysis.

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21
Q

burn where Destruction of all skin layers, extends to muscle, tendon, and bones

Black, eschar hard and inelastic

Insensate (no pain)

A

Deep Full thickness

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22
Q

mechanism of injury where the patient:

struck with an object
skin still intact but may be serious injury underneath
evaluated with ultrasound

A

blunt trauma

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23
Q

IV fluid resuscitation is instituted for patients with greater than __% TBSA

A

20

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24
Q

3 complications from organ donation

A

rejection
infection
post transplan malignancies

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25
Q

type of burn where

skin exposed to a caustic agent acids, bases, and organic compounds.

Contact
Inhalation of fumes
Ingestion or injection

(lye or oven cleaner)

A

Chemical burn

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26
Q

Findings include crackles, dyspnea, cough, anxiety, jugular vein distention, and tachycardia. Manifestations can progress to pulmonary edema.

A

circulatory overload blood transfusion reactions

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27
Q

2 treatments of Pneumothorax-

A

needle decompression

chest tube

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28
Q

Healthy individuals offer organs to a client with end-organ disease.

Examples of organs donated by living donors are kidneys, lung lobes, part of a pancreas

A

Living Donors

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29
Q

monitor chest tube drainage every ___ hours

unless fresh from surgery, then __ hours

A

4, 1

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30
Q

one who does not meet brain death criteria but has an illness from which no recovery is expected

A

Circulatory Death-

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31
Q

chest tubes can do what 3 things

A

restore inintrapleural pressure
allow reexpansion of the lungs
prevent air and fluid from returning into the chest

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32
Q

3 phases of a blast injury

A

positive pressure: organs that contain air can rupture

negative force: impailed with flying debris

Tossed about: how far from explosion determines injury

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33
Q

life threatening condition that is caused by rapid accumulation of fluid in pericardial sac

A

cardiac tamponade

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34
Q

is from fracture of 2 or more adjacent ribs creating a free-floating segment in the rib cage

A

A flail chest

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35
Q

in a chest tube, the drainage system should be kept __

and the insertion site should be _____-

coiled in a _______

A

always be kept below the level of the chest

insertion site covered with air tight dressing

coiled in a lazy loop

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36
Q

-Grafts for deep partial-thickness and full-thickness burns

A

Skin covering

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37
Q

for blood transfusions with older adults, administer the blood over ___-___ hours

A

2-4 hours

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38
Q

who is the most effected population for burns

A

children and elderly

less subcutaneous skin

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39
Q

includes obtaining the client’s medical history, getting lab specimens and radiology exams, possibly inserting foley catheters or NG tubes.

A

The secondary survey

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40
Q

4 treatments of A flail chest

A

Mechanical ventilation
Pain control
Pulmonary hygiene.
Cough and deep breathing

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41
Q

Results from a transfusion rate that is too rapid for the client. Older adult clients or those who have a preexisting increased circulatory volume are at an increased risk.

A

circulatory overload blood transfusion reactions

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42
Q

method used to calculate total body surface area rule of 9

head \_\_%
each arm arm\_\_%
torso\_\_%
each leg\_\_%
genitals \_\_%
A 
head - 9 
arm- 9
torso-18
leg-18
genital-1

posterior and anterior seprate

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43
Q

6 assesment findings that indicae a problem with breathing

A 
Absent or unequal breath sounds 
Asymetrical chest expansion 
Accesory muscle use
Anxiety 
Tracheal shift with tension pneumothorax
Loc decreased
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44
Q

-Impalement of body from foreign objects-complications include organ damage, hemorrhage, and infection.

A

Penetrating trauma

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45
Q

secondary head injury may result from what 4 things

A

Seizures
Hypotension
Hypoxia

Cerebral edema

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46
Q

brain and spinal cord injuries are included in ____

A

disability

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47
Q

burn that goes deep into the dermis

swelling, red or white appearance

require dressing changes and possibly skin graft

Heals within 2 to 4 weeks

A

Deep Partial thickness

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48
Q

2 injuries that can lead to problems with circulation

A

bodly fluid loss

bleeding

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49
Q

hypothermia an lead to what 2 complications

A

cardiac dysrthmias

coagulation disorders

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50
Q

is one who is pronounced dead by neurologic criteria; cessation of brain function

A

Brain Death

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51
Q

Hypothermia is a major concern, occurs when body temperature is _____ or less.

A

35 C (95.0 F)

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52
Q

4 nursing interventions for ANAPHYLACTIC blood transfusion reaction

A
  • Stop the transfusion.
  • Administer epinephrine, oxygen, or CPR if indicated.
  • Remove the blood tubing from the client’s IV access.
  • Initiate an infusion of 0.9% sodium chloride using new tubing.
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53
Q

is it normal to have bubbling in suction chamber?

A

yes gentle bubbling when suction is applied

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54
Q

if you notice Continious bubbling in water seal chamber what should you do

A

check for leaks and notify HCP

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55
Q

4 clinical manifestations of A flail chest

A

Paradoxical chest movement
Increased work of breathing
Tachypnea
Hypoxemia.

56
Q

type of burn whrere

Inhalation of hot smoke, chemical toxins, and products of incomplete combustion. Often occurs after fires or chemical leaks in enclosed space.

Superglottic injury & Subglottic injuries

A

Inhalation burn

57
Q

with Fluid Resuscitation what type of IV fluids do burn victims recieve

A

0.9 or lactated ringers

warmed

58
Q

with Fluid Resuscitation for burn patients

Administer half of total 24-hour IV fluids during first _ hours from time of injury

Administer the other half over the next __ hours from time of injury

A

8

16

59
Q

primary head injury may result from what 2 things

A

blunt or penetrating trauma

60
Q

Findings include chills, fever, low-back pain, tachycardia, flushing, hypotension, chest
tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom.

are all signs of ______

A

acute hemolytic blood transfusion reaction

61
Q

should you empty the contents of a drainage collection chamber?

A

no, can cause contamination of site

62
Q

may mask neuro responses and misleading findings

A

Alcohol

Recreational drugs

63
Q

burn that goes past the epidermis and into dermis layer

red or pinkish modeling , blisters and swelling

dressing changes with topical ointment

Heals in 7 to 10 days

A

Superficial Partial Thickness

64
Q

for prevention of conflict of interest who asks the family for organ donation

A

OPO

65
Q

3 complications from penetrating trauma

A

Organ damage
Hemmorage
Infection

66
Q

dark leathery necrotic tissue that has to be debreided and needs skin graft

A

eschar

67
Q

clinical manifestations of liver injuries include what 3 things

A

RUQ ecchymosis
Tenderness
Hypotension.

68
Q

in a disaster situation: clients that are awake and alertwith minor injuries such as

fractures
scrapes and bruises

A

non-urgent

69
Q

phase of burn that Begins 36 to 48 hours after injury when the fluid shift resolves

Ends with closure of the wound

A

Acute Phase

70
Q

Early treatment of fractures includes hat 2 things

A

immobilization with splints and traction

surgical management may be required.

71
Q

3 clinical manifestations that a patient is in the expectant category

A

Pupils fixed and dialated
Agonal respirations
Cervial spinal cord injuries

72
Q

clinical manifestions of cardiac tamponade

A

Hypotension
Muffled heart sounds,
Jugular venous distension

73
Q

burn patients Hypermetabolic-catabolic state (requiring _____ cal/day)

A

5000

74
Q

mechanism of injury where the patient:

A

Blast injuries-

75
Q

4 treatments for liver and spleen

A

bed rest
signs of hypovolemic shock
frequent CBC
surgical interventions

76
Q

in a disaster situationclients that: have major injuries requiring care within the hour

stable vital signs
fractured pelvis
severe abdonminal injury

A

urgent

77
Q

3 nursing interventions for circulatory overload blood transfusion reactions

A

Slow or stop the transfusion depending on the severity of manifestations.

Position the client upright with feet lower than the level of the heart.

Administer oxygen, diuretics, and morphine as prescribed.

78
Q

ABCDE stands for

A 
Airway
Breathing
Circulation 
Disability 
Exposure
79
Q

with burns

GFR will be:

urine output wil be:

BUN & creatinine will be:

A

GFR will be: down

urine output wil be: down

BUN & creatinine will be: up

80
Q

in a disaster situation:

Patients that are expected to die

comfort care measures

A

expectant

81
Q

May occur from explosions and combines elements of blunt and penetrating trauma.

A

Blast injuries-

82
Q

7 clinical manifestation of Pneumothorax-

A

Respiratory distress
Tachypnea
Tachycardia
Tracheal deviation

Chest pain
Blood tingled sputum
Diminished or absent breath sounds

83
Q

with an Inhalation burn what 2 things can happen

A

edema and swelling in upper airway

stridor

84
Q

increased pressure within a confined body space, especially of the leg or forearm.

A

Compartment syndrome

asess for 5 P’s

85
Q

Results from a transfusion of blood products that are incompatible with the client’s blood type or Rh factor. Can occur following the transfusion of as few as 10 mL of a blood product.

A

acute hemolytic blood transfusion reaction

86
Q

______ injuries occurs due to heat exposure below the glottis and often manifest breathing problem.

A

Subglottic

can lead to ARDS

87
Q

4 interventions for problems with breathing

A

Chest tube -pneumothorax
Cspine stableization
Intubation
Needle decompression - tension pneumothorax

88
Q

Destruction of entire epidermis and dermis as well as subcutaneous tissue

Thick, dry, red, black, brown, yellow, white, leathery appearance

Severe edema

Eschar hard and inelastic

Sensation minimal or no pain

skin graft needed

A

Full thickness

89
Q

with a chest tube:

is drainage rising up and down in tubing normal?

A

yes,

tidaling

90
Q

is a collection of blood in the pleural space.

A

Hemothorax

91
Q

______ injury is heat exposure above the glottis that can lead to airway obstruction.

A

Superglottic

92
Q

in chest tubes is bubbling in the water seal chamber okay

A

intermittin bubbling with coughin or forced expiration is okay

Continious bubbling is a sign of an air leak

93
Q

mechanism of injury where the patient:

impailment of the body from a foreign object
gunshot, stabbing, accidnet, etc

A

penetrating trauma

94
Q

Symptoms of splenic injury include what 3 things

A

LUQ tenderness,
Kehr’s sign (refered pain from left shoulder)
Hypotension.

95
Q

3 nursing interventions for febrile blood transfusion reaction

A

Use WBC filter for administration to prevent the reaction from occurring.

Stop the transfusion and administer antipyretics.

Initiate an infusion of 0.9% sodium chloride using new tubing.

96
Q

2 ways for prevention of DVT

A

low dose heparin

ambulation

97
Q

Results from the development of anti-WBC antibodies. Can be seen when the client has received multiple transfusions.

A

febrile blood transfusion reaction

98
Q

patients with abdoniminal injury and ____ injury will not be able to tell where their pain is coming from

A

head

99
Q

for blood transfusions always prime with what type of IV solution

A

0.9 NS

100
Q

open Pneumothorax treatment

A

3 sided dressing (allows the air to escape)

101
Q

with burns

blod volume will be:
blood pressure will be:
cardiac output will be: 
heart rate will be:
vasoconstriction will be:
A 
blod volume will be: down 
blood pressure will be: down
cardiac output will be: down
heart rate will be:up
vasoconstriction will be: up
102
Q

What is the appropriate management of an opioid overdose?

A

narcan

103
Q

5 interventions for ineffective airway with a trauma patient

A

Opening the airway

Gentle suctioning - bleeding or vomit in airway
Airway inserted (endotrachial tube)
Intubation
Neck injury - jaw thrust instead of head tilt

104
Q

is the only permanent method of grafting

A

Autograft

105
Q

treatment for Rhabdomyolysis

A

aggressive IV fluids

106
Q

Skin damaged by contact with heat

exposed the flame, scalding liquids is what type of burn

A

thermal burn

107
Q

cardiac tamponade treatment

A

Pericardiocentesis

108
Q

initial appempts to cleanse wounds are done when the patient is

A

stabalized

109
Q

4 interventions to prevent infection with burn patients

A

Restrict plants and flowers
No fresh fruits and vegetables
Limit visitors
Administer tetanus toxoid

110
Q

5 problems that can cause a blocked airway

A

Vomiting
Obstruction from foreign object
Tongue occlusion
Edema

Bleeding

111
Q

: more than 10% strongly indicates smoke inhalation

A

Carboxyhemoglobin

112
Q

type of burn where

electrical current passes through the body and can cause sever damage including lethal dysrhythmias, central nervous system defects, and respiratory arrest.

(electrical current or struck by lightening)

entry point and exit point

A

Electrical burn

113
Q

4 nursing interventions for allergic blood transfusion reaction

A

Stop the transfusion.

Initiate an infusion of 0.9% sodium chloride using new tubing.

Administer an antihistamine, such as diphenhydramine.

If the provider prescribes to restart the transfusion, do so slowly.

114
Q

5 nursing inerventions for acute hemolytic blood transfusion reaction

A

Stop the transfusion.

Remove the blood tubing from the IV access.

Initiate an infusion of 0.9% sodium chloride using new tubing.

Monitor vital signs and fluid status.

Send the blood bag and administration set to the lab for testing.

115
Q

5 injuries that can lead to problems with breathing

A 
Spinal cord injury 
Chest or thoracic injury
Rib fracture 
Altered LOC
Pneumothorax
116
Q

injury caused by external forces or violence.

A

Trauma

117
Q

Results from a sensitivity reaction to a component of the transfused blood products.

A

allergic blood transfusion reaction

118
Q

RhabdomyolysisMay result from crush injuries, compartment syndrome, burns.

Muscle damage leads to myoglobin (a muscle protein) released into the circulation

A

Rhabdomyolysis

119
Q

6 nursing interventsion for poision

A 
Obtain client history to identify the toxic agent.
Contact poison control center. 
Prevent further absorption of the toxin
Extract or remove the poison
IV therapy 
Administer antidotes when necessary.
120
Q

medication
drugs
household cleaners
snake and spider bites

are all types of

A

poisioning

121
Q

during the secondary survey if patient shows signs of

asymetrical chest expansion 
restlessness 
confusion
increase HR
decrease in BP

this is a sign to ____

A

go back to primary survey

122
Q

8 assesment findings that indicae a problem with circulation

A 
Systolic BP less than 90 
HR over 120 
Anxiety 
Decreased LOC 
Obvious bleeding 
Weak and thready paulses

Pallor
MAP less than 70

123
Q

burn that Epidermis only or small depth of dermis

Heals in 3 to 5 days without treatment

Erythema

Not calculated for fluid resuscitation

(sunburn)

not counted when calculating total body surface area

A

Superficial

124
Q

is a treatment for poision

A

activated charcoal

syrup of ipecac no longer recommended

125
Q

with a blood transfusion, you will need large bore IV acess between _____-____ gauge

A

18-20 G needle

older Adult - no larger than 19

126
Q

4 clinical manifestions for Rhabdomyolysis

A

Dark tea colored urine
Hyperkalemia
Increase in creatinine
Decrease in GFR

127
Q

Assess for neurological disabilities by evaluating what 3 things

A

Client’s LOC
Pupil response
Spontaneous movements.

128
Q

in the Resuscitative Phase

H&H:
Na:
K:
WBC:
glucose: 
ABG's:
protein & albumin:
BUN:
A 
H&H: increased 
NA: decreased 
K:increased 
WBC:increased 
glucose: increased 
ABG: resp alk/ met. acidosis
protein & albumin: decreased
BUN: increased
129
Q

5 assesment findings that indicae a problem in the airway

A 
Drooling 
Inability to speak or swallow
LOC decreased 
Facial or head trauma 
Stridor
130
Q

how to measure with Fluid Resuscitation

A

weight in kg plus TBSA%

131
Q

is a surgical procedure used to treat full-thickness (third-degree) circumferential burns where incisions are made

A

Escharotomy

132
Q

–% or more require burn center

A

20%
facial burns
genetalia burns

133
Q

Results from a transfusion of contaminated blood products.

Findings include wheezing, dyspnea, chest tightness, cyanosis, hypotension, and shock.

A

bacterial blood transfusion reaction

134
Q

Findings include chills, increase of 10 F (0.50 C) or greater from the pretransfusion temperature, hypotension, and tachycardia.

are all signs of _____

A

febrile blood transfusion reaction

135
Q

if chest tube dislodges what 2 things need to be done

A

cover area with sterile dressing (vasoline etc)

notify HCP asap

136
Q

candidates for organ donation are screened for what 3 things

A

alcohol or tobacco use
history of non compliance
active malignancy or infection

critical care (6 decks)

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