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Page | Nurse plans to administer a dose of metoprolol at 0900 to a client with IITN. At 0800 nurse notestelemetry pattern shows second degree heart block with Ventricular rate of SO. Action Hold scheduled dose and notify HCP of telemetry pattern Nurse is reviewing client ECG and determines PR interval prolonged. Indicates Increased conduction time from the SA node to the AVjunction When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on right side only. Action Reposition the depth of the ET tube Nurse called to a train derailment likely caused by terrorist bomb. Triage in order Middle-aged man wandering around Woman sitting on ground with blanket Crying child held by another passenger Mother and father just arrived on scene Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaQ2 60, PaCO2 62, HCO3 35.Which needs immediate communication to HCP Drowsiness and diff in arousing Assess a 78 year old with L sided HF. Symptoms Dyspnea, cough, fatigue Caring for a burn patient with serum potassium of 4. Question which medication Potassium Patient admitted with deep 2° degree burns of thighs, chest and arms covering 40% BSA. Fluid shift after burn so nurse expects Decreased cardiac output Patient bedridden for 2 wks with following lab values: pI1 7.37, PO2 90, PCO2 40, HCO3 25, hypoalbuminemia and hypocalcemia. Priority action Turn patient side to side q2h Which age group should nurse assess first 40 year old with sickle cell crisis There has been a major disaster. Triage nurse should give which patient priority Cut over eye Move which patient to medical surgical unit Patient with ABNL liver levels One open bed in ICU but reserved Lor patient coming lrom PACU with respiratory problems, what to do Take patient to ICU and arrange for respivatory patient to stay in PACU Carotid picture Point to neck Someone with wound vac how to make sure it is effective Check seal to make sure no leaks Magnesium antidote Calcium gluconate Patient having trouble swallowing when wife gives drink of water Assess gag reflex OR may have been thickening answer-there were two alike Chest tube becomes disconnected Get new saline bottle to stick end into until reconnect tube Patient in ventricular fibrillation Defih shock once Know calcium levels....there was a question with calcium 5.0 and the answer was patient with hyperthyroidism taking inderal (propanalol) Chest tube volume 125 Mark container between 100 and 150 Heart sounds audio SIS2 Patient on benzos Answer is not narcan eads Abdominal rigidity 4 patients-which one more concern Low Hgb level 4 patients with conditions of concern-priority Make sure patient has units of blood available Patient on Heparin going for surgery in a.m.,-priorily Assess patient for bleeds Patient with fever of 101-best nursing Dx r/t temperature elevation Listening and hearing silence, then kortokoff sound what to do follow through by checking BP Patient with pancreatitis and elevated liver function-what expect of patient patient drinks alcohol daily or lots/wk (alcohol related answer for sure) Page 2 Page 4 Cardiac enzymes that you need to know how ollen to assess aller initial CVA Troponin (1 hour), CKMB (2-4 hrs), Myoglobin (1-4 hrs), LDH1 (12-24 hrs) MI treatment Morphine, oxygen, nitro, ASA (NO digoxin, betablockers or atropine for these patients) Ventilators Make sure the alarms are on (Check every 4 hours minimum), when suctioning give 100% O2 before and after and make no more than 3 passes-no longer than 15 seconds Have to put in order of consideration to be delivered Nasal cannula, simple face mask, nonrebreather mask, partial rebreather mask, venturi mask Early signs of cerebral hypoxia Restlessness and irritability Necessary for Blood Product infusions 18-19 gauge needle with filter tubing NS only run with blood within 30 minutes of hanging Check vitals before infusing, at 15 minutes, 30 minutes, then every hour, and directly after Checking blood before infusing 2 RNs Check order (expiration date, clots, color, air bubbles, leaks) patient, product, previous transfusion Hx Premedicate with Benadryl for previous rxn What does the PR interval represent Time required for the impulse to travel from atria through the AV node Isotonic solutions DSW NS Lactated ringers Tracheostomy Keep Kelly clamp and obturator at the bedside To assess CVA [or hemorrhagic or ischemic CT sean first Heart conditions related to thrombus formation A-fib and A-flutter Aphasia, agraphia, slow, cautious, anxious, memory ok Left hemisphere lesion Cannot recognize faces, loss of depth perception, impulsive behavior, poor judgement, constant smile,loss of tonal hearing Right hemisphere lesion Page 5 Most important indicator of increased ICP Change in LOC Spinal shock Complete loss of all reflexes If the U wave is most prominent what condition hypokalemia Bums First degree- epidermis {superficial} Second degree- epidermis and dermis {deep partial} Third degree- epidermis, dermis, and subQ {full thickness} Pic of patient and description of burns, need to decide what % burned. [Rule of 9s- head and neck=9%, UE=9% each, LE=18% each, front trunk=18%, back trunk=18%] 5 Ps of neurovascular status (important with fractures) Pain, pallor, pulse, paresthesia, paralysis S/S of shock Increased pulse and decreased BP S/S of ICP Decreased pulse and increased BP with changes in LOC Suspected Post op bleeding if assess Frequent swallowing, vomiting blood, clearing of throat Primary medications given in ED for respiratory distress Bronchodilators [Sus-phrine (Epinephrine HCD and Theophylline (Theo-dur)] ABG normals for the following: pH, pCO2, HCO3 PH: 7.35-7.45, pCO2: 34-45 mmHg, HCO3: 22-26 mEq/L Calculation of the heart rate using an EKG rhythm strip count the number of R-R intervals in the 30 large squares and multiply by 10 Intracranial hypertension from a traumatic brain injury is admitted to the trauma unit Elevated head of bed CPR-Arrange in other of priority Establish unresponsiveness Call for help Assess patent airway Assess pt carotid pulses Endometrial carcinoma receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator Wear a dosimeter film badge when in the client’s room Page 7 Patient with wrist restraints the nurse first slides two lingers under the restraints and then notes that the lies are secured to the side rail using a quick-release tic Reposition the restraints ties, securing them to the bed frame sepsis and has a single-lumen, peripherally-inserted central bed for 9:00 a.m.and the nurse is running behind schedule Nursing home patient admitted with uring catheter (PICC). Four medications are pres (Zosyn) over 30 minutes g8 hours first During a family baseball game, an adult male is hot on the head with a bat, and he is suspected of sustaining an epidural bleed “Was your husband knocked out by the blow” CPR for a pregnant lady Heimlich w/ chest compression “{IESI HINT: At 20wks gestation & beyond, the gravid uterus should be shifted to the left by placing the women in a 15-30 degree angled, lefi lateral position or by using a wedge under her right side to tlt her to her left Patient has received 250 ml of 0.9% normal saline through the IV line in the last hour and is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. Decrease the saline to keep-open rate InEKG reading which complex represents depolarization of the ventricles ORS complex The risk for metabolic shock syndrome Toxic Shock Syndrome 23 year-old male brought to the ER by a group of fraternity brothers after a hazing event at the university. Blood alcohol level (BAL) of 3.8 and a Glasgow Coma Scale of 3 Initiate IV access using Lactated Ringer’s solution 1000m1 with thiamine 100mg The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane A yellow disaster tag means critical injuries and require immediate intervention Electrical burn pt put him ina cardiac telemetry monitor A pt ona trachea/endotrach with gurgling sound always pick suctioning Metabolic syndrome high cholesterol & high BP (cardiac strip) IV Line Flush line before and after compatible IV solution Priority pt Ruptured spleen life threatening Page 8 Endotrach has slipped into right main bronchus of no breath sounds are heard (Audio/Visual) Pleaurvac, know how to set vac at 850 39 to 48 Glucose Notify healthcare provider of client’s status Disseminated intravascular coagulation (DIC) best test to diagnose, D-Dimer Septic shock-best class of medicine to give are Anti infectives A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in hiseye Have the parent take the child for emergency help Patient admitted two hours ago with confusion, Kussmaul respirations, and warm, flushed skin. The healthcare provider determines the client is in acute renal failure (ARF) Hourly neurological assessments 14-year-old male arrives al the ER in status epilepticus. He was diagnosed with a seizure disorder in childhood Acute withdrawal from anticonvulsant medication Most important symptom the nurse should monitor the client for while assisting with the insertion of'a subclavian central venous catheter Shortness of breath Patient with Hx of chronic atrial fibrillation Be sure to take the prescribed daily aspirin Most important for the nurse to use an IV pump and/or Buretrol when initiating IV therapy after which surgical procedure Craniotomy Acute renal failure with a serum potassium of 7.5mEq/L. based on this finding Administer a retention enema of Kayexalate A client admitted to the hospital is suspected of having meningitis Lumbar puncture infant admitted to the NICU is tachypncic, tachycardic, and has bounding brachial pulses Monitor for congestive heart failure Feedings for low albumin Nepro, Ensure or TPN if pt is NPO BNP 500, prescribed diuretic indicates ITF Ventilator-ET to check placement listen to breath sounds Anaphylactic-bracelet patient should wear bracelet stating he is allergic to certain medication Shock hemorrhagic give isotonic 0.9% NS or LR Heat stroke increase IV fluids to 200ml/hr, apply cool packs to persons body CPR-absent lung sounds ventilate with twa mouth to mouth breaths over I second and make the chest rise then palpate for pulse, if no pulse do CPR Myxedema coma S&S. hypothermia, bradycardia, hypotension, res. Acidosis. Happens when patient suddenly stops taking thyroid med. Give thyroid replacement meds, Airway must be kept open Burn airway, administer LR, premedicate with sulfamylon CVA -— Anosognosia lack of awareness or a denial of a neurological defect paralysis Patient in cardiac arrest and monitor shows pulseless VT Defibrillation with 200 to 360 joules Determine the following acid-base disorders pH 7.50, pCQ2 30, HCO3 26 =respiratory alkalosis pit 7.30, pCO2 42, ICO3 20 = metabolic acidosis pH 7.48, pCO2 42, HCO3 32 = metabolic alkalosis PH 7.29, pCO2 55, HCO3 26 = respiratory acidosis Identily the waveforms found ina normal EKG P wave, ORS complex, T wave, ST segment, PR interval 
