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NSG 430 Exam 1 with correct answers
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NSG 430 Exam 1 with correct answers
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NSG 430 Exam 1 with correct answersPatient \stability \- \ANSWERS✔✔ \-mild \signs \of \deterioration: \mild \confusion, \tachypnea
-6-8 \hours \before \cardiac \or \respiratory \arrest
PCU \vs \ICU \- \ANSWERS✔✔ \-ICU \nursing \is \delivering \ICU \care \to \patients \wherever \they \may \be
-PCU \is \progressive \care \units \(intermediate \or \step \down) \that \provide \transition \between \ICU \and \
general \care \unit
>at \risk \for \serious \complications
Complexity \of \unstable \clients \- \ANSWERS✔✔ \#1: \physiologically \unstable
-critical \analysis \and \decision \making
#2: \risk \of \complications
-frequent \assess \and \treatments, \high \risk \of \delirium
#3: \IV \polypharmacy-titration
-vasoactive, \thrombolytics, \sedation, \insulin, \nutrition
#4: \advanced \tachnology/devices
-vents, \ICP, \svO2, \CCRT
#5 \psychosocial, \ethical \and \safety \concerns
Needs \of \caregivers \- \ANSWERS✔✔ \-information
-reassurance
-access
They \need \these \bc \without \them \they \feel \powerless \and \will \show \signs \of \this
Unstable \client \S/S \- \ANSWERS✔✔ \-↓ \Level \of \consciousness, \Anxiety, \Confusion, \Weakness, \
Restlessness
Feeling \of \impending \doom
,-Cool, \clammy \skin, \Pallor, \Cyanosis
-Dysrhythmias, \Tachycardia
-Hypotension, \Narrowed \pulse \pressure
-Rapid, \weak, \thready \pulses
-Tachypnea, \dyspnea, \or \shallow, \irregular \respirations
-↓ \O2 \saturation
-Temperature \dysregulation• \Chills
-Obvious \hemorrhage \or \injury, \Nausea \and \vomiting
Rapid \response \- \ANSWERS✔✔ \FUNCTIONS
-identification \and \activation \on \client \deterioration
-initiate \response \for \assessment, \intervention, \triage
-bedside \nurse \gives \SBAR!
FAILURE \TO \RECOGNIZE
-failure \to \recognize \changes, \diagnostics, \clinical \deviations \from \normal, \lack \of \nurse \intuition
TEAM
-respiratory \ventilates
-nursing \supervisor \is \general \support
-provider \is \hospitalist
-ICU \nurse \and \assigned \client \nruse
PROTOCOLS
-begin \tx \before \provider \arrives
-O2 \airway \management
-12 \EKG
-labs, \meds
-critical \thinking \in \action, \contact \the \provider \fast
Palliative \care \vs \hospice \- \ANSWERS✔✔ \PALLIATIVE
-*begins \during \RESTORATIVE \or \curative \health \care
, -indication: \diagnosis \of \a \life-limiting \illness
HOSPICE
-life \expectancy \is \6 \months \or \less
-requires \physician \certification \
END \OF \LIFE \CARE \GOALS
-when \death \is \imminent
-provide \comfort, \improve \quality \of \remaining \life, \ensure \dignified \death
End \of \life \- \ANSWERS✔✔ \MANIFESTATIONS
-decreased \metabolism, \body \function
-respiration \ceases \first, \heart \stops \beating \after \a \few \mins
-slow, \irregular \breathing, \cheyne-stokes \respirations
-inability \to \cough \or \clear \secretions \(death \rattle= \grunting, \gurgling, \congested \breathing)
-*hearing \is \the \last \sense \to \disappear
-decreased \sensation, \perception \of \pain \and \touch
-blurred \vision, \absent \blink \reflex, \patient \appears \to \stare, \eyelids \half \open
-decreased \taste \and \smell
-mottling \on \hands, \feet, \arms, \legs
-cold \and \clammy \skin
-cyanosis \of \nose, \nail \beds, \knees
-*waxlike \skin \when \very \near \death
-gradual \urinary \output \decrease, \incontinent \of \urine, \unable \to \urinate
-slowing \of \GI, \accumulation \of \gas, \distention \and \nausea
-loss \of \sphincter \control
-bowel \movement \may \occur \at \death
-trouble \holding \bosy \posture \and \alignment
-loss \of \facial \muscle \time: \sagging \jaw, \difficulty \speaking, \loss \of \gag \reflex, \swallowing \is \difficult
-increased \heart \rate, \then \later \slowing \and \weakend \pulse
-irregular \rhythm \of \heart, \decreased \BP, \delayed \absorption \of \IM \or \SQ \drugs
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