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NUR356 Exam With Complete Solution
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NUR356 Exam With Complete Solution 2024-2025Standard 8: Recognising and responding to Clinical Deterioration in Acute Health.
-Answer -Identify deteriorating respiratory, cardiovascular, and neurological
Assigns a score to measure routine vital signs.
A higher score reflects a higher risk of deterioration and death.
The purpose of these charts is to assist timely recognition of clinical deterioration.
Advanced life support (ALS) -Answer- uniform method for treating cardiac arrest
-
• Analyses the rhythm by the nurse and decide whether it is a shockable rhythm, such as
VF or pulseless VT, or to continue with CPR if it is Asystole or PE
ALS Drugs - Answer Adrenaline: Shockable and Non-Shockable
-1mg bolus (10ml of 1:10,000) or (1ml 1:1000)
• Vasoconstriction results in an increased coronary and cerebral perfusion
• Increases coronary and cerebral blood flow
Amiodarone: Shockable Only
-300mg bolus diluted in 20ml of 5% dextrose
• Anti-arrhythmic
• Prolongs the action potential and refractory period in atrial and myocardium
• AV conduction is slowed
Shockable - Answer Ventricular Fibrillation (VF) & Ventricular Tachycardia (VT)
,Non-Shockable - Answer -Asystole
-Pulseless Electrical Activity (PEA
4 Hs and 4 T's - Answer -Hypoxia
-Hypovolaemia
-Hypokalaemia
-Hypothermia
-Tension pneumothorax
-Tamponade
-Toxins
-Thrombosis
Post resus care - Answer -Re-evaluate A-E
-12 lead ecg
-Treat precipitating cause
-Aim for Sp02 94-98%
-Targeted temperature management
Endotracheal Tube (ETT) - Answer Indications:
• Upper airway obstruction
• Apnea
• High-risk aspirations
Equipment:
• Suction
• Laryngoscope
, • Cuffed ETT tube
• Lubricant
Nursing care of an intubated patient - Answer • Observant of the physical signs of the
patient
• Observe Tidal volume and pressure.
• Gas exchange
• Lung auscultation every 2-4hrs for presence of secretions
• Maintain humidification
• To monitor vital signs
Oral hygiene every 2hrs (Prevent VAP
Central Line Catheter CVC - Answer Benefits:
• Immediately accessed to the central venous system
• Less requirement for venepuncture • Continuous and quick delivery of medications and
fluids may be possible
Risks:
• Potential for systemic infection • Invasive nature of the procedure
positive end-expiratory pressure (PEEP) - Answer -It is the the positive pressure that will
remain in the airways at the end of the respiratory cycle through the use of a peep valve
causing resistant/pressure in the lungs which causing lungs not to fully deflate.
Anaphylaxis - Answer -mass release of histamine
-affects two or more system= adrenaline
What are signs of Anaphylaxis? - Answer - Upper respiratory- swelling lips, hoarse voice
(adrenaline)
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