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NUR 1020C HESI Exam Study Guide
- Course
- NUR 1020C
- Institution
- Florida State College At Jacksonville
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ADVANCED CLINICAL CONCEPTS out constricting clothing; keep legs elevated (not Trendelen-burg because the weight of the lower organs restricts
· ARDS is an unexpected, catastrophic pulmonary complication breathing).
occurring in a person with no previous pulmonary problems.
The mortality rate is high (50%) · Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
· In ARDS, a common laboratory finding is lowered PO2. How- · Epinephrine: 1:10,000, or 5ml IV for severe
ever, these clients are not very responsive to high concentra-
tions of oxygen. · Volume expanding fluids are usually given to clients in
shock. However, if the shock is cardiogenic, pulmonary
· Think about the physiology of the lungs by remembering edema may result.
PEEP: Positive End Expiratory Pressure is the instillation and
maintenance of small amounts of air into the alveolar sacs to · Drugs of choice for shock
prevent them from collapsing each time the client exhales. - Digitalis preparations: Increase the contractility of the heart
The amount of pressure can be set with the ventilator and is muscle
usually around 5 to 10 cm of water. - Vasoconstrictors (Levophed, Dopamine): Generalized va-
sonconstriction to provide more available blood to the heart
· Suction only when secretions are present. to help maintain cardiac output.
· Before drawing arterial blood gases from the radial artery, per- · A common volume-expanding substance is plasma and pos-
form the Allen test to assess collateral circulation. Make the sibly whole blood.
client’s hand blanch by obliterating both the radial and ulnar
pulses. Then release the pressure over the ulnar artery only. · You are caring for a woman who was in severe automobile
If flow through the ulnar artery is good, flushing will be seen accident several days ago. She has several fractures and
immediately. The Allen test is then positive, and the radial internal injuries. The exploratory laparotomy was successful
artery can be used for puncture. If the Allen test is negative, in controlling the bleeding. However, today you find that this
repeat on the other arm. If this test is also negative, seek an - client is bleeding from her incision, short of breath, has a
other site for arterial puncture. The Allen test ensures collat- weak thready pulse, has cold and clammy skin, and hema-
eral circulation to the hand if thrombosis of the radial artery turia.
should follow the puncture. - What do you think is wrong with the client, and what would
you expect to do about it?
· If the client does not have O2 to his/her brain, the rest of the - These are typical signs and symptoms of DIC crisis. Expect
injuries do not matter because death will occur. However, to administer IV heparin to block the formation of thrombin
they must be removed from any source of imminent danger, (Coumadin does not do this). However, the client described
such as a fire. is already past the coagulation phase and into the hemor-
rhagic phase. Her management would be administration of
· PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. clotting factors along with palliative treatment of the symp-
toms as they arise. (Her prognosis is poor).
· A child in severe distress should be on 100% O2.
· NCLEX-RN questions on CPR often deal with prioritization
· Early signs of shock are agitation and restlessness resulting of actions. Question: What actions are required for each of
from cerebral hypoxia. the following situations?
- A 24-year old motorcycle accident victim with a ruptured
· If cardiogenic shock exists with the presence of pulmonary artery if the leg is pulseless and apneic.
edema, i.e., from pump failure, position client to REDUCE ve- - A 36-year old first time pregnant woman who arrests during
nous return (HIGH FOWLER’s with legs down) in order to de- labor.
crease venous return further to the left ventricle. - A 17-year old with no pulse or respirations who is trapped in
an overturned car, which is starting to catch fire.
· Severe shock leads to widespread cellular injury and impairs - A 40-year old businessman who arrests two days after a cer-
the integrity of the capillary membranes. Fluid and osmotic vical laminectomy.
proteins seep into the extra vascular spaces, further reducing
cardiac output. A vicious cycle of decreased perfusion to ALL
cellular level activities ensues. All organs are damaged, and if · WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)
perfusion problems exist, the damage can be permanent. - The American Heart Association recommends that those
with known angina pectoris seek emergency medical care if
· All vasopressors/vasodilator drugs are potent and dangerous chest pain is NOT relieved by three nitroglycerin tablets 5
and require weaning on and off. Do not change infusion rates minutes apart over a 150minute period.
simultaneously.
- A person with previously unrecognized coronary disease ex-
periencing chest pain persisting for 2 minutes or longer
· A client is brought into the hospital suffering shock symptoms
should seek emergency medical treatment.
as a result of a bee sting. What is the first priority? Maintain-
ing an open airway (the allergic reaction damages the lining of
the airways causing edema). Also, keep the client warm with-
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,· It is important for the nurse to stay current with the American ally used in conjunction with the BUN test and they normally
Heart Association’s guidelines for Basic Life Support (BLS) by are in a 1:20 ratio.
being certified every two years as required. - Serum osmolality measures the concentration of particles in
a solution. It refers to the fact that the same amount of
· If one rescuer is performing CPR, 1 15:2 ratio of compression solute is present, but the amount of solvent (fluid) is de-
to ventilations is performed for 4 cycles, then reassess for creased. Therefore, the blood can be considered “more
breathing and pulse. If two rescuers are performing CPR, a concentrated.”
15:2 ratio is now recommended for compressions to ventila- - Urine osmolality and specific gravity increase.
tions. Perform for 15 cycles with a 100/min compression rate.
When trading off, start with compressions. · Check the IV tubing container to determine the drip factor
because drip factors vary. The most common drip factors
· Initiate CPR with BLS guidelines immediately, then move on to are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60
Advanced Cardiac Life Support (ACLS) guidelines. drops per milliliter.
· When significant arterial acidosis is noted, try to reduce PCO2 · Flushing a saline lock requires approximately 1 ½ times the
by increasing ventilation, which will correct arterial, venous, amount of fluid that the tubing will hold in order to efficiently
and tissue acidosis. Bicarbonate may exacerbate acidosis b flush the tubing. REMEMBER to use sterile technique to
producing CO2. Thus, the ACLS guidelines have recom- prevent complications such as infiltration, emboli and infec-
mended bicarbonate NOT be used unless hyperkalemia tion.
and/or preexisting acidosis is documented.
· A pH of less than 6.8 or more than 7.8 is NOT COMPATI-
· Infants/prematures may have problems with the following that BLE WITH LIFE.
can predispose to arrest: Beware of the “H’s” – hypoxia, hy-
poglycemia, hypothermia, increased H+ (metabolic and/or res- · The acronym ROME can help you remember: Respiratory,
piratory acidosis), hypercoagulability (if polycythemia exists). Opposite, Metabolic, Equal.
· Changes is osmolarity cause shifts in fluid. The osmolarity of · Review the order of blood flow to the heart:
the extracellular fluid (ECF) is almost entriely due to sodium. - Unoxygenated blood flows from the superior and infe-
The osmolarity of intracellular fluid (ICF) is related to many rior vena cava into the right atrium, then to the right
particles, with potassium being the primary electrolyte. The ventricle. It flows out of the heart through the pul-
pressures in the ECF and the ICF are almost identical. If ei- monary artery, to the lungs for oxygenation. The pul-
ther ECF or ICF change in concentration, fluid shifts from the monary vein delivers oxygenated blood back to the left
area of lesser concentration to the area of greater concentra- atrium, then to the left ventricle (largest, strongest
tion. chamber) and out the aorta.
- Review the three structures that control the one-way
· Dextrose 10% is a hypertonic solution and should be adminis- flow of blood through the heart:
tered IV. 1. Valves Atrioventricular valves Tricuspid (right side)
Mitral (left side)
· Normal saline is an isotonic solution and is used for irrigations, Semilunar valves Pulmonary (in pulmonary
such as bladder irrigations or IV flush lines with intermittent IV artery) Aortic (in aorta)
medication. 2. Cordae Tendinae
3. Papillary muscles
· Use only isotonic (neutral) solutions in irrigations, infusions,
etc., unless the specific aim is to shift fluid into intracellular or · Since the T waves represents repolarization of the ventricle,
extracellular spaces. this is a critical time in the heartbeat. This action represents
a resting and regrouping stage so that the next heartbeat
· Potassium imbalances are potentially life-threatening, must be can occur. If defibrillation occurs during this phase, the
corrected immediately. A low magnesium often accompanies heart can be thrust into a life-threatening dysrhythmia.
a low K+, especially with the use of diuretics.
· Observe the client for tolerance of the current rhythm. This
· Fluid Volume Deficit: Dehydration information is the most important data the nurse can collect
- Elevated BUN: The BUN measures the amount of urea nitro- on the client with an arrythmia.
gen in the blood. Urea is formed in the liver as the end prod-
uct of protein metabolism. The BUN is directly related to the · REMEMBER to monitor the client as well as the machine! If
metabolic function of the liver and the excretory function of the the EKG monitor shows a severe dysrhythmia, but the client
kidneys. is sitting up quietly watching a TV without any sign of dis-
- Creatinine, as with BUN, is excreted entirely by the kidneys tress, assess to determine if the leads are attached properly.
and is therefore directly proportional to renal excretory func-
tion. However, unlike BUN, the creatinine level is affected · Marking the operative site is required for procedures involv-
very little by dehydration, malnutrition, or hepatic function. ing right/left distinctions, multiple structures (fingers, toes), or
The daily production of creatinine depends on muscle levels (spinal procedures). Site marking should be done
mass, which fluctuates very little. Therefore, it is a better with the involvement of the client.
test of renal function than is the BUN. Creatinine is gener-
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, · Wound dehiscence is separation of the wound edges and is - Interpersonal skills
more likely to occur with vertical incisions. It usually occurs - Physical care: altering positions, touch, hot and cold applica-
after the early postoperative period, when the client’s own tions.
granulation tissue is “taking over” the wound, after absorption
of the sutures has begun. Evisceration of the wound is protru- · Narcotic analgesics are prepared for pain relief because
sion of intestinal contents (in an abdominal wound) and is they bind to the various opiate receptor sites in the CNS.
more likely in clients who are older, diabetic, obese, or mal- Morphine is often the preferred narcotic (REMEMBER: it
nourished and have prolonged paralytic ileus. causes respiratory depression).
· NCLEX-RN items will focus on the nurse’s role in terms of the · Other agonists are meperidine and methadone. Narcotic
entire perioperative process. Sample: A 43-year old mother of antagonists block the attachment of narcotics to the recep-
2 teenage daughters enters the hospital to have her gallblad- tors, such as Narcan (naloxone). Once Narcan has been
der removed in a same-day surgery using a scope instead of given, additional narcotics cannot be given until the Narcan
an incision. What nursing needs will dominate each phase of effects have passed.
her short hospital stay?
- Preparation phase: Education about postoperative care, NPO, · Do not take away the coping style used in a crisis state…
assist with meeting family needs. DENIAL. It is a useful and needed tool at the initial stage for
- Operative phase: Assessment, management of the operative some. Support, do not challenge, unless it hinders/blocks
suite. treatment – endangering the patient.
- Post-anesthesia phase: Pain management, post-anesthesia
precautions. MEDICAL –SURGICAL NURSING
- Post-operative phase: Prevent and assess for complications,
pain management, dietary restrictions, activity. RESPIRATORY SYSTEM
· HIV clients with tuberculosis require respiratory isolation. Tu- · Fever can cause dehydration from excessive fluid loss in di-
berculosis is the only real risk to non-pregnant caregivers that aphoresis. Increased temperature also increases metabo-
is not related to a break in universal precautions (i.e., needle lism and the demand for oxygen.
sticks, etc.).
· High risk for pneumonia:
· STANDARD PRECAUTIONS: - Any person, who has altered level of consciousness, has de-
- Wash hands, even if gloves have been worn to give care pressed or absent gag reflex and cough reflexes, is suscep-
- Wear gloves (latex) for touching blood or body fluids, or any tible to aspirating oropharyngeal secretions. (Alcoholics,
non-intact body surface. anesthesized individuals, those with brain injury, drug over-
- Wear gowns during any procedure that might generate dose, or stroke victims).
splashes (changing clients with diarrhea). - When feeding, raise the head of the bed and position the
- Use masks and eye protection during activity which might dis- client on side – not on back.
perse droplets (suctioning).
- Do not recap needles, dispose of in puncture-resistant con- · Bronchial breath sounds are heard over areas of density or
tainers. consolidation. Sound waves are easily transmitted over con-
- Use mouth piece for resuscitation efforts. solidated tissue.
- Refrain from giving care if you have open skin lesions.
· Hydration – enables liquification of mucous trapped in the
· Caregivers who are pregnant may choose not to care for a bronchioles and alveoli, facilitating expectoration. Essential
client with Cytomegalovirus (CMV). for the client experiencing fever. Important because 300 to
400 ml of fluid are lost daily by the lungs through evapora-
· Pediatric HIV is often evidenced by lymphoid interstitial pneu- tion.
monitis.
· Irritability and restlessness are early signs of cerebral hy-
· The focus of NCLEX-RN questions is likely to be assessment poxia – the client is not getting enough oxygen to the brain.
of early signs of the disease and management of complica-
tions associated with HIV. · Pneumonia preventatives:
- Elderly: flu shots; pneumonia immunizations; avoiding
· For narcotic induced respiratory depression, administer Nalox- sources of infection and indoor pollutants (dust, smoke, and
one 0.1mg to 0.4mg IV every 2-3 minutes as needed, until aerosols); do not smoke.
1.0mg is achieved. - Immunosuppressed and debilitated persons: infection avoid-
ance, sensible nutrition, adequate intake, balance of rest
· Use non-invasive methods for pain management when possi- and activity.
ble: - Comatose and immobile persons: elevate head of bed to
- Relaxation techniques feed; turn frequently.
- Distraction
- Imagery
- Biofeedback
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