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NUR 2214 ( LATEST 2024 / 2025 ) EXAM 3 | COMPLETE ANSWERS 100% CORRECT
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NUR 2214 ( LATEST 2024 / 2025 ) EXAM 3 | COMPLETE ANSWERS 100% CORRECT
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NUR 2214 Exam 31. Body systems involved in has exchange
Answer
neurologic respiratory
cardiovascular
2. labs indicative of impaired gas exchange
Answer
ABG CBC
Sputum Exam Skin tests
Pathologic analysis
3. S/S of adequate ventilation
Answer
breathing is quiet and effortless sat 95-100
skin, nail beds, lips are appropriate color
thorax is symmetric with equal thoracic expansion bilaterally
spinous processes are in alignment;scapulae are bilaterally symmetric AP is less than transverse
trachea is midline breath sounds are clear
4. NI for increased ICP
Answer
elevate HOB to 30 degrees distribute care
,only suction when needed
hyperventilation (decreases perfusion, only short-term intervention) bowel management ( stool
softeners, laxatives)
5. assessment of increased ICP
Answer
sustained or equal to 20 s/s
headache decreased LOC N/V
CN 6 palsies (inability to turn the eye laterally outward) papilledema
periorbital bruising
late sign
cushings triad
hypertension, bradycardia, irregular breathing
6. Fibrinolytic therapy indications
Answer
after an acute ischemic stroke
4.5 hours after unless
Answer
, older than 80
anticoagulation less than or equal to 1.7 NIHSS > 25
Hx of diabetes and stroke
7. how to give fibrinolytic therapy
Answer
dosage based on weight perform double check of glucose
programmable pump, initial dose is 0.9mg/kg (max dose of 90mg) ocer 60 mins with 10% of dose
as a bolus over 1 min.
admit to critical care
perform neuro assessment and VS every 10-15 mins during infusion and every 30 mins after for
at least 6 hours, monitor hourly for 24 hours after- be consistent with BP device
if BP is over 180/105, administer anti-hypertensive do not place invasive tubes
discontinue if pt reports severe headache, hypertension, bleeding, N/V obtain follow-up CT,
before anticoag/platelet drugs
8. ataxia
Answer
lack of muscle control or coordination of voluntary movements, such as walking or picking up
objects
9. broca's area
Answer
in the frontal lobe
expressive (broca's or motor) aphasia
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