Fnd Know of NUR Week 4

True or false: In face of violence, the number 1 priority is keeping yourself and others safe

• true

• false

True or False: Nurses who just follow orders are unsafe

• true

• false

Answer explanation

Need to think like a nurse and use clinical judgment!
- “Is this medication safe for me to give?”

Organize these options into the right breathing abnormalities

Groups:

(a) rhonchi

,

(b) Crackles

,

(c) Wheezing

• a clinical red flag when acute

• clinical red flag when acute

• clinical red flag when acutee

• i.e. COPD

• caused by fluid in the small air sacs (alveoli) of the lungs (bases)

• clears with a cough

• primarily expiratory, but can be inspiratory too

• i.e asthma

• low pitched, loud, coarse, snoring/gurgling tone

• caused by secretions in larger airways

• caused by narrowing of small airways

• high-pitched, muscial sound similar to a squeak

• i.e pneumonia

• does not clear with a cough

• may be defined as "coarse" or "fine"

If the chest pain worsens on inspiration, then it's likely

• respiratory

• muscular

If the chest pain worsens with palpation, then it's likely

• respiratory

• muscular

true or false: Side rails up x 4 is a form of restraint

• true

• false

Possible signs of a Myocardial Infarction (MI) 🚩?

• heavy, tight pressure in the anterior chest (women may have atypical pain (ex. back))

• pain that radiates to jaw, neck, back, arm, shoulder

• Shortness of breath and diaphoresis

• Anxiousness/restlessness

• pale, cool skin

signs of compensation includes

• Tachypnea

• Tachycardia

• Hypoxia

• Hypotension

signs of decompensation includes

• Tachypnea

• Tachycardia

• Hypoxia

• Hypotension

Joan is a healthy 62-year-old woman who was admitted to the hospital for cholecystitis and recently returned from the operating room having undergone a routine laparoscopic cholecystectomy,

After arrival to the med/surg floor her VS are listed below. Which vital sign is the most concerning?

• T: 99.5 (oral)

• P: 90

• R: 24
  

• BP: 135/84
  

• O2 sat: 95% room air

Answer explanation

earliest sign of compensation- tachypnea