Most correct statement describing Primary Survey?
ABCDE; Vital Signs; Clients status
Health History; Systematic examination
Clients Status; ABCDE; Health History
ABCDE; Vitals
Which Accronym represents the nursing process
A D P I E : Assess . Diagnosis . Plan . Implement . Evaluate
A S P A R : Assess . Survey . Plan . Action . Reflect
A D P I D : Assess . Diagnosis . Prepare . Implement . Document
A S P A E : Assess . Survey . Plan . Action . Evaluate
Which type of data collection is the following; The patient expressed feelings of being dizzy, confused of surroundings, and unable to follow direction
Objective
Subjective
Which of the following are NOT involved in Post Op Assessments
General Appearance and status
Allergy Status
Other Medications
Specific Obs for procedure
Which of the following is expected to be seen in the intermediate post-op period between 24 - 72 hours?
shock
Acute Confusion State
Nausea/vommiting
Which of the following is not a general vital sign included in routine observations
BP
SpO2
Pulse Rate
Respiratory Rate
Pain
LOC
Which type of fluids are Isotonic, Hypotonic, and Hypertonic solutions?
Colloid
Crystalloid
Normal Saline like Hartmans and Rigers lactate are which of the following crystalloid fuids?
Isotonic
Hypotonic
Hypertonic
Which CVADS are inserted into the jugular or sub-clavian and have a 1-2 week life?
Large Bore Catheters (eg. Vascath, Gamcath, Permacath, Hickmans)
Smaller Bore Central Lines (eg. Groschung, Arrow)
Implantable devices (eg. Powerpoint, passport, port-a-acath, Infuse-a-port, medi-port)
PQRST is used for which of the following
Pain assessment tool
Segments on an ECG
Both are correct but used differently
How is the Wong - Baker face pain assessment tool not used
Observing patients expressions
Getting patients to rate their pain 1 - 10
Using general survey techniques to assess pain across the body
Which is not the most correct statement in relation to neurovascular assessments
Peripheral circulation and general colour
Pulse rate, rhythm and volume
Peripheral pulses
DVT
A diagnostic tool using ultrasound that creates pictures of heart chambers and vessels to test their functioning is which of the following
Electrocradiogram
Echocardiogram
Acute Coronary Syndrome involves all of the following except
Chronic Stable Angina
Unstable Angina
Non-STEMI
STEMI
Coronary Heart Disease is caused by all except which of the following
impaired blood flow to myocardium
atherosclerotic plague
thrombus or vessel spasm
reduced systemic circulation
Which is incorrect about Angina
Usually Chronic
Cause of sudden death
occurs by increase in physical exertion
pain can occur unpredictably
Which of the following are the types of Angina?
Stable, Variant & Unstable
Stable & Variant
Stable & Prinzmetals
Stable & Unstable
Which of the following is the incorrect statement about Acute Cardiac Ischaemia
Non-STEMI > no elevated markers of myocardial necrosis > unstable angina
Non-STEMI > elevated markers of myocardial necrosis > MI
STEMI > elevated markers of mycardial necrosis > MI
STEMI > no elevated markers of myocardial necrosis > Unstable angina
Which of the following is not a sign or symptom of an MI?
Nausea/vomitting
sense of impending doom
Diaphoresis
All are correct
An angio-cath is iserted into an artery in the arm, groin or neck and threaded into the coronary arteries. The client is given IV radio-opaque medium. X-rays are taken while the medium flows through the coronary arteries. What am I?
Coronary Angiogram
Electrocardiogram
Angioplasty and Stenting
What is the purpose of a Coronary Angioggram?
Allows pictures of the heart chambers and vessels to be captured, and any thrombus locations identified or where stents may be required
Provides direct vision inside coronary vessels and allows for removal of thrombus of placement of stents
which assessments are not used in a client with chest pain?
vital signs and manual BP
PQRST pain assessment
Rapid top-to-toe assessment (appearance, colour etc)
Sit in high fowlers to increase lung capacity
Priorities for care with client with chest pain is
reduce 02 demand and increase perfusion of the myocardium
reduce the pain using GTN
Goals of care for the client with MI
Reduce pain
minimise damage
maintain cardiovascular stability
decrease cardiac workload
MI requires rapid assessment and early intervention. Which of the following assessments would you routinely undertake in an acute MI patient?
vital signs, O2 sats, pain assessment
ECG and continuous monitoring
Diet, nutrition and exercise education
Blood tests / cardiac enzymes
From aspirated objects, tumour/growths or spasm, excessive local inflammation or a fractured thyroid or cricoid cartilage from trauma. What am I?
Laryngeal obstruction
Nasal obstruction
Epistaxis
An obstructed larynx or upper airway can result in asphyxiation and is a medical emergency
True
False
Which of the following is not an example of acute upper respiratory infections
Rhinitis, sinusitis
Respiratory Syncytial Virus (common in kids and affect lower resp tract in infants)
Pertussis
Tonsillitis and Laryngitis (incl, epiglottis)
Bronchitis
Influenza A, B & C (A most common)
A client would have a permanent tracheostomy following a partial or complete laryngectomy
In a respiratory assessment which of the following is incorrect?
Obtain specimen
Note cough, cough effectiveness and if productive
peak flow/spirometry
vitals and physical assessment
Which of the following is not a diagnostic test for respiratory conditions
Pulse oximetry; Aminocentesis
Arterial blood gasses; FBC; Electrolytes; Co-ag studies
sputum specimen; throat swab (if upper tract)
Chest X-ray; Pulmonary angiogram
Bronchoscopy; Lung biopsy
What would the following medications be used for; Heparin, Clexane, Warfarin
Anticoagulant therapy for PE
Anti fungal agents for fungal infections
Antibiotics
corticosteroids and bronchodilators
decongestants and mild analgesics
antihistamines
What are other treatments used in respiratory conditions?
Oxygen therapy
Chemotherapy and/or radiation
Thoracotomy
Plerodesis
Peak-flow rate
What is not involved in nursing care of a respiratory patient
Respiratory/droplet precautions
Oral and skin care
spacer education
showing them the smokers section of the hospital
Effective coughing exercises; client positioning - high fowlers/semi; and support and resources for lifestyle choices are which of the following?
Providing education on activities to support respiratory function
Expected routine assessments carried out daily
Which COPD is the following; inflamed lungs , windpipe ad passageways from severe irritation or infection?
Emphysema
Which COPD is this? gradual destruction of the alveoli resulting in shortness of breath, and difficulty to breathe
which of the following does not effect ventilation
pleura disorders
infections and inflammation
pnumothorax
emphysema
which is true regarding gas exchange?
reactive airway disease and obstructive disorders
pulmonary vascular disorders
Acute Respiratory distress
broken nose
What am I; > commonly caused by bacteria > most common in females, elderly, diabetes patients, and those who are immunosuppresed > Can lead to kidney damage and renal failure
UTI
Dehydration
electrolyte imbalance
Hyperglycaemia
