NUR 333 Final Exam Blueprint PDF

NUR 333 Final Exam Study Outline The final exam will consist of 75 questions and will be worth 15 points. You will have 120 minutes to complete it. The questions may be in various formats, including multiple-choice, fill-in-the-blank, multiple-answer, and alternate-style Next Generation NCLEX quest...

NUR 333 Final Exam Study Outline The final exam will consist of 75 questions and will be worth 15 points. You will have 120 minutes to complete it. The questions may be in various formats, including multiple-choice, fill-in-the-blank, multiple-answer, and alternate-style Next Generation NCLEX questions. This will be a comprehensive exam with questions on specific learning outcomes for each experience (see below) Medication Math- 10 questions You will have 10 questions on medication math. Questions could include all types of medication math including (but not limited to) infusion rates, IV push volume calculations, weight-based medication calculations, drug concentration identification, oral medication dosage calculation, and others. Experience 1: 10 questions + Demonstrate proper application and removal of various types of restraints, while explaining the appropriate circumstances for their use and the ethical considerations involved, as outlined in the ANA position statement. (2 questions) Restraints should only be used as a last resort, when less restrictive alternatives have failed, and for the shortest duration possible to prevent harm to the patient or others ○ sedation over restraints; reduce risk for harm and create a safe environment ○ Reduce pt restraints: collab with healthcare team to implement alt measures ex) electronic remote observation for 1:1 continuous pt obs + restraint rounds ○ Violence Prevention: recognize, assess, report, prevent incidents of potential violence De-Escalate and edu techniques Usage of badge alarms ○ Ethical Considerations Pt and family education Must have an order, inform pt and obtain consent Provider must see pt face to face within 1 hrs; 1:1 supervision is required Interprofessional education Address complaints by pts who are restrained Ongoing review of best practices for pt injury prevention Use a quick release knot on an immovable part of bed (not side rail) Check for skin breakdown Q2hrs Document: usage, duration, pt response Secure restraints to the bed frame (not side rails) to avoid patient injury, using a quick-release knot that can be easily undone in emergencies. Check circulation by ensuring at least two fingers can fit between the restraint and the patient’s skin.  NUR 333 Final Exam Study Outline + Demonstrate proficiency in implementing and documenting a comprehensive care plan for restrained patients, including de-escalation techniques, skin integrity assessments, and frequent monitoring, while critically evaluating potential safety hazards. (2 questions) Initial Assessment ○ Understand the reason for restraint use ○ Assess the patient’s current condition (e.g., agitation, confusion, risk of self-harm, or harm to others). ○ Review the patient’s medical history, noting any conditions that might increase the risk of complications from restraints (e.g., diabetes, dementia, skin fragility). ○ Identify alternative measures attempted prior to restraint (e.g., verbal de-escalation, redirection, medications). De-escalation Techniques ○ Reduce agitation and prevent the need for restraint or facilitate early removal. ○ Use calm, non-threatening communication to build rapport and help the patient feel safe. Offer choices or involve the patient in decision-making to reduce feelings of powerlessness. Reorient the patient by explaining the situation and why restraint is necessary. Create a calming environment (e.g., reduce noise, dim lights, remove stimuli that could increase agitation). ○ Note any triggers that worsen the patient’s agitation or distress. Care Plan for Physical Restraint Application ○ Choose the least restrictive restraint appropriate for the situation (e.g., soft wrist restraints rather than four-point restraints). ○ Apply restraints to the bed frame, ensuring a quick-release mechanism is used. Avoid side rails to prevent injury. ○ Allow for two fingers’ space between the restraint and the patient’s skin to prevent circulation issues. Skin Integrity Assessment ○ Prevent pressure ulcers, bruising, and other skin complications from restraints. ○ Inspect the skin at restraint points (e.g., wrists, ankles) for signs of redness, bruising, or pressure sores. ○ Provide padding at restraint contact points to reduce friction and pressure. ○ Reposition the patient regularly (every 2 hours or per institutional policy) to prevent pressure injuries. ROM ○ Assess Q 15 Min; document Q 15 min: patient’s behavior and physical condition Document start and stop times, reasons for restraints, plan of care, assessment (check skin breakdown) Frequent Monitoring and Reassessment ○ Monitor the patient every 15-30 minutes, checking vital signs, mental status, circulation, and comfort level. ○ Assess for early signs of distress, such as difficulty breathing, changes in mental status, or indications of pain. ○ Remove restraints at least every 2 hours (or more frequently if possible) to assess range of motion and the continued need for restraints.  NUR 333 Final Exam Study Outline ○ Document the results of range-of-motion exercises and other care activities provided during restraint-free periods. ○ Include notes on any psychological effects observed, such as anxiety or depression. Safety Hazard Evaluation. ○ Ensure restraint ties do not create a risk of strangulation, and that restraints do not limit access to emergency equipment (e.g., IV lines, catheters). ○ Remove any objects near the patient that could cause injury if the patient becomes agitated (e.g., sharp objects, medical devices). ○ Adjust the patient’s environment to ensure comfort and minimize distress (e.g., access to call light, water, or personal items within reach). ○ Monitor for the development of restraint-related complications, such as asphyxiation, falls, or emotional trauma. Plan for Restraint Removal ○ Safely discontinue restraints as soon as possible. ○ Reassess the patient’s behavior and condition frequently to determine if restraints are still necessary. ○ Gradually loosen or remove restraints while monitoring the patient’s response. ○ Implement non-restraint strategies (e.g., increased supervision, medication adjustments, or physical therapy) to maintain patient safety post-restraint. ○ Document the criteria used to decide on restraint removal. ○ Record the time and manner of restraint removal, noting the patient’s behavior and physical condition afterward. ○ Note any post-restraint care provided, including psychological support and further de-escalation strategies. + Effectively set and adjust patient monitoring equipment alarm limits (includes concept of alarm fatigue and its implications for patient safety in various settings) (2 question) Alarm fatigue: develops in those who hear an excess # of alarms = causes sensory overload ○ Intervention: Customize alarm parameters based on pt specific needs ○ Identify pt safety risks: suicide, O2 therapy, fall risk ○ Use alarms systems safely: do not turn alarms off, and respond to alarms promptly ○ Regularly assess and make sure alarms are set appropriately Avoid false/missed alarms; delayed responses Overly sensitive alarm parameters increases risk for alarm fatigue + Demonstrate care of a simulated patient experiencing alcohol withdrawal (2 questions) Long-term effects: HTN, heart disease, stroke, liver disease, and digestive problems Short term effects: increases risk for injury from MVA, fall, firearms, assault, drowning, and burns S/S: ○ Tremors ○ HA, HTN ○ Seizures  NUR 333 Final Exam Study Outline ○ Diaphoresis ○ Delirium, hallucinations ○ At risk for GI bleeds, malnutrition, cardiac dysrhythmias Interventions ○ Early detection of withdrawal sx ○ Frequent monitoring of VS ○ Withdrawal protocol: benzo, precedex, octreotide, thiamine, cardiac monitoring, Mg/K replacement, labs ○ Determine time of last drink ○ Dim lights, quiet environment, limit visitors ○ Strict I&O ○ Encourage fluids ○ Seizure Precautions ○ Remote cardiac monitor ○ Provide thiamine, folic acid for 7 days PO ○ Provide multivitamins with mineral and Fe tablet PO daily ○ Lorazepam: drug of choice for pt 65 yrs+ ○ Perform RASS assessment (Richmond Agitation Sedation Scale) Withhold if score is below -1 Assess and document RASS Q hour (include miscellaneous nursing notes + neuro assessment) ○ Perform CIWA-Ar assessment and record in pt’s chart If CIWA-Ar greater than 15 – Q1 hour assessment = Give Lorazepam 2 mg IV every 1 hr for CIWA score greater than 15 If CIWA-Ar 8-15 – Q2 hour assessment = Give Lorazepam 1 mg IV every 2 hrs for CIWA score 8-15 If CIWA-Ar less than 8 – Q4 hour assessment. When 3 consecutive CIWA-Ar scores are less than 8, may discontinue CIWA-Ar checks. Notify provider for maintenance dose prescription ○ In the case that necessitates flumazenil (benzo reversal agent to reduce sedation) = RASS score below -3 = give max dose 1mg over 15 sec Notify provider if CIWA score stays above 20 for 2 hours Notify provider if any seizure activity occurs. Notify provider of any new onset delirium and/or hallucinations. May wake patient to perform assessments as ordered Scoring: CIWA 20, severe withdrawal + Demonstrate care of a simulated patient during end of life care (e.g. advanced directives, palliative versus hospice care) (2 questions) 5 wishes:  NUR 333 Final Exam Study Outline ○Five Wishes is the first living will (also called an advance directive) that talks about your personal, emotional, and spiritual needs as well as your medical wishes. Informs about preferred health care decisions The person I want to make care decisions for me when I can't The kind of medical treatment I want or don't want How comfortable I want to be How I want people to treat me What I want my loved ones to know Goals of palliative care: Lewis textbook table 10.1 ○ Provide relief from pain and other physical symptoms ○ Maximize quality of life ○ Provide psychosocial and spiritual care ○ Help patients and their families determine goals of care ○ Neither hasten nor postpone death; recognize dying as a natural process ○ Provide support to the family and the caregivers during the patient’s illness and in bereavement ○ Recognize and respect the cultural values and beliefs of the patient and the family Resources: - ANA Position Statement on Use of Restraints - Final Exam Jeopardy - Simulation resources for alarm fatigue, CIWA, end of life care - Alcohol Withdrawal Powerpoint - 5 wishes document - Lewis text (pre-sim prep reading re palliative care and end of life) Experience 2: 11 questions + Analyze the Multifaceted Nature of Trauma Care including legal and sexual trauma considerations(e.g. Mandatory reporting, EMTALA) (2 questions) Mandatory reporting: ○ Children: abuse, a significant cause of morbidity and mortality such as infectious diseases and health hazards ○ Intimate Partners: sexual/ domestic abuse, SANE nurses ○ Elderly: abuse and mistreatment ○ Infectious disease: CDC ex STDs, tetanus, TB, covid Emergency Medical Treatment and Active Labor Act (EMTALA) ○ Law that prevents refusing care to uninsured pts ○ Requires that any pt who has a medical or psychiatric condition, who brings themselves or is brought to an ED, must be evaluated and stabilized before being discharged or transferred to another clinical facility NINP (no information, no publication): to stay anonymous in the hospital + Develop Strategies for Managing Patient Safety in Trauma Scenarios(2 questions) ABCDE- Airway, Breathing, Circulation, C-spine, Disability, Exposure  NUR 333 Final Exam Study Outline ○ Do NOT move the spine of someone who potentially had injury to spine (immediate c collar, log roll, lay flat in supine) + Understand the Indications and Complications of Airway Suctioning(2 questions) Indications of Suctioning ○ Visible Secretions ○ Respiratory Distress: Signs of respiratory distress or difficulty breathing, especially in patients with conditions like chronic obstructive pulmonary disease (COPD), asthma, or cystic fibrosis. ○ Decreased Oxygen Saturation ○ Ineffective Cough: Inability of the patient to effectively clear secretions through coughing. ○ Mechanical Ventilation: Patients on mechanical ventilation or tracheostomy may require regular suctioning to maintain patency and prevent complications. Complications of Airway Suctioning: ○ Hypoxia: Reduced oxygen levels during the procedure due to the removal of oxygen-rich air and potential disruption of ventilation. ○ Trauma: Injury to the airway structures, such as the mucosa, trachea, or bronchi, caused by the suction catheter. Discomfort ○ Infection: Risk of introducing pathogens into the airway, leading to infections. ○ Arrhythmias: Stimulation of the vagus nerve during suctioning can cause cardiac arrhythmias, esp bradycardia ○ Bleeding: Possible bleeding from the mucosal lining of the airway. ○ Increased Secretions: Suctioning can sometimes lead to an increase in the production of secretions. ○ Atelectasis: Collapse of lung tissue due to over-suctioning or inadequate ventilation. Best Practices: ○ Use sterile technique to minimize the risk of infection. ○ Preoxygenate the patient before suctioning to reduce hypoxia. ○ Limit the suctioning time to avoid damaging the airway and causing hypoxia. ○ Monitor the patient’s vital signs and oxygen saturation throughout the procedure. ○ Ensure proper technique and catheter size to reduce trauma and complications. ○ Encourage cough and apply suction by squeezing suction control mechanism as withdraw catheter continuously for no more than 10 sec ○ Wait 1 min before suction again ○ Flush once done + Demonstrate Competence in Arterial Line Management ( also includes possible complications and concepts of dampening)(2 questions) Verify all connections are secure and caps on stopcocks are closed-ended- secured lure locked system Ensure that infusion to maintain patency of the arterial line is 0.9% normal saline under a pressure of 300 mmHg Label the arterial line  NUR 333 Final Exam Study Outline Trace the arterial line from the solution and pressure device to the insertion site Monitor blood pressure Zero the transducer- transducer at the phlebostatic axis Perform fast flush or square waveform test Assess the quality of the waveform and accuracy of the blood pressure Perform dressing change Change tubing if needed Draw blood sample evaluate the outcome of the arterial line management at the appropriate time frame Monitor for dislodgement Monitor for under- or over-dampening of waveform ○ Overdamping: results in less than 1.5 oscillations and a waveform without a dicrotic notch leading to an underestimated blood pressure Complications: bleeding, perfusion issues, infection + Apply Knowledge of Arterial Blood Gas Interpretation(3 questions) pH 7.35-7.45 acid/alk PaCo2- 35-45 alk/acid HCo3- 22-26 acid/alk Pao2- 80-100 Resources: - Final Exam Jeopardy - Mandatory Reporting Laws article - ATI-Engage- Introduction to Critical Care and Emergency Nursing- Lessons: Legal Issues in Emergency Nursing (e.g. EMTALA) - Materials/discussion during trauma considerations experience - ATI: Engage Medical Surgical. “Arterial Line Management” - ATI: Engage Medical Surgical. “ABG Interpretation” - ATI: Engage Medical Surgical. “Inline closed system suctioning” Experience 3: 11 questions + Prioritize care of multiple patients(3 questions) 5 rights of Delegation Right task Right circumstances Right person Right directions and communications Right supervision and evaluation Do not delegate what you can EAT- educate, assess, teach  NUR 333 Final Exam Study Outline + Identify actions to decrease the risk of infection related to CAUTIs and CLABSIs(2 questions) CAUTIs: ○ Catheter selection: Use the smallest appropriate size and type. ○ Insertion: Maintain strict aseptic technique. ○ Securement: Prevent movement and pulling on the catheter. ○ Maintenance: Perform routine perineal care and catheter care. CLABSIs: ○ Consider an antimicrobial line ○ Hand hygiene ○ Maxim sterile barrier precautions (head-to-toe sterile drape, mask, cap, sterile gown, sterile gloves) ○ Chlorhexidine skin prep ○ Avoidance of femoral vein if possible + Demonstrate appropriate care of the mechanically ventilated client (including high and low alarms, prevention of complications) (4 questions) High pressure limit alarm- Low pressure limit alarm- Secretions, coughing, gagging Total or partial ventilator disconnect Patient fighting ventilator (ventilator Loss of airway asynchrony) ET tube or tracheostomy cuff leak (patient Condensate (water) in tubing speaking, grunting) Kinked or compressed tubing (patient ○ Apnea- biting) Respiratory arrest Increased resistance (bronchospasm) Oversedation Decreased compliance (pulmonary edema, Change in patient condition pneumothorax) Loss of airway Under-sedation Risk of accidental extubation Weaning- the process of reducing ventilator support and resuming spontaneous ventilation Prevention of complications: early mobility, frequent thorough oral care, sedation vacations, only suction PRN, PPI therapy + Apply critical thinking to complex ICU patient care situations (includes ICU admission)(2 questions) ????????????? Resources: - Final Exam Jeopardy - ICU Escape Room and simulation activities (for ICU room readiness and assessment) - Ventilator Alarms Powerpoint  NUR 333 Final Exam Study Outline - Lewis text: Reading on mechanical ventilation- specifically table 28.10 “Care for the Patient Requiring Mechanical Ventilation” - Simulation experience related to care of client on a ventilator and receiving sedation - CLABSI Prevention: https://www.myamericannurse.com/revisiting-clabsi-prevention-strategies-part-1/ - Links to an external site. - ANA CAUTI guidelines (download the prevention tool on this page): https://www.nursingworld.org/practice-policy/work-environment/health-safety/infection-preventio n/ana-cauti-prevention-tool/ - Links to an external site. Experience 4: 11 questions + Demonstrate knowledge of suprapubic catheters including indications and post-operative care (2 questions) Suprapubic catheters ○ provide an outlet for urinary elimination when other routes are not flexible ○ Flexible tube placed percutaneously into the bladder to allow urine to drain when a routine catheter is contraindicated ○ placed just above the public bone and is the preferred route for long term catheterization due to decreased incidence of catheter related UTIs ○ Change dressing using aseptic technique, secure cath to abdomen, place the bag below the level of the bladder, examine urine volume, color, clarity, odor Postop Care ○ Apply non sterile gloves and PPE if indicated ○ Don non sterile gloves inspect and palpate bladder ○ Removing dressing over insertion site and discard ○ Inspect skin for excoriation, bleeding, and drainage ○ Verify catheter placement ○ Inspect urine drainage bag for volume of urine, clarity, color, and odor ○ Maintain drainage bag below the level of the bladder and is not placing tension on the catheter ○ Remove gloves and perform hand hygiene ○ Use clean and aseptic technique ○ Use warm water and provider prescribed or facility approved cleansers. Clean the catheter site using a circular motion. Begin at the insertion site and move away from the insertion site. Also cleanse the catheter beginning at insertion site and moving away from the insertion site being careful not to pull on the catheter. ○ Dry skin using a clean towel, as indicated, place drain sponge around insertion site and secure with tape. ○ If the catheter is not sutured in place, per facility protocol or provider prescription, rotate the SPC. ○ Secure catheter to the client's abdomen. Use facility approved securement devices. Check the catheter is not kinked or has any dependent loops.  NUR 333 Final Exam Study Outline + Demonstrate knowledge of chest tubes (3 questions) Chest tubes ○ remove air, fluid, or blood from the pleural space ○ Helps lungs re-expand in conditions with fluid accumulation or after heart/lung surgery pneumothorax, hemothorax, or pleural effusion. thoracic surgery, during cardiac surgery, empyema Small bore chest tube ○ Used for draining air or small amounts of fluid (pneumothorax) ○ Ex- pigtail catheter Large bore chest tube ○ Used for draining larger amounts of blood or fluid (hemothorax) ○ More rigid and larger in diameter Nursing care ○ Always keep drainage system below the pt chest ○ Never strip or milk the tubing, never clamp it ○ Monitor drainage, color and quantity q 1hr ○ Evaluate for indications of alterations in O2 and pain ○ Check occlusive dressing integrity and evidence of moisture: ensure intact/ drainage (palpate it to assess for subcutaneous emphysema) Change daily, when soiled, or at interval determined by facility ○ Check patency: No kinks, loops, or occlusions; all are connected and secured with tape ○ Confirm suction is good and connected ○ Encourage deep breathing and mobility ○ Report bright red blood (indicates active bleed), dark red is expected ○ Educate pt to do the ‘valsalva maneuver’ when provider is removing the chest tube (take a deep breath, exhale, and bear down) 3 chambers ○ Drainage chamber- fluid is collected from the pt ○ Water-seal chamber- allows air to be removed from the pleural space without outside air entering the lungs Continuous bubbling = air leak = BAD; check tubing for disconnections or breaks Tidaling- water rises and falls w/ each breath (good) ○ Suction-control chamber- two types; wet and dry suction Wet suction- uses water to control the level of suction (will have gentle bubbling) Dry suction- there is no water column, the suction is controlled by a suction monitor bellows that balances wall suction Dislodgement- cover site with sterile dressing, if the pt has a pneumothorax, leave one side of the dressing open to allow air to escape and prevent tension pneumothorax, notify provider No drainage- check for kinks, assess for clot formation Increased drainage- monitor for signs of hemorrhage, report immediately  NUR 333 Final Exam Study Outline Damaged- place tubing in sterile water while waiting for a new system + Demonstrate care of a simulated burn patient (3 questions) Pathophysiology of burns ○ ↑ Capillary permeability ○ Fluid components of blood leak into interstitial space = edema and decreased blood volume (except RBC and WBCs) ○ ↑ Hct = viscous blood ○ ↑ peripheral resistance ○ Fluid and electrolytes shift out to interstitial space = edema Intervention for Burns ○ Airway maintenance Early endotracheal intubation Escharotomies of chest wall (An escharotomy is an emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation.) Fiberoptic bronchoscopy (Fiberoptic bronchoscopy (FOB) is a diagnostic and prognostic tool for smoke inhalation lung injury (SII) in burn patients. SII is a leading cause of death in burn patients and can cause: Respiratory failure, Pneumonia, Septicemia, and ARDS.) Humidified air and 100% O2 ○ Fluid therapy Parkland formula- used to calculate total fluid patient requires for first 24 hrs after burn injury Replacement depends on size, depth, burn, age 2 large bore IV lines ○ Wound care Delay it until airway patent and have adequate circulation and fluid replacement  NUR 333 Final Exam Study Outline Cleansing Debridement (sometimes done in OR) ○ Personal care Facial care Eye care for corneal burns = antibiotics Ears should be kept free of pressure = avoid pillows Keep hands and arms extended and elevated on pillows or foam wedges Keep perineum dry and clean = indwelling cath, perineal care Routine labs Early ROM exercises ○ Drug therapy Analgesics and sedatives: morphine, haloperidol, lorazepam, hydromorphone, midazolam Tetanus immunization Antimicrobial agents: silver sulfadiazine, mafenide acetate Systemic agents (only if sepsis diagnosis is made) VTE prophylaxis: low dose heparin, SCDs, compression socks ○ Nutritional therapy Caloric needs of 5000 kcal/day Early, continuous enteral feeding Supplemental vitamins + iron ○ Emotional needs Promote self esteem Address spiritual and cultural needs; family and pt support groups + Demonstrate care of a simulated patient experiencing cardiac symptoms (3 questions) Reperfusion therapy - restore blood flow & minimize heart muscle damage & improve pt outcome ○ STEMI - total occlusion of the artery causing cell death EKG: ST elevation PCI >90 min -> Fibrinolytics ○ NSTEMI - partial occlusion of the artery EKG: non ST-elevation (ST depression & T-wave inversion) Anticoagulant & antiplatelets Coronary angiography ○ MONA Morphine - relieve pain, decrease workload, & vasodilates O2 Nitrate - helps vasodilate Aspirin - prevents further clots from forming Oxygen, 12 lead ECG, identity rate and rhythm, IV access, obtain labs Monitor ABCs, vitals, LOC, oxygen, and heart rhythm  NUR 333 Final Exam Study Outline Synchronized cardioversion is a procedure similar to electrical defibrillation in that a transthoracic electrical current is applied to the anterior chest to terminate a life-threatening or unstable tachycardia arrhythmia Resources: Final Exam Jeopardy ATI: Engage Medical Surgical. “Suprapubic Catheter” ATI: Engage Medical Surgical. "Caring for a client with a chest tube" Experience activities: chest tubes and suprapubic catheters Burn Patient Care Powerpoint Pre-sim prep for Coder (synchronized cardioversion, acute coronary syndrome) Experience 5: 15 questions + Engage in role-play to navigate end-of-life conversations (includes palliative versus hospice care, end of life discussions with families) (2 questions) Hospice Care ○ Focus on comfort rather than cure, has a terminal illness of about 6 months or less ○ Manage pain and other sx to ensure comfort and quality of life. Palliative care: available at any stage of a serious illness and can be provided alongside treatments aimed at prolonging life, like antibiotics or physical therapy ○ It focuses on managing symptoms—like pain, difficulty swallowing, or breathing issues—and supporting both the patient and the family emotionally and spiritually. + Describe appropriate end of life and post-mortem care(1 questions) Physiological changes- ○ Rigor Mortis- stiffening of the muscles begins within 2-6 hrs after death, can last up to 72 hrs ○ Livor Mortis- blood settles in the lower parts of the body, causing a purplish discolartion. 30 mins- 2 hrs after death, can last 6-12 hrs ○ Algor Mortis- cooling of the body after death, body temp drops to match the ambient temp. Takes several hours ○ Decomposition- cellular breakdown and decomposition begin soon after death, but external signs such as tissue breakdown or odor usually take longer to become noticeable. Basic post mortem care ○ Cleaning the body ○ Positioning ○ Dress and cover ○ Removal of tubes and equipment Culture considerations ○ Open communication ○ Family involvement ○ Timing  NUR 333 Final Exam Study Outline ○ Avoid assumptions + Demonstrate care of a simulated patient experiencing a cardiac arrest(4 questions) Check for responsiveness Check for breathing and pulse Call for help Chest compressions: 100-120 compressions per minute, with a depth of at least 2 inches Rescue breaths: 2 breaths after every 30 compressions, ensure chest rises with each breath Attach defibrillator pads, analyze the rhythm Shockable rhythms: V FIB, pulseless V TACH Use 200 joules, make sure everyone is clear when delivering shock Resume CPR immediately after the shock for 2 minutes before reassessing the rhythm Non shockable rhythms: asystole or pulseless electrical activity Epinephrine (for all cardiac arrest rhythms): give 1 mg IV or IO every 3-5 mins Amiodarone or Lidocaine (for V FIB or pulseless V TACH): amiodarone 300 mg IV/IO bolus, second dose of 150 mg may be given. Lido 1-1.5 mg/kg IV/IO may be used if amiodarone is unavailable Reversible causes Hs and Ts ○ Hypoxia, hypovolemia, hydrogen ions (acidosis), hyperkalemia, hypothermia ○ Tension pneumothorax, tamponade, toxins, thrombosis Cardioversion: delivers a shock synchronized with the patient's QRS complex, to avoid delivering a shock during the vulnerable period of the cardiac cycle (T wave) ○ Afib- 100-200 jules ○ Unstable V TACH- 100 jules Return of spontaneous circulation (ROSC)- ○ Monitor pts vitals ○ Assess oxygenation ○ Manage blood pressure, consider vasopressors ○ Consider targeted temp management, especially pts who remain unconscious  NUR 333 Final Exam Study Outline + Demonstrate care of multiple patients(3 questions) Maslow hierarchy of needs ABCs Urgent and severity Triage 5 Rights + Demonstrate appropriate delegation decisions based on scope of practice (3 question) Risk task, right circumstance, right person, right direction/communication, right supervision/evaluation Don't delegate what you can EAT ○ Educate, assess, teach Know the scope of practice Assess the pts needs Match tasks to skill levels Provide clear instructions Monitor and evaluate + Developing effective communication skills for delegation(2 questions) Clear and concise instructions Use active listening Define roles and responsibilities Encourage questions and discussion Provide rationale Monitor and provide feedback Use nonverbal communication Document clearly Resources: Final Exam Jeopardy ATI: Engage Medical Surgical. “End of Life Care” (Lessons and Skills sections) DNR/DNI/Advanced directives activities in lab Pre-simulation prep for Coder (Lewis text, including table 35.6/Table 39.6 “Emergency Management of Dysrhythmias”) Simulation experience: Coder codes Simulation experience: Multi-patient experience  NUR 333 Final Exam Study Outline Experience 6: 5 Questions + Demonstrate appropriate nursing considerations in the context of telehealth.(2 questions) Those living in rural areas are at an increased risk of death from 5 leading causes of death in US ○ Distance between provider and pt does not matter ○ Pt does not require transportation ○ Pt must have access to the internet or cellular connection ○ Pt can receive immediate evaluation during a possible emergency so further steps can be determined quickly CDC sponsored telehealth projects: ○ cardiac rehab, diabetes management and prevention, tobacco cessation, epilepsy management Behavioral telehealth: ○ promising results from individual and group therapy, video conferencing, asynchronous counseling, internet games, simulation, potential to aliens those with disabilities, quality control, insurance coverage Pandemic impact: ○ 5% of americans reported they or family member used telehealth for the first time ○ 10% of employers have begun offering new telehealth options ○ 52% are concerned about getting prescriptions on time ○ Increase in perceived impact of at least one SDoH Consumer interest: ○ Post surgical care ○ Chronic disease management ○ Millennials ○ Seniors ○ Caregivers (most interested) ○ Heaviest users of healthcare system Driving change: ○ Incentivizing providers for offering higher quality care ○ Elderly populations would like to stay in their homes for as long as possible through the aging process ○ Conditions requiring lifestyle changes and daily management Barriers: ○ No in person contact might yield poor results ○ Seems impersonal ○ Health info could be leaked ○ Info could be misused ○ Reliable and private connection is necessary ○ Might be difficult to use ○ Understanding of pt is difficult to assess from a provider perspective Seniors:  NUR 333 Final Exam Study Outline ○ Most likely to use sensors ○ Least interested in telehealth ○ Most likely to feel strongly about having a consistent provider Baby Boomers: ○ Least willing to pay out of pocket for telehealth services Gen X: ○ Moderate in both interest and willingness to pay out of pocket Millennials: ○ Least interested in sensors ○ Most interested in telehealth ○ Least likely to feel strongly about seeing a consistent provider ○ Willing to pay out of pocket Potential issues related to telehealth: access to the internet and phone signal, health and technology literacy, issues with care coordination for pts with multiple specialists + Apply prioritization principles to complex patient scenarios (including care of the patient with sepsis)(3 questions) Initial resuscitation for sepsis and septic shock HR 1 bundle ○ Measure lactate level (remeasure if initial lactate elevated >2 mmol/L) ○ Obtain blood cultures before administering antibiotics ○ Administer broad spectrum antibiotics ○ Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate > 4 mmol/L ○ Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP of >65 Surviving sepsis campaign ○ Act quickly upon sepsis and septic shock recognition ○ Minimize time to treatment- medical emergencies ○ Monitor closely for response to interventions ○ Communicate sepsis status in shift report Resources: Final Exam Jeopardy Telehealth Prep Powerpoint, Technology meets Healthcare Surviving Sepsis Campaign Hour 1 Bundle document Pre-sim prep for Arne related to sepsis (Lewis reading, e.g. septic shock sections of table 42.9 sepsis) Simulation experience with Arne Experience 7: 3 Questions + Demonstrate safe care of the client with DKA (3 questions) still adding info Adequate insulin to reduce blood glucose Fluids for dehydration  NUR 333 Final Exam Study Outline Electrolyte replacement, esp potassium Venous access, weight, cardiac monitoring, q1 hr vitals, neuro assessment, I/O, blood sugars After initial insulin bolus, give insulin drip at 0.1 units/kg/hr Should not drop more than 100 units/hr; notify provider Resources: Final Exam Jeopardy DKA Prep Powerpoint DKA PICU Pearls document Simulation experience with Anastasiya Tarasova Overall You may be tested on the following medications: Lorazepam- benzo for anxiety, alc withdraw Precedex (dexmedetomidine)- used for sedative and anxiety control in severe alc withdrawal sx Propofol: anesthetic and sedative Epinephrine: used for cardiac arrest, anaphylaxis, hypotension Amiodarone: antiarrhythmic, decreases heart rate for VFib, Vtach Lovenox- blood thinner; used for blood clots Other concepts to know: Know all normal ABG values (pH, PaCO2, HCO3-, PaO2) ○ pH 7.35-7.45 acid/alk ○ PaCo2- 35-45 alk/acid ○ HCo3- 22-26 acid/alk ○ Pao2- 80-100 Understand what the RASS measures (do not need to be able to identify specific levels) ○ Richmond agitation sedation scale: measures alertness and agitation in sedated pts What is a CBC/what (in general) is included in this lab series ○ Complete blood count, WBC, RBC, H/H, platelets, RBC indices What does serum lactate measure/what does elevated lactate signify ○ Lactate: measures amount of lactic acid in your blood byproduct of anaerobic metabolism; occurs when body produces energy without  NUR 333 Final Exam Study Outline sufficient oxygen ○ High levels = blood becomes too acidic and can indicate various medical conditions Indication of tissue hypoperfusion, hypoxia, and metabolic disturbances Delegation and prioritization principles (e.g. scope of practice for UAPs, LPNs) ○ Unlicensed Assistive Personnel (UAPs/CNAs): Tasks: Non-clinical, routine, and stable patient care (e.g., bathing, feeding, ambulation, hygiene, vital signs on stable patients, I&O measurements). Exclusions: No clinical judgment, medication administration, or invasive procedures. ○ Licensed Practical Nurses (LPNs): Tasks: Basic nursing care, stable patient monitoring, wound care, administering oral and some injectable medications (depending on the state). Exclusions: No initial assessments, care plans, or teaching for unstable patients