001-010.pdf

‫أوليس يُجزى ُم ٌ‬ ‫حسن اال باحسان‬ ‫ك غيث‬ ‫نحيا‬ ‫فكلنا كالغيث للغير مازالت‬ ‫الدنيا بخير‬ ‫قلبي اطمان‬ ‫ملف تحديث شهريا الضافة الجديد‬ ‫وتصحيح اي اخطاء‬ ‫‪1‬‬ ‫أوليس يُجزى ُم ٌ‬ ‫حسن اال باحسان‬ ‫التعديالت‬ ‫‪1392 A‬‬ ‫‪1487 B‬‬ ‫‪2‬‬ ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ Positioning 📍Cra...

‫أوليس يُجزى ُم ٌ‬ ‫حسن اال باحسان‬ ‫ك غيث‬ ‫نحيا‬ ‫فكلنا كالغيث للغير مازالت‬ ‫الدنيا بخير‬ ‫قلبي اطمان‬ ‫ملف تحديث شهريا الضافة الجديد‬ ‫وتصحيح اي اخطاء‬ ‫‪1‬‬ ‫أوليس يُجزى ُم ٌ‬ ‫حسن اال باحسان‬ ‫التعديالت‬ ‫‪1392 A‬‬ ‫‪1487 B‬‬ ‫‪2‬‬ ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ Positioning 📍Craniotomy👉semi fowler 📍Hip surgery👉keep leg in abduction 📍Cast👉elevate extremity to prevent edema 📍Asthma👉sitting position 📍Icp👉elevate the head of the bed 📍Distended neck vein👉elevate 30 degree 📍Enema👉sims position 📍Post cardiac cath👉semi fowler 📍Spinal pefida👉prone position 📍Seizure👉side lying 📍Shock👉supine with elevated leg 📍Nasogastric tube👉high fowler 📍Nasogastric tube irrigation and tube feeding 👉 HOB evelvated 30-45 📍Central venous catheter👉trendelenburg position 📍Endoscopy👉left lateral position 📍Cleft palate👉supine upright position 📍Cleft palate👉 elbow restrain and avoid prone 📍Post tonsillectomy👉side lying/lateral/prone 📍Teratology of fallout 👉knee chest position 📍During liver biopsy👉position client supine with the right side of the upper abdomen exposed. 3 ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ 📍After liver biopsy 👉right lateral, side lying, position ........💕‫️☺غيث‬. 📍After. hemorrhoidectomy👉lateral, side lying, position, Jackknife position 📍perineal or vaginal procedures👉lithotomy position 📍Central line CVP👉 trendelenburg position 📍The nurse would increase the comfort of the patient with appendicitis by👉Flexing the patient's right knee 📍Post thyroidectomy position 👉👉Place the client in the semi-Fowler’s to Fowler’s position to reduce swelling and edema in the neck area. 📍Mastectomy👉👉 with arm on affected side elevated to allow lymph drainage Cranial Nerves Nerve I Olfactory Nerve smell Nerve II Optic Nerve Vision Nerve III Oculomotor Nerve Eye function , pupil dilation. Bottle containing something that smell Use visual acuity chart. ( Snellen chart Have patient blink their eyes Nerve IV Oculomotor Nerve Eye movement Have patient look down Nerve V Trigeminal Nerve Sensory of the face, chewing pinprick & brushing teeth (Clench jaw. Test for feeling by lightly touching forehead, cheek and jaw. Nerve VI Abducens Nerve Eye movement Have patient look to each side Nerve VII facial Nerve Facial expression, wrinkle forehead, taste anterior tongue Auditory acuity, balance and postural responses Cotton , hammer , sweats and salts Nerve VIII Vestibulocochlear Nerve Nerve IX Glossopharyngeal Nerve Taste and swallowing Nerve X Vagus Nerve Nerve XI Accessory Nerve Nerve XII Hypoglossal Nerve Gag reflex Muscles of neck Tongue movement. 4 Rinne test (nap fingers beside patient ear, have them stand on one foot) Tongue depressor and pen light Tongue depressor stick tongue out ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ Rule of the B’s.. If the pH & the bicarb are both in the same direction = metabolic If they are in different directions = respiratory RESPIRATORY OR METABOLIC ! PH ↑ HCO3 ↑ or PH ↓ HCO3 ↓ it is Metabolic PH ↑ HCO3 ↓ or PH ↓ HCO3 ↑ it is Respiratory Respiratory ‫………………… عكس االتجاه تكون‬.Metabolic ACIDOSIS OR ALKALOSIS ! PH < 7.45 Alkalosis PH > 7.35 Acidosis ‫نفس االتجاه تكون‬ pH = 7.35-7.45 acidosis/alkalosis HCO3 (bicarb) = 22-26 (2+2+2 = 6) CO2 = 45-35 Compensated or uncompensated ! Un compensated if PCO2 or HCO3 are Normal Partially compensated if Nothing is Normal Compensated if PH is Normal ---------------------------------------------------------------------------------------------------------------ex: PH: 7.30 ↓ bicarb: 20 = ↓ = metabolic acidosis ex: pH: 7.58 =↑ bicarb: 32 = ↑ = metabolic alkalosis ex: pH: 7.22 =↓ bicarb: 30 =↑ = respiratory acidosis 5 ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ Vomiting Metabolic Alkalosis Nasogastric tube suction Metabolic Alkalosis Diarrhoea Metabolic Acidosis Ileostomy Metabolic Acidosis Dehydration Metabolic Acidosis CPR Respiratory Acidosis Drowning Respiratory Acidosis Cushing syndrome Metabolic Alkalosis 1. A 12- year- old boy was brought to the Emergency respiratory arrest due to drowning. Cardiac resuscitation what is the major complication that might happen if treated after drowning quickly? A. Sepsis B. Alkalosis C. Acidosis D. Hypothermia 2. An ICU nurse reviews the chart of a 47-year-old man patient mechanical ventilator for a long time. Arterial blood gas result see lab results). Test Result Normal Values ABG HCO3 24 22-28 mmd/L ABG PCO3 10.66 4.7-6.0 KPa PH 7.16 7.36-7.45 ABG PO2 6.13 10.6-14.2 KPa SA O2 81 95-100 % What condition the patient is experiencing presently? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis 3. Gastric suction can cause : A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis. 4. ABG reading was low PH ,HIGH PCO2 , NORMAL Hco3 what the interpretation ? A. Compensated respiratory acidosis B. Uncompensated respiratory acidosis C. Metabolic acidosis D. Metabolic alkalosis 5. Patient with ABG PH 7.33 ‫ و‬HCO3 30 , PCO2 50 6 ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ A. B. C. D. Compensate respiratory Compensate metabolic Uncompensated respiratory Uncompensated metabolic 6. The nurse assesses a client with an ileostomy for possible development of which of the following acid-base imbalances? A. B. C. D. Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis 7. The nurse is assigned to care for the a patient with Cushing syndrome on adrenal corticoid hormones syndrome on adrenal corticoid hormones Ph 7.2 Which of the following condition should nurse expect to patient A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis 8. A nurse reviewed a chart of a 42 year-old man whose ABG analysis report is shown PH 7.20 20. Which of the following I the most likely interpretation of the findings in the report? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic acidosis PCO2 35 HCO3 9. A 20 year old woman, a case of panic attacks, comes to the emergency department. An arterial blood gas analysis is done PH 7.53 7.35-7.45 HCO3 22 22-26 PCO2 27 35-45 what is most likely? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis . 7 ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ Intravenous solution 10. A client was admitted in the Emergency Room due to mild metabolic acidosis associated with dehydration and potassium the doctor administered Hartmann’s (lactated Ringer’s) intravenous fluid and electrolyte replacement. Which of the following elements of the lactated Ringer’s solution highest value? A. Calcium B. Sodium C. Potassium D. Magnesium 11. Ringer Lactate consider as which type of IV solution? A. Hypotonic B. Hypertonic C. Isotonic D. Hyper alimentation 12. physician orders an intravenous fluid of D5NS at 100cc/hr. This is an example of which of the solution? A. hyper alimentation B. hypertonic C. hypotonic D. isotonic 13. 13-year-old patient is admitted for diarrhoea and vomiting. He looks pale and lethargic. A nurse is preparing to give IV hypotonic solution. Blood pressure 110/70 mmHg Heart rate 76 /min Respiratory rate 18 /min Temperature 36.1°C Which IV solution is most appropriate? A. 0.9% saline B. Lactated ringers C. 10% dextrose in water D. 0.45% sodium chloride 8 ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ CPR Questions 14. CPR DEPTH ONE THIRD OF CHEST = 1.5 INCH =4CM IN INFANTS , IN ADULT 2 INCH = 5CM 15. CPR site 16. CPR Technique IS : A. 30:2 B. 15:2 120 100 17. You are performing CPR on an infant when a second rescuer appears. What is the next step in management? A. Immediately transport the patient B. Wait until exhausted, then switch C. Have the second rescuer help with CPR, to minimize fatigue D. Have the second rescuer begin ventilations; ratio 30:2 18. What should be your first concern at the scene where a person has been seriously burned? A. Checking the scene for safety. B. Checking the victims breathing and pulse. C. Calling your local emergency phone number. D. Cooling the burned area. 19. While performing cardiopulmonary resuscitation (CPR) on a 5-year-old child, the nurse palpates for a pulse. Which of the following sites is best for checking the pulse during CPR in a 5-year-old child? A. Femoral artery B. Carotid artery. C. Radial artery D. Brachial artery 20. After activating the emergency call system, what should be the next immediate action? A. Initiate ventricular pacing B. Administer a bolus of lidocaine as prescribed C. Defibrillate the patient D. Open the patient's airway 21. A nursing instructor teaches a group of students about basic life support. The instructor asks a student to identify the most appropriate location to assess the pulse of an infant under 1 year of age. Which of the following if stated by the student, would indicate that the student understands the appropriate procedure: A. Carotid B. Popliteal C. Radial D. Brachial . 9 ٌ ‫أوليس يُجزى ُم‬ ‫حسن اال باحسان‬ Chest Tube questions 22. A nurse is transferring a patient with chest tube the X-ray department for chest X-ray. Which location should the nurse place chest tube A. Directly on the stretcher in an upright B. On the side of stretcher next to patient C. Hanged on IV pole that is attached to the D. Attached to the stretcher and hanged 23. 69 year-old man is admitted to the intensive care unit following cardiac surgery. Two hours after admission, the nurse performs a routine assessment and notes the patient's chest tube drainage is 200 milliliters and a dark red color. He has had 60 milliliters output from the indwelling urinary catheter Blood pressure 138/68 mmhg Heart rate 76/min Respiratory rate 16/min Body temperature 37.0C oral Oxygen saturation 94% 6L/min nasal cannula Which finding should be reported to the doctor? A. Dark red chest tube drainage B. Urinary output C. Oxygen saturation D. Chest tube output volume 24. 40 year-old male patient has a chest tube and properly fixed following cardiac surgery. The chest tube is patent and functioning. When the nurse removes the dressing the tube falls out of the chest. Which is the most appropriate initial intervention the nurse should take? A. Reinsert the chest tube and notify the surgeon B. Apply an occlusive dressing to the insertion site C. Place the open end of the tube in 20 cm of water D. Administer O2 at 10L/min via non-rebreather mask 25. While attempting to get of the bed a patient accidentally disconnects the chest tube from the pleura evac drainage system which of the following actions should the nurse take first A. Insert the end of the chest tube in a container of sterile solution B. Raise the end chest tube above the level of insertion of the chest tube C. Clamp the chest tube near pleura evac drainage system D. Apply pressure dressing to chest tube insertion site 26. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should: A. Observe for intermittent bubbling in the water seal chamber B. Flush the chest tubes with 30-60 ml of NSS every 4-6 hours C. Maintain the client in an extreme lateral position D. Strip the chest tubes in the direction of the client 27. A client chest tube is connected to a chest tube drainage system with a water seal . The nurse noted that the water seal c is fluctuating with each breath that client takes . The fluctuation mwans that A. There is an obstruction in the chest tube B. The client is developing emphysema C. The chest tube system is functioning properly D. There is leak in the chest tube system 28. 20-Your patient has a chest tube. Your assessing the water seal chamber and you note ).11 that the water moves up as the patient inhales and then moves down when the patient ?exhales. What may be causing this to happen 10