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NRSG258 Exam Revision


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Explain how the stress response alters glucose metabolisn
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Stress triggers the release of catabolic hormones: adrenaline, noradrenaline, glucagon and cortisol. Adrenaline, glucagon and noradrenaline all work synergistically to promote glycogenolysis in the liver, which increases BGL. Cortisol promotes gluconeogenesis, lipolysis, and increases insulin resistance leading to a decrease in cellular uptake of glucose. As a result of all these physiologic changes, the patient may become hyperglycaemic.

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Explain how the stress response alters glucose metabolisn
Stress triggers the release of catabolic hormones: adrenaline, noradrenaline, glucagon and cortisol. Adrenaline, glucagon and noradrenaline all work synergistically to promote glycogenolysis in the liver, which increases BGL. Cortisol promotes gluconeogenesis, lipolysis, and increases insulin resistance leading to a decrease in cellular uptake of glucose. As a result of all these physiologic changes, the patient may become hyperglycaemic.
What is an APTT test?
The activated partial thromboplastin time. It is used to measure the effect of heparin.
What is an INR test?
The international normalised ratio, which measures the prothrombin time. It is used to measure the effect of warfarin.
What class of drug is warfarin (coumadin)?
It is a vitamin K antagonist (anticoagulant)
What class of drug do apixaban and rivaroxaban belong to?
They are factor xa inhibitors (anticoagulants)
What is the antidote for heparin? What is the mechanism, preparation and contraindications
Protamine sulfate. Mechanism: binds to heparin and renders the molecule inert. Preparation: slow IV injection within 3 hours of heparin injection. Contraindications: allergies to protamine or fish.
What is the mechanism of warfarin?
Blocks conversion of inactive vitamin K so that clotting factors II, VII, IX and X are not produced in the liver
How do you wean a patient off heparin?
Commence on warfarin (coumadin), overlap with heparin for 48 hours before ceasing heparin.
What is the mechanism and preparation of UFH?
Mechanism: inhibits factor Xa and thrombin IIa. Given SC or IV but never IM.
Why can't you give heparin IM?
There is a significant risk of intramuscular haematoma if given IM.
What is the antidote for dagibatran (pradaxa)? What is the mechanism and preparation for this antidote?
Idarucizumab (praxbind). Mechanism: inhibits thrombin. Preparation given IV.
Name two antifibrinolytic agents and some common indications for use.
Aminocaproic acid and Tranexamic acid, indicated in preventing blood loss for trauma, epistaxis, surgery and PPH.
What is the effect of St Johns Wort on heparin?
St Johns Wort increases the bleeding effect of warfarin
What is involved in an ERAS protocol?
Early enteral feedings, encouraging early ambulation, use of opioid-sparing analgesia, a laproscopic approach to colorectal surgery, aggressive management of PONV, use of prophylactic ABs
What is involved in the nursing management of surgical drains?
Measure the output on a FBC, noting the amount, colour and consistency; inspect surrounding skin for signs of infection or excoriation; ensure drain is on the correct suction and that the catheter is patent; report the presence of excessive drainage or unusual clotting to the doctor; change the dressing around the insertion site as required using aseptic technique; remove drain once approved by RMO.
What is involved in nursing management of the Pt receiving a blood transfusion?
Check the packed cell order and bag according to the 6 rights; ensure IV access via a large bore catheter (e.g.18G in a cubital vein); flush the line to ensure patent; only administer the blood product using an approved giving set (i.e. one that has a filter that will remove any unwanted clots); record baseline VS; continuously monitor patient for first 15 minutes of infusion for any potential anaphylactic reactions; repeat and record vital signs every 15 minutes until the infusion is complete.
What should the nurse do if the Pt has a reaction to a blood tranfusion?
Immediately stop the transfusion and change the line; send the entire bag to the laboratory for investigation; flush line with normal saline TKVO; notify the nurse in charge and doctor ASAP; collect venous blood sample for sepsis screen; collect urine sample to Ax for haemolytic reacions; complete a full riskman / incident report
What are the stages of haemostasis in order?
1. vascular phase; 2. platelet phase (ie primary haemostasis); 3. coagulation phase (ie secondary haemostasis); 4. clot resolution; 5. fibrinolysis
What are the nursing priorities for a Pt in fluid overload in order?
1. administer O2 via N.C. titrated to SpO2 >96%; 2. sit Pt upright in high fowler's; 3. administer diuretics; 4. commence strict FBC; 5. repeat full set of VS and respiratory Ax; 6. manage cause
Fine crckles vs coarse crackles
Fine crackles suggest fluid in the small airways & alveloli such as in APO, pneumonia. Coarse crackles suggest fluid in the larger bronchioles such as in bronchitis, infective COPD.
Bilateral crackles vs coarse crackles
Bilateral crackles suggest cardiogenic APO. Unilateral crackles suggest atelactasis.
Nursing goals for Pt in respiratory distress
RR 12-20; lungs clear to auscultation; pH 7.35-7.45; paO2 80-100mmHg; PaCO2 35-45mmHg; O2 >96%; Pt has a calm affect
What obs do you do on a Pt with a PCA every hour?
RR, SpO2, sedation score, PCA attempts, bolus dose given in last hour and the progressive total dose
Indications for rapid response / MET call for a Pt on a PCA?
Respiratory rate less than 5 and/or sedation score of 3
What class of drug is spironolactone (aldactone)?
It is a potassium sparing diuretic
What is first spacing?
It is the normal distribution of fluid in the ICF and ECF
What is second spacing?
It is the abnormal accuulation of interstitial fluid, i.e. oedema
What is third spacing?
It is excess fluid accumulation in the nonfunctional area between cells. Fluid is trapped where it is difficult to move back into the cells or blood vessels such as in ascites, or oedema assciated with burns, trauma and sepsis.
What is the other name for antidiuretic hormone? Where is it produced?
Vasopressin. Produced in the hypothalamus & stored in the pituitary gland.
What does the hormone ADH do?
Increase vascoconstriction and H2O reabsorption
What does the hormone aldosterone do?
Increase Na reabsorption (which increases H2O reabsorption by osmosis). Produced by adrenal cortex.
What does atrial natriuretic peptide do? Where is it produced?
Causes vasodilation and excretion of sodium and H2O. Produced by the heart.
Nursing priorities for patients on TPN?
Facilitate: EUCs measured daily, LFTs measured weekly; BGL measured every 6/24; daily weighs
What are some sympathetic changes associated with vomiting?
Tachycardia, tachypnoea, increased sweating
Why are NSAIDs best taken with food?
NSAIDs block prostaglandins in the stomach, which lead to an increase in production of gastric acid. If there is no food in the stomach, this can lead to gastric ulcers and bleeding.
Paracetamol: adverse effects
Gastric upset, skin rash, itching. OD can lead to hepatotoxicity.
Paracetamol: containdications
Pt has already taken paracetamol in the last 6 hours or exceeding daily limit (4g); known hypersensitivity to paracetamol; abnormal liver function
Ibuprofen: adverse effects
Increases risk of MI & CVA; GI upset (ulcer / bleeding); tinnitus; bronchoconstriction; renal failure
Aspirin: adverse effects
Gastric irritation / ulcer; bronchoconstriction; renal failure (long-term, high dose); tinnitus (sign of OD); Rey's syndrome (swelling of liver and brain
General adverse effects associated with opioids
Respiratory depression, bradycardia, euphoria, sedation, pupil constriction, constipation, pruritus (itching), depressed cough reflex, bronchoconstriction & hypotension r/t histamine release
Morphine: drug interactions
Alcohol & other depressants; opioid antagonists (e.g. Naloxone); MAOIs with pethidine (can cause serotonin syndrome)
Morphine: contraindications & cautions
Head injury, respiratory depression, alcoholism
Tramadol: adverse effects
Nausea, seizures (caution in epilepsy)
Codeine: uses
Analgesia, cough suppressant, anti-diarrhoeal
Codeine: adverse effects
Constipation, addiction, respiratory depression
Naloxone: cautions
Will reverse the effects of morphine including analgesia; half-life shorter than morphine so monitor for signs of re-sedation
Nursing management of Pt with nausea and vomiting
Place pt in high-folwer's to reduce aspiration risk; provide emesis bag; remove any noxious stimuli (e.g. bed pans); administer anti-emetics, reduce oral intake until nausea is controlled (sips of water or ice chips for comfort only); for Pts with NGT - aspirate tube; listen for bowel sounds and check abdomen for distension (paralytic ileus?); check BGL as dysglycaemia can cause nausea
Prochlorperazine: adverse fx
Constipation, dry mouth, sleepiness, dizziness, blurred vision, extrapyramidal side effects (tremor, dystonia)
Metaclopramide: adverse fx
Diarrhoea, sleepiness, restlessness, EPSEs, hypotension
What class of drug is metaclopramide (maxalon)?
Dopamine antagonist (i.e. BLOCKS dopamine)
Ondansetron: adverse fx
Constipation, headache, anxiety, dizziness, reduces effectiveness of tramadol if given together
What is the indication for Kwells?
Motion sickness - blocks ACh receptors in vestibular apparatus which decreases vagal stimulation of the medulla
What is the indication for Buscopan?
Abdominal cramps - blocks ACh receptors in smooth muscle of GI tract which reduces spasms
What is the indication for promethazine (phenergen)?
N&V associated with inner ear disturbances
Name five classes of antimicrobial drugs
Antivirals, antibiotics, antifungals antiprotozoals, antihelminthics (for worms)
General adverse reactions for most antimicorbials
Diarrohoa, nausea, vomiting, skin rashes, gives, pruritus, thrush, anaphylaxis, nephrotoxicity
Define bactericidal
The drug kills the organism
Define bacteriostatic
The drug inhibits the growth of the organism
Features of a gram positive organism
Have no outer lipid membrane, appears blue upon staining
Features of a gram negative organism
Have an outer lipid membrane, do not stain with blue dye
Features of eukaryotes (human cells)
Have nucleus and a cell membrane but no cell wall
Features of prokaryotes (bacteria)
Do not have a nucleus. Has a cell wall and a cell membrane.
Antibiotic vs antibacterial
Antibiotic = substance produced by micro-organisms that inhibits other micro-organisms. Antibacterial = a chemically modified antibiotic or a synthetic drug.
Stages of wound healing
1. Inflammation; 2. Proliferation / epithelialisation / organisation; 3. Regeneration / fibrosis
Primary intention healing is...
Closure by a surgical suture / staple. Edges are well approximated.
Secondary intention healing is...
Spontaneous healing - the edges aren't approximated. Healing occurs from the base upwards.
Tertiary intention healing is...
When the wound is purposefully left open to allow for oedema or infection to resolve, before being closed up by sutures, stapes or adhesive skin closures. Also called "delayed primary closure."
What is the nurse's role in preventing antibiotic resistance?
Know the indications for the AB (judicious use); participate in audits; Provide pharmacoeducation to ensure that the Pt and family know how to use the AB correctly according to prescriber's instructions; participate in audits; recognise the causes of AB resistance and take measures to prevent it (e.g. careful preparation of IV drugs); facilitate wound culture testing as required
The apex of the heart in a child is located...
In the 4th intercostal space, left of the mid-clavicular line
Developmental assessment covers a number of areas, which include...?
Fine motor, gross motor, psychosocial, cognitive
Key differences between the paediatric and the adult respiratory system include...
Children's upper airways are: shorter & narrower; they have a small oral cavity with a relatively larger tongue; they have a long floppy epiglottis which is prone to swelling - meaning children air prone to airway obstruction. The bifurcation of the trachea is higher in children and a more acute angle into R&L bronchi - means it is easier for infection to enter the lungs