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CEN "Must Knows" and "Critical Thinking"

PDB Nurse Education, LLC CEN “Critical Thinking” and “Must Know”

1. What infection is characterized by fever, chills, night sweats, Janeway lesions, Osler nodes, and a new-onset heart murmur? Endocarditis.

2. What shock state is suspected in the pediatric patient with tachycardia, tachypnea, fever, bounding peripheral pulses, and flash capillary refill? Septic shock.

3. How do you treat the patient with a decreased preload due to gastroenteritis? Infuse isotonic fluids intravenously.

4. Why is digoxin used in the management of heart failure. Digoxin is a positive inotrope used to increase contractility.

5. What is the purpose of drug-assisted intubation? The purpose is to reduce the risk of aspiration, so place the patient in a ramped position, and passively pre-oxygenate the patient with high-flow oxygen, not with a BVM. Review the ACLS and TNCC airway chapters for more information.

6. Why is breathing effectiveness a concern with rib fractures? Rib fractures are painful, so the patient takes shallow breaths. Treat pain with nerve blocks, lidocaine patches, and NSAIDs. Narcotics reduce breathing effectiveness.

7. What acid-base imbalance in seen in a patient with bradypnea? Respiratory acidosis with hypoxia, high PaCO2 with low pH and PaO2

8. A patient with a femur fracture returns 36 hours post-op with restlessness, dyspnea, and a petechial rash along the axillae. The nurse suspects what life-threatening disorder? Fat embolism syndrome.

9. What are the first steps in neonatal resuscitation? Dry, warm, position, and stimulate following NRP algorithm.

10. A patient with which type of posturing has a lower chance of survival? Decerebrate posturing indicates damage to the brainstem.

11. Why is monitoring the patient’s level of consciousness (LOC) and assessing for headache the most important parts of assessment after the administration of r-TPA? If the patient’s LOC decreases or they complain of a headache (even ocular pain), the patient may have an intracranial bleed, so stop the r-TPA and notify the provider STAT.

12. What are signs and symptoms of an obstructed ventricular peritoneal (VP) shunt in a patient with hydrocephalus? Vomiting, lethargy, bulging fontanelles in infants, ataxia in children. Many obstructions occur during growth spurts.

13. What ECG change do you see in hypokalemia? Flattened “T” wave.

14. How do you know the treatment of corticosteroids has been effective in Bell’s palsy? The symptoms resolve, so the patient can close the eye they could not close on arrival to the ED.

15. What is the purpose of lifting the presenting part off the umbilical cord in prolapsed cord? To prevent fetal anoxia, palpate the umbilical cord for a pulse to ensure effectiveness.

16. Why do you NOT apply a pressure dressing in patients with eyelid lacerations? Hyphemia's and ruptured globes are commonly seen with eyelid lacerations. Apply a rigid shield instead.

17. Why do you advise the patient with a hyphema NOT to take NSAIDs? NSAIDs create bleeding.

18. Why do you NOT apply a tourniquet in pit viper snake bites? The venom accumulates in one area causing more damage. Never apply ice or administer NSAIDs that would promote bleeding. Initial management includes immobilizing the extremity in a neutral position.

19. Why is applying a tourniquet NOT the first step in stopping active bleeding? Tourniquets cut off the blood supply distally, so the patient may lose the extremity. Direct pressure is always the first step in stopping active bleeding, as taught in the “Stop the Bleed” program.

20. Why do you only gently rinse amputated parts? Scrubbing the severed part would damage it making it less likely to be successfully replanted.

21. What is the purpose of applying a traction splint in a femur fracture? Splints decrease bleeding and pain.

22. Why would you NOT treat a patient who is hyperventilating by asking them to breathe into a paper bag or applying a non-rebreathing mask without oxygen? The patient may be hyperventilating due to a pulmonary embolus of myocardial infarction. Set the tone and be supportive, while encouraging the patient to breathe through pursed lips.

23. Why is important to inquire about previous suicide attempts, history of mental illness, alcohol/drug abuse, and family history of suicide in patients with suicidal ideation? Patients who have previously attempted suicide are most likely to attempt suicide again. In addition, the other histories increase the risk.

24. Which medications are more likely to cause neuroleptic malignant syndrome? Antipsychotic medications Haldol and Thorazine.

25. What communicable infection is suspected in a child with red eyes, runny nose, white spots in the mouth, and a maculopapular rash along the forehead? Measles. A vesicular rash is seen in chicken pox.

26. Why is the patient in cardiac arrest not tagged as RED during a mass casualty disaster? In a mass casualty, follow disaster triage using START based on RPM. Patients tagged as RED spontaneously breathe when airway is opened but have respirations < 10 or > 30 (like a patient with a tension pneumothorax, or have a capillary refill > 2 seconds, or are unable to follow commands. The goal of disaster triage is to help the most victims.

27. What is the purpose of following the chain of custody? To ensure integrity of the evidence.

28. After inquiring about chief complaint, what is the next question to ask a transgender patient? What pronouns they would like to be referred to by (he, she, they) and note in the medical record. Also ask if they are taking any hormones or have undergone surgeries to align with their gender.

29. Any hospital death of a patient in physical restraints must be reported to which organization? Report to the Centers for Medicare and Medicaid Services (CMS) as a sentinel event.

30. What are key elements of forensic documentation? Never change the patients' words to “clean it up”, use quotation marks whenever possible, and never use the word “alleged” in the medical record.

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