FINAL EXAM REVIEW
Which sign could be related to acute bronchitis? Select all that apply. One, some, or all responses may be correct.
Cough Fatigue Chest pain Sputum production Dyspnea on exertion Wheezing or rhonchi
What signs should you look for with a pt that just returned from a cardiac Cath?
Respiratory distress Pain Check for bleeding at the site
When would infection control precautions be discontinued for a client with active tuberculosis (TB)?
Three consecutive negative sputum tests
The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching?
"I will take enteric-coated aspirin for my headache because it is coated."
A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be avoided. Which response by the nurse is appropriate?
"Scratching results in skin breaks that can lead to infection."
What are normal PTT levels?
1.5-2.5
A nurse must administer streptomycin 1 g intramuscularly (IM) to a client with tuberculosis. The vial contains 500 mg/mL. How much solution must the nurse administer?__________ mL
2
What is a normal K+ level?
3.5-5.0 mEq/L
What are normal T4 levels?
4-12
The nurse is assisting with monitoring the functioning of a chest tube drainage system in a client who just retuned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? SATA
50mL of drainage in the drainage collection chamber The drainage system is maintained below the clients chest An occlusive dressing is in place over the chest tube insertion site Fluctuation of water in the tube of the water seal chamber during inhalation and exhalation
How many mg are in 1 grain?
65 mg
What is a normal blood glucose level?
70-110
What are normal T3 levels
70-204
What is a normal calcium level?
8.5-10.2
Which condition may cause respiratory alkalosis?
Asthma
Which is a clinical manifestation of metabolic alkalosis?
Atrial tachycardia
Who is at greatest risk for stroke?
AA and hispanic males with HTN
Where do you administer lovenox?
Abdomen
Which clinical finding indicates to the nurse that a client may have hypokalemia?
Abdominal distention
What tx plan do you use for a patient with asthma?
Albuterol Ipratropruim Methylprednisone
Which definition relates to hemoptysis?
Blood in sputum
Where are red blood cells made?
Bone Marrow
A pt had a reaction to a med but is ordered another dose, what should you do?
Call the MD
The nurse is caring for a postoperative client who has had a Jackson Pratt drain inserted into the surgical wound. Which actions would the nurse take in the care of the drain? SATA
Check the drain for patency Check that the drain is decompressed Observe for bright red, bloody drainage Maintain aseptic technique when emptying Empty the drain when it is half full and every 8-12 hours
The nurse is assigned with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water seal chamber. Based on this observation, which action would be appropriate?
Continue to monitor. This is a sign of a patent drainage system
Which is the cause of dyspnea in a client with emphysema?
Difficulty in expelling the air trapped in the alveoli
What med would you use to increase production of blood in an anemic patient
Epogen
A client has a tentative diagnosis of Cushing syndrome. Which finding would the nurse expect on assessment?
Hypertension and moon face
What lab should you check frequently with a patient taking Warfarin?
INR (2-3)
When would a nurse expect increased pain and limited movement of the joints in a client with rheumatoid arthritis?
In the morning on awakening
Which finding would a nurse expect when assessing a diabetic client receiving long-term corticosteroid therapy admitted to the hospital with leg ulcers?
Inadequate wound healing
Which event occurs soon after the time of injury in a client who sustained minor skin injuries from an accident?
Migration of leukocytes to the site of injury
Which describes how coarse rhonchi sound in a client with chronic obstructive pulmonary disease (COPD)?
Moist rumbling sounds that clear after coughing
An adolescent who was admitted to the hospital with ketoacidosis is stable and receiving insulin subcutaneously. One hour after its administration the nurse enters the room and notes that the adolescent is diaphoretic and irritable. Which intervention is the nurse's priority?
Obtaining a blood glucose reading
Which position would the nurse encourage a client with chronic obstructive pulmonary disease to take to enhance respiratory function?
On edge of bed, leaning forward, arms folded and elevated
The nurse is assigned to care for a client who has a chest tube. the nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method would be used to monitor the client for crepitus?
Palpating the skin around the chest and neck for a crackling sensation
The nurse will monitor a client who experienced chest trauma for which sign of flail chest?
Paradoxical chest movement
What disease is treated with the med dopamine?
Parkinsons
Which measurement helps clients with asthma assess the severity of their symptoms?
Peak Expiratory Flow
Which test is used to diagnose sleep apnea?
Polysomnography
What outdoor activity is not safe for a patient that has sickle cell anemia disease?
Running a marathon
A client with a spinal cord injury tends to assume the low Fowler position excessively. Which area of the body is most vulnerable to the development of a pressure ulcer in this client?
Sacrum
The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection?
The presence of purulent drainage, and tender firmness palpable around the incision.
Which is a clinical manifestation of respiratory acidosis?
Tremors
What are the 3 factors in Virchows Triad?
Venous Stasis Endothelial Damage Blood Hypercoagukability
Heparin Sodium is prescribed for the client. Which laboratory result indicate that the heparin is prescribed at a therapeutic level?
aPTT of 55 seconds
What is a thrombus?
blood clot
What is used to diagnose leukemia?
bone marrow biopsy
What is an important sign of organ failure?
dark, scanty urine
What is aplastic anemia?
destruction or inhibition of red bone marrow (suppression)
what is a symptom of anemia?
elevated HR
What does ADH regulate?
fluid balance, it comes from the posterior pituitary gland
What type of diet should the nurse teach a diabetic to be on?
high protein, low carb, leafy veggies, low fat diet
What levels should you monitor for a child that has leukemia?
platelets
What are some signs of dehydration?
prolonged skin turgor dried cracked lips
What kind of risk factor can a pt change with CAD?
smoking
Why do we give B12 for anemia?
the pt may lack intrinsic factors for B12 absorption
What is the function of vasoconstrictor meds?
to narrow the blood vessels
What is a complication of sickle cell disease?
vaso occlusive problems
A client is reviving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? SATA
visual disturbances (halo) N/V Serum level of 2.3
When should you not give a patient oral meds?
vomiting, lethargic, sleeping
name an example of a growth hormone antagonist?
Insulin
If you have a pt on lasix which lab should you be checking frequently?
K+ Levels
The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via righht subclavian vein. The nurse prevents dislodgment of the pacing catheter by implementing which intervention?
Limiting movement and abduction of the right arm
What are some discharge teaching tips you should give a pt that's returning home after having a stroke?
Raised commode Shower chair hand rail in the bathtub
what area would you NOT use to take a temperature for a child with leukemia?
Rectal because it can cause bleeding
Which sound would the nurse document in the medical record when hearing a low-pitched sound over the lungs while percussing?
Resonance
The client who is hyperventilating is at risk for which complication?
Respiratory alkalosis
