NURS 100 fundamental final
Which of the following would be considered subjective data?
dizziness, pain
opioid adverse effects
sedatioin resp. depression orthostatic hypotension urinary retention N/V constipation
what are 5 clincal manifestations for fluid volume deficit?
tachycardia, weak and thready pulses, hypotension, skin tenting, dry mucous membranes, oliguria and flat neck veins
vital signs
temperature pulse respiration blood pressure pain
What are 3 oxygen complications?
toxicity, induced-hypoventilation, skin breakdown related to equipment and combustion
An example of situational crisis and who is at highest risk
unanticipated loss caused by external factor, and someone with mental health issues.
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?
washing dishes
What is the best technique used to check placement of an NG tube?
x-Ray
Describe dehisence/evisceration and nursing interventions
Dehisence partial or total separation of wound and evisceration os dehisence with protrusion of viseral organs through wound opening. Medical emergency, cover wound with moistened sterile gauze.
Name and describe 4 landmarks for IM injections
Deltoid vastus lateralis ventrogluteal dorsogluteal
A nurse is caring for a patient who has just been diagnosed with terminal cancer. He states, "I don't care what the doctors say I am not going to die". What stage of grief is the patient experiencing?
Denial
The nurse is taking care of a 26 year-old woman who just had a colostomy bag placed. Which action made by the patient would indicate she is having a hard time adjusting to her new body?
Refusing to look or help with any care related to the colostomy
A nurse is providing an in-service on fire safety. Which on the following is in the correct order?
Rescue, alarm, contain, extinguish (RACE)
Which category drugs has the highest potential for abuse?
Schedule 1
What are the five types of wound exudate (drainage and describe?
Serous(clear, watery), purulent (yellow/green/brown), serosanguineous (pink watery), sanguineous(red), and purspsanguineous (pus and blood)?s
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?
Sit at the bedside while feeding the client.
Nursing interventions with enteral nutrition (6)
assessing placement, tolerance (residual checks Q4-6H), label date, time, and initials when opening bag, only hang for 24 hrs with tubing, water flush 30 ml Q4-6H, glucose checks Q6H, I & O, VS, and daily wts
What is the correct example of a pharmacologic classification?
calcium channel blocker
Which of the following would the nurse document as objective data?
cyanosis
a home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
Educating clients about the recommended immunization schedule for adults.
You are caring for patient who is legally blind. When you hand the client his food tray, which intervention should you take to promote feeding independently?
Explain to the patient where his food is located on the tray, using a clock formation.
A patient refuses to take his medication. What should the nurse do first?
Explore the reasons why the patient does not want to take his medication.
what are two nursing interventions only for fluid volume excess
Fluid restriction and diuretics
The nurse is taking care of a patient who is receiving NG tube feedings. The patient suddenly starts having diarrhea. What is most likely the cause of the diarrhea?
Formula intolerance
Normal Urine output is?
Greater than 30 Ml/Hr and 0.5 Ml/Kg/Hr
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the clients understanding of the process within the psychomotor domain of learning?
Have the client demonstrates the procedure
When gathering information as to why a patient is coming to the hospital. Which question would the nurse use to promote a conversation?
"what brought you to the hospital?"
The transplant coordinator comes to speak with your deceased patient's spouse about organ donation. The spouse states she is unsure of what to do? Which is an appropriate response by the nurse?
"what do you think your husband would have wanted?"
What are five early signs of hypoxemia and five late signs of hypoxemia
(EARLY) tachypnea, tachycardia, Hypertension, ALOC, restlessness, and pallor (LATE) Bradypnea bradycardia hypotension cyanosis dysrhythmias
Difference between enteral and parenteral nutrition
(enteral) is entering the GI tract (parenteral) is entering the blood stream
What are early signs of hypoxemia? (Select all that apply).
-Tachycardia -Nasal flaring -ALOC (Altered level of consciousness)
A nurse is going to administer a tuberculin test intradermally. What angle should the nurse insert the needle?
15 degrees
A nurse is preparing to administer Motrin 500mg PO every 8 hours. The amount avilable is 250mg tablets. How many tablets should the nurse adminster with each dose? (round your answer to the nearest whole number).
2 tablets
What is the value of FiO2 on room air?
21%
what angle is SUBQ?
45-90 degrees
timeframes for STAT, rountine, and now orders
5 mins for stat 30 before/after for rountine 90 minutes for now orders
Normal range for oxygen saturation
95-100%
Which patient would be a good candidate for hospice care?
A client who is terminal and needs pain management
The nurse is caring for a patient whose potassium is 3.1 mEq/L. The patient is scheduled to take 40 mEq/L PO daily. What should the nurse do?
Administer the potassium per order
What is the correct example of a therapeutic classification?
Antiemetic
The nurse gives the wrong medication to a patient. What is the first thing the nurse should do?
Assess the patient
A patient has been sent home with a terminal diagnosis, but denies hospice care. What should the nurse do first?
Assess the patient's understanding of hospice care
A patient has been sent home with a terminal diagnosis, but denies hospice care. What should the nurse do first?
Assess the patient's understanding of hospice care.
Which finding would confirm orthostatic hypotension?
BP sitting 140/70; BP standing 110/60
Which of the following would be clinical manifestations of someone who is dying? (Select all that apply).
Bradycardia Hypotension Mottling of the skin Cheyne-Stokes
Evisceration
Dehiscence with protrusion of visceral organs through wound
Four CS of a cultural/spiritual assessment is?
Call Cope Concerns Cause
The nurse is taking care of a patient who is getting his medications via NG tube. The NG tube keeps getting clogged. Which action is best for the nurse to take?
Check with pharmacy to see if the medication comes in liquid form.
A nurse is taking care of a patient who is experiencing a breathing pattern characterized by alternating periods of apnea and hyperventilation. The nurse should document this as?
Cheyene-Stokes respirations
5 clinical manifestations at the end of life and 3 nursing interventions
Cheyne stokes (death rattle) Tacky> brady, hypotension, diminshed reflexes, mottling skin, decreased urine output, incontinence, muscle loss, anxiety and life review.... Symptom management (pain control), keep clean, elevate HOB, and collaborative care
A nurse is measuring a patient's temperature. The nurse witnessed the client drink ice water. What should the nurse's action be next?
Come back in 20-30 minutes to check the temperture
5 Stages of grief
DABDA Denial, anger, bargaining, depression and acceptance
A patient is at increased risk for constipation. What type of diet should the patient be placed on?
Fiber
nurse is teaching a patient with right-sided hemiparesis how to use the Cane properly. Which instructions should the nurse include?
Hold the cane on the left side of the body to provide support for the weaker leg.
A patient who is on furosemide for CHF, should be monitored by the nurse for which adverse effect?
Hypokalemia
A nurse is taking care of a patient who is receiving palliative care. Which statement made to the nurse by the client would indicate an understanding of the treatment?
I am hopeful this will help with my discomfort
The nurse is watching a patient care for her hearing aids. Which of the following would indicates the patient understand how to take care of her hearing aids?
I will clean the hearing aids with a clean, dry cloth not with alcohol
A nurse is educating a patient who recently started taking aspirin. Which of the following education is correct?
Monitor for tinnitus
The nurse is admitting a patient with active TB. What PPE does the nurse need to gather? (Select all that apply).
N95 mask Negative pressure room Gown Gloves
A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?
Observe the rate, depth, and character of the client's respirations.
A nurse is caring for a patient who is on a PCA pump. Which education should the nurse provide to the patient? (Select all that apply).
Only you are allowed to push the pump for more medication. The pump will provide a constant plasma level. You will still be administered medication even if you do not push the button.
Values for hypoxemia (2 of them)
PAO2 < 80 MM HG and SPO2< 90%
a nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?
Position the client on his left side
When completing a skin assessment, which assessment is priority?
Pressure points
A nurse is consulting with the dietitian about a patient with a pressure ulcer. What should the patient's diet be high in?
Protein
Diet should include this to help in wound healing
Protein
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care?(select all that apply.)
Provide oral hygiene frequently measure the drainage from the NG tube every shift Secure the NG tube to the client's gown
The nurse is taking care of a patient who suddenly lost their father. The patient is unable to cope and feels depressed. Which type of crisis is the patient experiencing?
Situational
name and describe each pressure ulcer
Stage I (erythematous non-blanchable) Stage II (exposed dermis-partial thickness loss) Stage III (subcutaneous tissue, full-thickness loss, slough.eschar) Stage IV ( muscle, tendon, bone, full-thickness loss, slough/eschar), unstageable (can't determine extent, full-thickness, need to do)
What are early signs of hypoxemia? (Select all that apply).
Tachycardia Nasal flaring ALOC (Altered level of consciousness)
determining orthostatic hypotension
Technique: BP & HR in supine then change to sitting/standing (wait 1-3 mins) BP & HR if SBP dec. More than 20 mm hg and/or DBP dec. more than 10 mm hg w/ a 10-20% inc. in hr=orthostatic hypotension
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
The AP hangs the collection bag at the level of the bladder.
A patient has restraints applied to his wrists. Which clinical manifestation would be a sign the restraints are too tight?
The patients hand is cool and pale.
What is the correct way to insert an NG tube?
Tip of nose, to the earlobe, to the xiphoid process.
explain chovstek's and trousseau's sign and what two electrolyte imbalances are they positive for?
Touch the cheek (facial twitching), hypocalcemia Inflate BP cuff (carpal spasm) and hypomagnesemia.
A patient is developing a stage 3 pressure ulcer. What are some nursing interventions the nurse could use? (Select all that apply).
Turn the patient every 2 hours Apply barrier cream Keep patient clean and dry
A nurse notices a patient having a seizure. Which of the following should the nurse do? (Select all that apply).
Turn the patient to the side.Remove objects from around the patient.Place pillow under patient's head
A nurse is taking care of a patient who is being admitted for possible dehydration. His lab values read BUN 25 and creatine 1.9. Which lab value would be order to confirm dehydration?
Urine specific gravity
Three common nursing interventions for FVD and FVE
VS, I&O and daily weights
What is the best technique used to check placement of an NG tube?
X-ray
surgical asepsis
aim is to eliminate all micro-organisms from an object or area to prevent contamination "sterile technique"
medical asepsis
aim to reduce the number, growth and spread of micro-organisms "clean technique"
AND stands for
allow natural death
A nurse is caring for a patient post op abdominal surgery and the client tells the nurse he felt a pop early and his incision split open. What should the nurse do first?
apply a moist sterile gauze to the site
Complications with enteral nutrition (3)
aspiration, diarrhea, delayed gastric emptying, skin irritation and dehydration
percussion in physical assessment is
assessing location, shape, size, and density tissues
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
repeat each joint motion five times during each session.
what are two potassium reducing medications?
furosemide and sodium polystyrene
Airborne precautions
gown, mask(N95) and gloves. make sure patient is in negative pressure room
Elevated white blood cell count (WBC) test
greater than 11,000, test would be looking for white blood cells
elevated erythrocyte sedimentation rate (ESR)
greater than 22mm/hr for men greater than 29mm/hr for women
The number one way to prevent the spread of an infection is?
hand hygiene
The nurse is taking care of a patient and upon assessment she hears crackles in the lungs, +3 pitting edema, and notices the patient is short of breath. These are all clinical manifestations of what?
hypervolemia
Inflammatory process of injury healing
lasts 3 to 6 days hemostasis occurs controls bleeding with vasoconstriction delivers oxygen, WBC's, and nutrients via blood
Main difference between palliative care and hospice care?
less than 6 months to live
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?
lower the client to the floor and place a pad under the client's head.
Droplet precautions
mask, gloves, gown and eye cover
Proliferative stage of injury healing
next 3 to 24 days replaces lost tissue contracting wound edges and resurfacing of epithelial cells
Maturation or remodeling stage of injury healing
occurs after 21 days and up to 1 year strengthening of collagen scar
what are 3 key points with suctioning?
only suction when needed, hyperoxygenate 100% 3min before.< 15 seconds on removal, 1min. between attempts, only 2 attempts in 5 mins, assess before and after
Four nursing interventions to prevent cauti's
only when necessary, sterile technique on insertion, peri care at least Q8H, hang bag below bladder, increase fluids and only good for 30 days.
Incubation period
organisms growing and multiplying
Dehiscence
partial or total rupture
What are three components of chest physiotherapy (CPT)?
percussion, vibration and postural drainage
Prodromal stage
person is most infectious, vague and nonspecific signs of disease
Full stage of illness
presence of specific signs and symptoms of disease
Convalescent period
recovery from the infection
What solution is used to clean wound before obtaining specimen?
0.9% sodium chloride (normal saline)
A patient presents to the emergency room with a productive cough, blood in his sputum, and a positive AFG test. What isolation precautions should the patient be placed on?
Airborne
inspection is physical assessment
assessing size, color, shape, position and symmetry
Palpation in physical assessment is
assessing temperature, turgor, texture, moisture, vibrations and shape
auscultation in physical assessment is?
assessing the four character and duration
patient education for aspirin and acetaminophen is
reports bleeding, ringing in ear, and not taking if 19 with viral infection (aspirin). avoid alcohol, do not exceed 3gm/day, and routnine blood pressure (acetaminophen)
A nurse administered morphine to a patient. When she came back to assess the patient, the patient's respiratory rate was 6. What medication should the nurse adminster?
Furosemide
A patient on isolation for MRSA needs wound care to be done on her infected wound. Which PPE should the nurse take with?
Gown and sterile gloves
