Final Exam

Question 1

What is essential to note for IV potassium?

Answer 1

NEVER push potassium

Question 2

What is atelectasis?

Answer 2

collapse of the alveoli

Question 3

How can we prevent atelectasis?

Answer 3

encourage coughing/deep breathing, incentive spirometer

Question 4

What does poor skin turgor and dry mucous membranes indicate?

Answer 4

fluid volume deficit

Question 5

what may happen to the blood pressure during fluid volume deficit? What about the HR?

Answer 5

decreased BP
tachycardia

Question 6

How can we prepare a patient for an MRI?

Answer 6

remove jewelry or metal, remove transdermal medication patches and insulin pumps/implants

Question 7

Case study:
Exhibit 1
Patient is irritable, agitated, restless.
Exhibit 2
Nurse assesses client room and hears alarm beeping, overhead light is on, and TV is turned to full volume.

Which sensory condition are they likely
experiencing?

Answer 7

sensory overload

Question 8

what interventions should be implemented for fluid volume overload?

Answer 8

daily weights (same time, same clothes), for bed weight-1 gown, sheet, pillow, assess for weight gain, I & O s

Question 9

Which assessments are needed for suspected fluid volume overload?

Answer 9

breath sounds, check pulse, edema, JVD

Question 10

When is the STOP BANG assessment required?

Answer 10

to assess a pt for a need of sleep study r/t sleep apnea

Question 11

After assessing a post-op patient, a nurse auscultates all 4 quadrants of the pts abdomen and hears no bowel sounds after listening to each for 5 mins, what does the nurse suspect?

Answer 11

paralytic ileus

Question 12

Give 3 examples of individuals who are at high risk for CAUTI?

Answer 12

older adults, prolonged catheter use, and immune compromised

Question 13

What interventions can the nurse implement to prevent CAUTI?

Answer 13

-sterile technique
-routine perineal care
-bag below bladder
-empty bag regularly

Question 14

What should the nurse do if a patient requiring a blood transfusion states, “I’m Jehovah’s Witness and can’t take that?”

Answer 14

accept their refusal and document

Question 15

What condition may a patient develop if atelectasis is not treated?

Answer 15

fluid builds up making a place for bacteria to cause pneumonia

Question 16

What are the main indications of late stage hypoxia?

Answer 16

blue on lips and fingertips

Question 17

What type of medication causes extravasation?

Answer 17

vesicant

Question 18

Name the IV complication:
cold, pale, puffy

Answer 18

infiltration

Question 19

Name the IV complication:
redness, warmth, pain, burning, streaking

Answer 19

phlebitis

Question 20

what are the rights of medication administration?

Answer 20

med, dose, route, client, time, documentation

Question 21

What type of order is needed right away, where you must stop what you are doing and perform the task?

Answer 21

STAT

Question 22

What are some required components of a medication order?

Answer 22

patient name
medication name
dose
strength
route
specific instructions (frequency, take w/food, etc.)
reason for admin
provider signature

Question 23

The nursing student asks the RN what PPE they need to put on for contact precautions, how should the nurse respond?

Answer 23

gloves and gown

Question 24

What type of precaution requires face mask?

Answer 24

face mask (surgical)

Question 25

What type of solution can be used with blood products?

Answer 25

0.9 % normal saline (this is isotonic)

Question 26

How often does TPN tubing need to be changed to prevent infection?

Answer 26

every 24hrs

Question 27

what symptoms may a septic pt present with?

Answer 27

fever >100.4 F elevated HR BP trending downward

Question 28

What are s/s of sleep apnea?

Answer 28

daytime sleepiness, snoring, O2 drop while asleep, abrupt cessation to breathing

Question 29

What instruction should be provided for a midstream urine collection?

Answer 29

1. clean urinary meatus 2. start peeing 3. catch in cup from middle of stream, not the first drips

Question 30

A patient with a healing wound is due for a dressing change. The nurse assesses clear-light yellow drainage, free of blood. How can the nurse best document this finding?

Answer 30

serous drainage

Question 31

what consideration must be made while wasting a narcotic (controlled substance)?

Answer 31

another licensed nurse (RN) must be witness

Question 32

In addition to being incontinent, what else must a patient have to require a catheter?

Answer 32

perineal wound (not just incontinence alone)

Question 33

What does the presence of a bleb/wheal indicate for an intradermal injection?

Answer 33

effective administration

Question 34

what angle is indicated for an intramuscular injection?

Answer 34

90 degrees

Question 35

Mrs. Parker hears the RN tell the nursing student, "give this injection at a 45-90 degree angle." What type of injection can Mrs. Parker suspect they are giving?

Answer 35

subcutaneous

Question 36

This method is used for intramuscular injections to prevent the medication from leaking out of the muscle tissue.

Answer 36

z-track method

Question 37

What type of injection is an insulin injection?

Answer 37

subcutaneous (45-90 degrees)

Question 38

This type of drainage appears light pink and is watery.

Answer 38

serosanguineous

Question 39

How should green, yellow wound drainage be documented?

Answer 39

purulent

Question 40

what is known as the output of a stoma?

Answer 40

effluent

Question 41

Which stage of sleep is the most restful portion and is the period of time where vivid dreams occur?

Answer 41

REM

Question 42

what is a common sign of early hypoxia?

Answer 42

restlessness

Question 43

Upon removing staples, the nurse notices the incision site pulling apart, what should they do?

Answer 43

this is dehiscence, they must stop

Question 44

What are the benefits of colostomy irrigation?

Answer 44

increases quality of life provides scheduled bowel movements

Question 45

What should the nurse promote in patients to help thin secretions for pts with pneumonia?

Answer 45

increase fluid intake

Question 46

Provide some examples of food that the nurse should encourage their pt to eat who is trying to promote wound healing?

Answer 46

beef, eggs, cottage cheese

Question 47

What should TPN be administered through?

Answer 47

central line (device that terminates in a great vessel)

Question 48

What electrolyte are bananas and potatoes good sources of?

Answer 48

K + (potassium)

Question 49

What foods should be avoided on a low sodium diet?

Answer 49

junk food, canned food, and fast food

Question 50

What foods should the nurse encourage for a client who has low calcium?

Answer 50

dairy, tofu, and broccoli

Question 51

Nuts, seeds, fatty fish, and dark chocolate are foods high in which electrolyte?

Answer 51

magnesium

Question 52

What condition may a client experience if TPN is discontinued abruptly?

Answer 52

hypoglycemia

Question 53

What components are in lipid solutions?

Answer 53

fatty acids and additional calories

Question 54

While preparing a lipid solution, the nurse notices a pepper like substance floating on the top, and the the contents look similar to a lava lamp. What should the nurse do?

Answer 54

The nurse should not use this solution. Do not try to mix it back together, get a new one.

Question 55

What interventions can be implemented for the treatment of RLS (restless leg syndrome)?

Answer 55

limit caffeine and alcohol and implement exercising potential need for medication

Question 56

What type of breathing may indicate hypoxia?

Answer 56

rapid, shallow w/dyspnea

Question 57

Why should pts remain upright for 1 hr following bolus tube feedings?

Answer 57

to prevent aspiration

Question 58

How can the nurse determine correct placement of the feeding tube?

Answer 58

aspirate gastric secretions (use pH indicator strip)

Question 59

Why is it important to check the expiration date on enteral feeding solutions?

Answer 59

expired formula may promote transmission of microorganisms

Question 60

What statement by the RN to the new grad nurse demonstrates the correct rationale for tube-feeding formula to be at room temperature before administration?

Answer 60

"cold formula causes gastric cramping and discomfort"

Question 61

How can we promote client comfort and autonomy for vaginal installation medication administration?

Answer 61

ask them if they are able to do it on their own

Question 62

What condition is excessive daytime sleepiness often associated with? What is the treatment for this?

Answer 62

sleep apnea CPAP

Question 63

Stage this wound: skin intact, nonblanchable erythema

Answer 63

stage 1

Question 64

Identify the wound stage: full skin loss w/possible muscle, bone, or tendon or tunneling

Answer 64

Stage IV

Question 65

Which pressure injury stage is marked by full skin loss, damaged subcutaneous tissue, and potential for visible fat?

Answer 65

Stage III

Question 66

Which stage of pressure injuries may look similar to a blister, but no fat tissue is visible?

Answer 66

Stage II

Question 67

The patient has a very dry appearing wound, what type of dressing may the nurse prepare to administer?

Answer 67

hydrogel or hydrocolloid

Question 68

The patient has a foul smelling wound with stringy yellow exudate, what type of wound dressing would the nurse prepare to apply?

Answer 68

Aquacel Ag (silver)

Question 69

What is orthopnea?

Answer 69

SOB while lying down

Question 70

A patient is newly prescribed take home O2 via nasal cannula, what are some teaching points the nurse should make?

Answer 70

NO smoking with O2 cotton fabric only heat sources >10ft away caution not to dent canister

Question 71

While obtaining the pts BP, the nurse notices spasm/contraction of the hand. Which electrolyte change can the nurse MOST likely prepare to treat?

Answer 71

hypocalcemia

Question 72

What is the nursing priority for central lines?

Answer 72

sterile technique

Question 73

Which statement by the new grad nurse BEST demonstrates understanding of how to prevent speed shock?

Answer 73

giving medications at their recommended push rate

Question 74

What s/s may indicate speed shock?

Answer 74

facial flushing, irregular pulse, headache, hypotension, LOC, cardiac arrest

Question 75

Immediately following administration of IV med administration the nurse assesses facial flushing and hypotension, what actions should the nurse take?

Answer 75

this is speed shock, the nurse should clamp IV, notify MD, apply O2 if indicated, and continually monitor vital signs

Question 76

Why should we prep the feeding tube with enteral feeding solution prior to administration the feeding solution?

Answer 76

prevents excess air from entering GI tract once the infusion begins (less discomfort)

Question 77

What is a priority nursing intervention for a client with impaired cognition receiving enteral tube feeding?

Answer 77

gastric residual checks, as this decreases the risk of aspiration