Which nursing action is important when suctioning the a client with a tracheostomy?

Initiate suction as the catheter is being withdrawn.

Signs of increased ICP include ______________.

AMS, unequal pupils, low HR, high BP

Nursing care for patients with Parkinson's should focus on

Helping the pt function at their highest level

Signs and symptoms of Right sided heart failure are

JVD , edema or ascites , increase HR

A disorder in which to lose weight one refuses to eat

Before providing trach care you should FIRST....

complete a respiratory assessment and check 02 Sat

Early signs of hypoxemia in the adult immediately after anesthesia may include:

restlessness, confusion, anxiety

Which of the following statements is true of chest tubes?

The chest drainage must be observed for amount and color

What should be done once a day on a patient with cirrhosis?

Daily weights and measure abdominal girth

When your CD4 T cells fall below 200 due to HIV infection

Medications for Alzheimer's do what?

Slow down symtoms and improve quality of life

Which COPD pt should the nurse assess first?

52-y.o. in a tripod position using accessory muscles

A client with MS is prescribed Baclofen. Which statement should the nurse include?

"This medication may make you tired."

Client with low literacy level is learning self- injection of insulin. Which strategy to promote client understanding?

Ask the client to demonstrate the skill.

What kind of patient cannot take Isoniazid?

pts with liver diseases (Hepatitis, Cirrhosis)

What is the role of the State Board of Nursing?

To regulate nursing practice and protect the public

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Final Exam Prep SP22

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Questions 73

Answers

1
What is a sign/symptom of Lithium toxicity?
Depression
Insomnia
Irregular Heartbeat
Vomiting
2
Which is not a reason to administer Vasopressin:
Hypertension
Decreases portal blood flow & portal htn
Vasoconstriction
Decreases bleeding & esophageal varices
3
What can cause a high pressure alarm on a mechanical ventilator?
Water in the inspiratory limb of the circuit
Patient developed a pneumothorax
All of the above
Patient coughing
4
A Nurse is held accountable for tasks that are delegated
depends
false, the worker is
not usually
true
5
Normal calcium level:
7.5-11 mg/dl
8.5-10 mg/dl
10.5-13 mg/dl
5.5-7.0 mg/dl
6
While assessing lung sounds in an asthmatic patient, you would MOST likely expect to hear
snoring.
stridor.
crackles.
wheezing.
7
Accrediting agency that focuses on safe, quality patient care and continuous improvement:
Evidence-based practice (EBP)
Diagnosis-related groups (DRGs)
Health Insurance Portability & Accountability Act (HIPAA)
The Joint Commission (TJC)
8
What are some signs of Digoxin Toxicity
Glaucoma
Macular Degeneration
Cardiac Arrhythmias, halos
Diplopia
9
Which nursing action is important when suctioning the a client with a tracheostomy?
Initiate suction as the catheter is being withdrawn.
Remove the inner cannula before inserting suction catheter.
Insert the catheter until the cough reflex is stimulated.
Use a new sterile catheter with each insertion.
10
What kind of diet should a patient with cirrhosis follow?
Decreased protein
Increased fat
Increased protein
Decreased fat
11
What is a sign of a patient having active esophageal varicies?
bright red emesis
large abdominal distention
clay colored stool
jaundice skin
12
Antidote for warfarin
Steroid
Protamine Sulfate
Prednisone
Vitamin K
13
Eating disorder in which guilt and shame leads to the purge of the food eaten in excess.
Bulimia
Vomit
Binge Eating
Anorexia
14
Signs of increased ICP include ______________.
AMS, irregular HR, Battle's sign, low BP
unresponsiveness, racoon eyes, Battle's sign
AMS, unequal pupils, low HR, high BP
agitation, high HR, low BP
15
Nursing care for patients with Parkinson's should focus on
Having family do majority of the care to preserve energy
Helping the pt function at their highest level
Getting the pt on a rigid schedule
Encouraging the pt to ask for help with ADLs
16
Dysrhythmias can be a sign of potassium imbalances.
False
True
17
What is the Normal INR range for a Pt. NOT on Warfarin?
1.5 - 2.5 X Normal
40 - 50
≤ 1.1
25 - 35
18
Signs and symptoms of Right sided heart failure are
anasarca , decreased HR , increased wt
murmur, no edema or ascites, hepatomegaly
JVD , edema or ascites , increase HR
19
Normal ICP?
2-10 mmHg
5-15 mmHg
10-20 mmHg
25-35 mmHg
20
Fidelity Definition
to be annoying
with a sharp point
the state of being faithful
unfeeling
21
Anorexia nervosa
A healthy way to become skinny
A disorder in which anxiety causes one to be unable to eat
A disorder in which one eats to appease societal norms
A disorder in which to lose weight one refuses to eat
22
Normal GFR?
>60 mL/min
≥40 mL/min
48 mL/min
15 mL/min
23
Before providing trach care you should FIRST....
complete a respiratory assessment and check 02 Sat
complete a full head to toe assessment
auscultate bowel sounds
suction
24
Decorticate movement is Abnormal flexion
True
False
25
Normal potassium level is between
5 and 7 mEq/L
2.2 and 3.4 mEq/L
1.3 and 3 mEq/L
3.5 and 5 mEq/L
26
Early signs of hypoxemia in the adult immediately after anesthesia may include:
restlessness, confusion, anxiety
symmetrical chest movement with normal breath sounds
pulse oximetry measurement of 92 - 96%
12 - 16 respirations per minute
27
Client with cirrhosis and ascites needs diet teaching. What should RN teach client?
Increase fluid intake
Chooses low sodium foods
Choose high protein foods
Reduce alcohol intake
28
Which of the following statements is true of chest tubes?
The drainage system must be kept above the resident's chest
The chest drainage must be observed for amount and color
Chest tubes will only be in the front of the body
The tubing should be kinked
29
When advising the elderly to move from a lying to standing position slowly they can be at higher risk of ?
increased vision accuracy
postural hypertension
orthostatic hypotension
decreased urinary output
30
What is a symptom of autonomic dysreflexia?
Hypotension
Watery eyes
Severe pounding headache
Stomachache
31
What should be done once a day on a patient with cirrhosis?
Daily weights and measure abdominal girth
Intake and output
Blood pressure and pulse
Withhold medications that could cause restlessness
32
AIDS
Human immunodeficiency virus
Accumulated Immunodeficiency Syndrome
Asymptomatic HIV infection
When your CD4 T cells fall below 200 due to HIV infection
33
Medications for Alzheimer's do what?
Make things easier on the caregivers
Slow down symtoms and improve quality of life
Stop Alzheimer's from developing
Make people happy
34
What is a late sign of increased ICP?
Slurred speech
Cushings triad
Nausea/vomiting
Agitation
35
Atenolol and Digoxin?
Hold for BP less than 200
Hold if Diastolic is greater than 90
Hold for pulse less than 90
Hold for pulse less than 60
36
anthrax is a _________ disease of livestock
bacterial
zoonotic
fungal
parasitic
37
Nursing Practice Act
manage care
perform delegated tasks
follow doctor's orders
meet Medicare and Medicaid standards
38
Chest Tubes are Inserted into the ____ Space
retroperitoneum
pericardial space
Viscera
pleural space
39
Which COPD pt should the nurse assess first?
46-y.o. with a 30–pack-year history of smoking
68-y.o. who has dependent edema and clubbed fingers
52-y.o. in a tripod position using accessory muscles
74-y.o. with a chronic cough and thick secretions
40
Which is a result of untreated increased ICP?
Hypothermia
Herniation
Autonomic dysreflexia
Encephalitis
41
Left sided congestive heart failure causes
shortness of breath
all the above
coughing
fluid in the lungs
42
Patients with renal disease should avoid which antiacid
calcium antiacid
WHAT????
aluminum antiacid
magnesium antiacid
43
A client with MS is prescribed Baclofen. Which statement should the nurse include?
"This medication may make you tired."
"This medication is used to take away your tremors."
"This medication will decrease your fatigue."
"This medication is to help you not be incontinent."
44
Which are risk factors for suicidal behavior?
Mental intelligence
Previous suicide attempt
Carefulness
Pride
45
Client with low literacy level is learning self- injection of insulin. Which strategy to promote client understanding?
Simplify terms using acronyms.
Ask the client to demonstrate the skill.
Provide a long teaching session.
Provide the client with written materials using large print.
46
What kind of patient cannot take Isoniazid?
Patient with neurological disorders (Myasthenia Gravis)
Tuberculosis Patients
What kinda drug is this?
pts with liver diseases (Hepatitis, Cirrhosis)
47
Baclofen increases and manages what?
Mobility and muscle spasms
bleeding and swelling
seizures and cough
Nothing, it sucks!
48
What is the role of the State Board of Nursing?
To keep trained people from practicing nursing
To regulate nursing practice and protect the public
To advocate for better working conditions for nurses
To defend nurses wrongfully accused of malpractice
49
A complication of cirrhosis is
clay colored stools
encephalopathy
goiter
elevated lipase enzymes
50
What is an early sign of increased ICP?
Bradycardia
Dilated pupil
Constipation
Lethargy
51
What causes esophageal varicies?
Cholecystitis
Fatty foods
Portal Hypertension
Ascities
52
What's the difference between latent TB and TB disease?
Latent refers to inside the body while TB disease is outside
Latent occurs in newborns while TB disease occurs in elders
Nothing; they're both the same thing with different names
One has active bacteria and one has inactive bacteria
53
Signs of increased ICP include the following:
Restlessness, ↓pulse, ↑BP and widening pulse pressure
Restlessness, ↓pulse, ↓BP and widening pulse pressure
Restlessness, ↑pulse, ↑BP and widening pulse pressure
Restlessness, ↑pulse, ↓BP and widening pulse pressure
54
Prone position for a patient with ARDS to increase Pa02? p. 1602
increase mobilization of pulm secretions
promote perfusion nonatelectatic alveloi in ant. port. lung
promote opening of atelectatic alv. in upper port. lung
decrease workload of the diaphragm and intercostal muscles
55
How many degrees should be head of the bed be elevated for a suspected head injury patient/ICP?
No elevation is needed for the patient
90 degrees
55-90 degrees
At least 30 degrees
56
signs and symptoms of autonomic dysreflexia
slowed HR
all the above
goose bumps
sudden rise in BP
57
Neuro - Why is pupil assessment important for a patient with a neurological injury?
Sluggish pupillary response can indicate a rise in ICP
Contracting pupils indicates pressure on the optic nerve
To assess whether the patient is conscious
To assess if patient is orientated to time/place/person
58
A person with latent TB infection can spread TB bacteria to others.
False, cannot
True
59
What is the first priority for a patient in VTACH rhythm?
Administer Lidocaine
Defib
Call MD
Check for pulse
60
What does the RN do with Evidence based research?
Integrates evidence and research into practice
finds examples how it doens't work
Do what the manual says
create a form to be filled out when charting
61
what is not related to Wasting syndrome?
chronic diarrhea
Protein energy malnutrition
unexplained weight gain
10% weight loss and
62
The nurse is preparing discharge education after hospitalization for a hemorrhagic stroke. What should the nurse include
Mild, intermittent seizures can be expected
Take ibuprofen for complaints of a serious headache
Take antihypertensive medication as ordered
Drowsiness is normal for the first week after discharge
63
Which of these are all symptoms of emphysema?
wheezing, shortness of breath, heartburn
Difficulty breathing, wheezing, obesity
Difficulty breathing, chest tightness, shortness of breath
Bleeding from mouth, chest tightness, difficulty breathing
64
What effect does Warfarin have on tests?
Increased PT/INR, Increased aPTT
Decreased PT/INR, Increased TT
Increased PT/INR, Increased BT
Decreased PT/INR, Decreased aPTT
65
A pt. w/ increased ICP be on seizure precautions.
True
False
66
Which finding would be consistent with autonomic dysreflexia?
Hypertension
Hypotension
Tachycardia
Constricted pupils
67
You hear a high pressure alarm on the ventilator, what should you do?
Listen and the alarm should go off in 5 minutes.
Instruct the CNA to silence the alarm
Check the patient; the patient may need suction
Reposition the endotracheal tube and deflate the cuff.
68
Define: Personal Protective Equipment (PPE)
Where pathogens live and multiply
Barrier between a person and a potentially harmful organism
The biological agent that causes disease
to isolate the potentially harmful microorganism
69
A patient with cirrhosis may have alterations in which laboratory value?
Prothrombin time
pH
Carbon dioxide level
White blood cell count
70
What is the Normal INR range for a Pt. ON Warfarin?
2 - 3
11 - 13.5
25 - 35
40 - 50
71
A client with C. Diff diarrhea would be on this type of precautions
Contact
Droplet
Airborne
Routine
72
Which assessment finding has the most serious implications for a client with emphysema?
Bilateral crackles throughout the lung fields
Circumoral cyanosis
Increased anterior - posterior diameter of the chest
Pursed- lip breathing
73
What are some side effects after dialysis?
All of the above
Low blood pressure
Abdominal and muscle cramps
Nausea and vomiting

Final Exam Prep SP22 Flashcards | StudBud