What is the nursing priority for a pt in anaphylactic shock?

Position pt's head to maintain open airway

What are age related changes in the immune system*?

Failure of immune system to differ self from non-self, Increased hematuria, Altered nutritional intake

What indicates a positive Mantoux test?

patient has been infected and has a T-cell response

RN forgot to admin. a med that causes an adverse incident to the patient. Why is it negligence

She failed to perform a necessary procedure

Patient begins to hyperventilate w/ news of breast cancer. Complains of tingling fingers/lips

Have the patient breath into a paper bag

Which activities would RN perform post-op to decrease risk of complications*

Monitor vitals on a regular basis, Assist the pt to turn, breath deeply and cough every 2 hours, Assess the drainage from the surgical site

What dietary adjustments should RN recommend to older adult to prevent/manage constipation*?

Drink more juice and water, More fruit and fiber

Pt w/ risk of injury r/t decreased vision. The client will benefit MOST from ...

become oriented to the position of the furniture and stairs

Which of the follow is an example of fidelity?

Returning to explain results after stating your intent

What are nursing interventions for hypothermia

Adjust room temp, monitor pt temp, Use warm blankets, limit exposed skin surface, warm lavage, Humidify airway

What is the nursing care goal for a client who is at risk for injury?

The patient will remain free from injury

How should the nurse evaluate the effectiveness of home care teaching on wound care*

Have the pt or caregiver verbalize the procedure, Have the pt or caregiver demonstrate the procedure

What is the RN's first step to determine best practice to prevent pneumonia after heart Sx?

Search for evidence via case studies

What should a patient expect after Sx for ulcerative colitis

Placement of stoma with collection bag attached at all times

What statement by pt indicates need for additional teaching for pre-op patient

I will go to the bathroom right after I take my pre-op meds

What are the concerns with NSAIDs to treat the patient with arthritis*?

Patient has increased risk of bleeding, Risk of GI toxicity

What effects does the aging process have on thermoregulation*?

More likely to develop adverse effects from extreme temps, Loss of fat, lower body temp, feeling cold, Average body temp is 96.8

A client on prolonged bed rest, nurse observing for signs assoc. w/ immobility. Nurse alert to*

muscle weakness, decreased peristalsis, skin breakdown

Appropriate interventions for pt with Hypovolemia*

Monitor electrolytes, Encourage fluid intake, I&O daily

Why would a senile dementia pt be incontinent of urine*?

Loss of sphincter control, Mental inability of voluntary control

Priority Nsg action in pt with urinary retention who has an indwelling catheter

Provide catheter care every shift

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Nursing 1 Final Review

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Answers

1
What is the nursing priority for a pt in anaphylactic shock?
Place oxygen on patient
Administer epinephrine
Call MD
Position pt's head to maintain open airway
2
What are age related changes in the immune system*?
Increased response to immunogens
Failure of immune system to differ self from non-self
Increased hematuria
Altered nutritional intake
3
A patient who smokes will receive what Rx post-op?
Rx for nicorette after they are discharged
Rx to decrease alcohol cravings
Rx to reduce nicotine cravings
Rx to reduce anxiety
4
for intravascular dehydration with cellular fluid overload...e.g. D5LR, D51/2NS, D5NS
Hypertonic
Hypotonic
Isontonic
5
What indicates a positive Mantoux test?
IgA increased
patient has been infected and has a T-cell response
hives
fever
6
What is the stage of infection when a person might be contagious?
Incubation
Convalescence
Infection
Prodromal
7
RN forgot to admin. a med that causes an adverse incident to the patient. Why is it negligence
Bitch, please. "Forgot"?!? yeah right
Battery means it was intentional
She failed to perform a necessary procedure
Because harm was caused to the patient
8
Patient begins to hyperventilate w/ news of breast cancer. Complains of tingling fingers/lips
Tell the patient to calm down, it could be worse
Sing to the patient to help her relax
Have the patient jog in place
Have the patient breath into a paper bag
9
Finds indicative of Systemic manifestations of inflammation*
Fatigue
Discharge
elevated WBCs
Fever
10
Which activities would RN perform post-op to decrease risk of complications*
Restrict the number of visitors during the first 24 hours
Monitor vitals on a regular basis
Assist the pt to turn, breath deeply and cough every 2 hours
Assess the drainage from the surgical site
11
What dietary adjustments should RN recommend to older adult to prevent/manage constipation*?
More lean protein and dairy
Add a multivitamin
Drink more juice and water
More fruit and fiber
12
Positive sign of response to injury and host defense
fever
thermoregulation
malaise
rash
13
Sodium 142, K 2.5, Ca 8.5, chloride 98. Electrolyte disturbance?
Hypocalcemia
Hyperkalemia
Hypernatremia
Hypokalemia
14
Pt w/ risk of injury r/t decreased vision. The client will benefit MOST from ...
sell his house and move to assisted living
have a friend or family member move in to the home
become oriented to the position of the furniture and stairs
having a seeing eye dog
15
Which of the follow is an example of fidelity?
Returning to explain results after stating your intent
Holding the hand of a scared teen until they fall asleep
Respecting pt wish to cancel Sx to get a 2nd opionion
Report abuse witnessed by a CNA to a patient
16
What are nursing interventions for hypothermia
Adjust room temp, monitor pt temp
Use warm blankets, limit exposed skin surface, warm lavage
Humidify airway
Place the patient in a hot shower
17
What is the nursing care goal for a client who is at risk for injury?
The patient will acknowledge their risk for injury
The patient will remain free from injury
The patient will do their best to avoid injury
The patient will identify factors increasing injury risk
18
What type of Immunity is provided via IV administration of IgG?
Passive
Innate
Altered
Active
19
How should the nurse evaluate the effectiveness of home care teaching on wound care*
Have the pt or caregiver verbalize the procedure
Have the pr read the written instructions provided outloud
Have the pt or caregiver demonstrate the procedure
Document the caregiver's statement "OK, we'll manage"
20
What increases chance of allergy to IVP (intravenous pyelogram)
Test anxiety
Allergy to tetracyclines
Taking blood thinners
Allergy to shellfish
21
What is the cancer mnemonic?
C A U T I O N
C H E M O
F A T A L
C A N C E R
22
What's the #1 goal for Rheumatoid Arthritis?
Increase physical activity
Find a cure
improve fine motor skill function
Control inflammation
23
RN suspects a pt who abuses which medication is at risk for metabolic alkalosis
Alchohol
Milk of magnesia
Tums
Senna
24
Pt presents with skeletal pain and tenderness w/o Hx of injury and has a waddling gait
osteomalacia
hypokyphosis
osteoarthritis
osteoporosis
25
What is the RN's first step to determine best practice to prevent pneumonia after heart Sx?
have the pt use an incentive spirometer 1 hour after Sx
Ask the other nurses what works best
Search for evidence via case studies
Keep patient supine for full lung expansion
26
RN primary concern re: psychological adaptation for a toddler post-op
separation from parents
anxiety
separation from security blanket
depression
27
What should a patient expect after Sx for ulcerative colitis
Placement of stoma with collection bag attached at all times
Pain and only pain
Staying in bed for 48 hours following surgery
Going home the same day
28
What is the primary prevention tool for Colon Cancer Screening?
Digital rectal exam
Colonoscopy
Occult Blood testing
Genetic screening for Lynch syndrome
29
When applying cold therapy, the cold should be applied for how long a period of time?
30 minutes at a time
20 minutes at a time
45 minutes at a time
15 minutes at a time
30
What statement by pt indicates need for additional teaching for pre-op patient
I will go to the bathroom right after I take my pre-op meds
I will leave my valuable jewelry at home
I will remove my nail polish before arriving
I will not eat anything for 6-8 hours before my surgery
31
Exposure to what molecules illicit an immune response?
pathogens
mold spores
parasites
Immunogens
32
What's the best indicator for fluid status?
daily weight
electrolyte levels
Monitoring I&O
ask the patient if they are thirsty
33
Which age group do nurses make car crashes a priority teaching topic when it comes to safety
20-40
13-19
65 and older
41-65
34
What are the signs of IV site infiltration
swollen, pain, warm, blanchable
swollen, no pain, weeping, red
swollen, pain, cool, pale
swollen, pain, warm, red
35
Which if the following assessments with the complete first for a pt that had general anesthesia
Patent airway
Ascultate bowel
Circulation
Apical pulse
36
Medications given for a fever*
Ibuprofen
acetaminophen
Aspirin
antiemetic
37
High caffeine intake can increase the risk of which condition?
Irritable bowel syndrome
Osteomalcia
Osteoporosis
Osteomyelitis
38
What are the concerns with NSAIDs to treat the patient with arthritis*?
They have to be taken for prolonged period of time to work
NSAIDs have addictive properties
Patient has increased risk of bleeding
Risk of GI toxicity
39
What effects does the aging process have on thermoregulation*?
More likely to develop adverse effects from extreme temps
Loss of fat, lower body temp, feeling cold
Average body temp is 96.8
Feel warmer than those of younger ages
40
A client on prolonged bed rest, nurse observing for signs assoc. w/ immobility. Nurse alert to*
muscle weakness
decreased peristalsis
positive mental attitude
skin breakdown
41
Pressure ulcers form primarily as a result of
Improperly turning a patient
Being too thin
Tissue ischemia
too much pressure
42
Appropriate interventions for pt with Hypovolemia*
Monitor electrolytes
Encourage fluid intake
Push potassium rich foods
I&O daily
43
causes fluids to move out of vessels...0.45%NS, 0.25%NS...caution for cellular edema
Hypertonic
Hypotonic
Isotonic
44
Pt education when given Rx for trimethoprim-suflamethoxazole (Bactrim)
Decrease fluid intake while taking medication
Stop taking when symptoms improve
Avoid tyramine rich foods
Do not take with antacids
45
Inspection - Auscultation - Percussion - Palpation when assessing what part of the body?
Abdomen
Heart
Kidneys
Lungs
46
Why would a senile dementia pt be incontinent of urine*?
Loss of sphincter control
Mental inability of voluntary control
It's a normal part of the aging process
Forgets where they are headed when going to the restroom
47
Priority Nsg action in pt with urinary retention who has an indwelling catheter
Irrigate the catheter
Monitor I & O
Provide catheter care every shift
Replace catheter
48
Outcome of the post-surgical elderly patient
Improved cognitive function
Palliative care
Still breathing
Depends on severity of illness
49
What is an appropriate nursing goal for a 2 year old after tonsilectomy?
increased social interaction with nurse
decreased separation anxiety
decreased level of pain
increased appetite
50
What is the inability to stop urine flow long enough to get to the toilet?
functional incontinence
Nina-waits-to-go syndrome
Urge incontinence
Stress incontinence
51
What causes Nociceptive pain*?
cut
Burn
broken bone
nerve injury
52
Post abd. Sx pt going home. RN knows teaching effective if pt does which of the following*
Restates signs and symptoms of infection
Performs the dressing change as prescribed
Completes regiment of antibiotics
States she will remain on bedrest until her doctor appt.
53
What is the reason for culturing the exudate of a wound
To determine the type of pathogen causing the infection
To make the patient have to stay in the hosital longer
Because the lab needs practice identifying pathogens
To determine the source of the infection
54
Dc pulse, RR, & BP; shivering, pale, cool, shiny skin, dc urine output, disoriented, dizzy ...
Hyperthermia
Hypocalcemia
Hypercalcemia
Hypothermia
55
Which client at greatest risk for compromised immunity
Client who just had surgery
Client who travels extensively for work
Client who eats a healthy diet and exercises
Client who works in a daycare setting
56
What are nursing interventions for hyperthermia
Limit exposed skin surface
Blood cultures, count, sed rate, and electrolytes
Use of antipyretics and antibiotics
Provide, fluid, rest, and reduce activity, change damp linen
57
treats intravascular dehydration...e.g. 0.9% NS, LR D5W
Hypertonic
Hypotonic
Isontonic
58
RN priority action for pt with reduced immune function?
Place contact precautions on pt's door
Have housekeeping use bleach to clean the room
Wash hands before entering the room
Use disposable items as much as possible
59
Can person w/ h/o Chicken pox concerned with getting shingles visit a kid with pox outbreak?
Yes, the virus lies dormant and visit will not increase risk
No, the patient is susceptible to developing shingles
60
In surgery, when will scripts be given on an "on-call basis"?
Meds to be given when the patient requests them
Meds to be given when OR staff notifies RN to do so
Meds to be given when the family member asks for them
Meds to be given when the RN feels the patient needs them
61
Client has a serum sodium level of 129. Which solution to adminster
D2.5w
D10w
Lactated ringers
Normal Saline
62
What manifestation nurse expects to find during physical assessment of a pt w/ osteoarthritis?
calculi
strong bones
Apathy
Atrophy
63
Which instruction by RN help client/family meet expected outcome for functional incontinence
Buy pants with elastic waistbands that are easy to pull down
Have the pt wear depends whenever leaving the house
Remind patient to perform kegel exercises 4 times a day
Restrict fluid intake to minimize restroom needs
64
What diet information is important to collect for a pt after abdominal surgery
Monitor fluid intake
Monitor bowel sounds
Monitor food intake
Monitor if they prefer pudding or jello
65
Pt's lab = severe hypokalemia, RN tells MD. Assess shows heart rhythm normal. Next priority?
Seizure precautions
Administer potassium
fall precautions d/t potential OTHN & weak leg muscles
Increase fluids and change meals to potassium rich foods
66
Strategies a nurse can teach a patient to help reduce symptoms of fibromyalgia
Take NSAIDs round the clock
combine alcohol with opiates to help forget you have pain
Establish a regular sleep pattern
Eat a low carb, high protein diet
67
Convulsions, flushed skin, tachycardia, tachypnea, and warm to the touch are symptoms of what?
Hypothermia
Hyponatremia
Hyperthermia
Hypernatremia
68
Which is part of the primary prevention for systemic disorders
Exposure to virus
Transfusions of globulins
Vaccinations
cell mediated activity
69
Appropriate method to assess pain in an adolescent
Numbered pain scale
Watch their reaction as you trigger pain response
Wong-Baker face scale
Ask the parent(s)
70
Principle site for regulation of fluid and electrolyte balance
renal
cardiac
hepatic
endocrine
71
Pt with NURSING Dx excess fluid volume, nurse alter to which sign or symptom?
Hypertension
Hypotension
Fever
Migraines
72
What are the signs of inflammatory response?
BP, RR, Pulse, Temp
dry, cool, diaphoretic, pain
Pain, turgor, cyanosis, heat
Edema, heat, erythema, pain
73
Primary instructions for patients with difficulty passing stool
Drink Dunkin Donuts coffee
Increase exercise
Administer a stool softener
Increase fluid and fiber intake
74
What supplement should A RN be concerned about a pt taking during a pre-op assessment?
Vitamin A
Vitamin D
Vitamin E
Vitamin K
75
What are the risks for a baby who had recent thymectomy*?
increased inflammation
Autoimmune response
infections
increased age related chronic disease
76
Dressing to use for deep wound with tunneling, seroussanguenous fluid & 100% red-beefy tissue
Hydrogel dressing
Alginate dressing
Optifoam dressing
Wet to dry dressing
77
How long should a nurse wait after pt drinking, eating, or smoking to obtain a temperature?
No need to wait
20-30 minutes
10-15 minutes
45-60 minutes
78
Pt with poor healing infected leg ulcers. Why is patient's nutritional history important?
good nutrition rules out weakened immune system
Food is always a good discussion topic during orientation
To meet his dietary needs while admitted to hospital
poor nutrition negatively affect healing & infection control
79
Pt headed to knee Sx states "Dr. didn't mark my knee". What is the priority action?
Tell the patient to tell the anesthesiologist in the OR
mention it to the surgeon during the timeout
Pull out your sharpie and mark the knee the pt states to
Stop and call the surgeon to mark site before moving to OR
80
RN assess no bowel sounds w/ occasional splashing sounds over large intestines suggests what?
bowel obstruction
Ulcerative colitis
Diverticulitis
Testanxietyitis
81
What is the best response when asked to explain palliative care?
It's a nice way of saying the pt is terminal
Its the only option at this point
Its all about pain management at this point
Surgery will relieve symptoms but not cure the disease
82
Things to do when using a piggyback IV
change flow rate to administer antibiotic
flush before and after with incompatibility
check compatibility of meds
Administer at same flow rate as fluid
83
Pt is CAOx3 and wants off vent. RN SUPPORTS decision, stays to SUPPORT him. Moral principle?
Beneficience
Veracity
Fidelity
Autonomy
84
When should the nurse initiate the education/discharge plan for a patient?
Upon Admission
When the patient states they want to go home
After surgery is successful
When the doctor tells you to
85
What helps to prevent acid-base imbalances*?
staying hydrated
place aspirin away from child's reach
Dialysis
take insulin as prescribed
86
What is the device used to prevent atelectasis?
N95 respirator
Atelectater
refridgerator
Incentive spirometer
87
The nurse must consider this when encouraging a fitness plan for older adults
Orange theory is a good option to promote
Activities should incorporate improving balance
Whether they wear velcro or laced shoes
Walk a minimum of 5 miles a day
88
What does serous exudate leaking from a wound indicate?
The bandage isn't placed correctly
The wound is healing
It contains materials from the initial inflammation response
The infection is spreading and needs to be irrigated
89
(Do I really need to ask this?!?) Abnormal urine output is ...
Below 30mL/hr
Less than 1500mL/day
Around 30mL/hr
Above 30mL/hr
90
physiological changes assoc. w/ aging place older adults at risk for which nursing Dx?
Risk for being placed in a home by ungrateful children
Risk for infection
Risk for cognitive impairment
Risk for falls
91
Immunosupression patient teaching for new kidney transplant
Alteration to Ig status common
meds are used to decrease chance of attack on new kidney
May experience personality changes with new organ
92
What intervention should be encouraged for respiratory function of an immobile client
Breath into a paper bag
Use an inhaler to improve respiratory function
remain supine as much as possible to keep lungs expanded
deep breathing and coughing
93
Mom of newborn worried baby will get sick being around others. RN says baby has what immunity
Altered
Compromised
Innate
Active
94
Pt being d/c after spleenectomy. What info on immune fxn in education plan?
Proper diet main impact
Antibiotics serve as shield of protection
Basic infection control techniques
Immune is what it is, can't be altered
95
What statement by a client with Paget's Dz indicates good understanding of causative factors?
I may have a genetic predisposition
I bet I got this from a blood transfusion
This is a bacteria that can be cure with antibiotics
I must have contracted this when I traveled overseas
96
During pre-op client states takes NSAID regularly. What question is most important to ask?
Do you buy those over the counter or are they prescribed?
Tell me why you take NSAIDs?
Which brand of NSAID do you take?
When was the last time you took your NSAID?
97
RN assessed 4 pts at start of shift. which most urgent to report to MD?
Patient is mad that he can't have beer with dinner
Chronic hypertensive pt with c/o headache
Post op with no BM in 2 days
Positive Chvostek's sign in pt with acute pancreatitis
98
What is the primary advantage to using conscious (minimal) sedation?
The patient can drive themselves home
The patient can tell you if something is going wrong
It's more cost effective than general anesthesia
Respiratory support is not needed
99
Major problem associated with severe diarrhea in the very young
weight loss
electrolyte and fluid loss
Can't tell you that they are in pain
May cause abuse of laxatives in the future
100
Which is a description of Kussmal respirations
shallow and rapid
gasping for air
Normal breathing with gaps in respirations
deep and rapid

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