NUR 215 FINAL EXAM
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NUR 215 Final exam
On assessment of a patient a nurse pushes down one finger on the UPPER
LEFT of the abdomen and notes rebound tenderness and pain of the abdomen
that shoots to the other side. The nurse should expect this to be signs of ?
Acute Pancreatitis
A patient with cirrhosis and high amonia levels is placed on a low cholesterol
and low protein diet. The nurse expects this in the plan of care because ?
Aids in preventing malnutrition and prevents hepatic encephalopathy
A nurse is looking at a patient's chart and notices that the patient has gained
weight rapidly within the past 72 hours. This leads the nurse to indicate the
patient is becoming _________volimic
hypervolemic
A patient comes in stating they took "a lot of Tylenol pills" the nurse expects
to give the patient __________?
Activated Charcoal (No more than 1 hr after ingestion)
Upon assessment a patient complains of RUQ (Right Upper Quadrant) pain
when the nurse pushes down in that area. The nurse knows this as a sign of
_________?
Gall Stones
Symptoms of Cushing's Triad - Indicative of ICP (Intercrainial Pressure)
- Bradycardia
- Irregular RR
- Widened Pulse Pressure
Treatment for Cushings Triad
- IV Mannitol
- Elevating HOB
- Hyperventilation
Risk factors for Breast Cancer
- Women
- 50+ years
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- Genetics
- Family Hx
- Obesity
- Radiation Exposure
The nurse gets a newly admitted alcoholic patient and expects them to have
the following deficiencies in these vitamins/minerals (There could be more but
think of the two MOST COMMON)
- Folate (Folic Acid)
- Thiamine
What does pruitis mean?
itching
What is angioedema?
swelling of the face due to fluid build up
A nurse is teaching how to decrease the risk of developing breast cancer at a
community health event, what should be included in their teaching ? Also out
of the "3 Types of Prevention" which one is this ?
- Smoking cessation
- Self exams of breasts
- No tanning beds
What is the worse type of shock ?
Anaphalactic Shock - Due to narrowing of the airway and inability to get an ETT tube
in a patient, leading to a trach as last resort.
A patient arrives in the ER and states they have fallen off a ladder, the nurse
assesses the patient's neurological function with the GCS (Glascoma Scale)
and notes clear nasal drainage. The nurse should expect to test the fluid for
what to confirm a spinal leak ?
Glucose
A nurse has a patient that experiences a fall, later throughout the shift the
nurse expects to make multiple neurological and memory assessments. T or F
?
True
A nurse has orders to place an oral tube in their patient but is unable to do so,
the nurse should expect to replace the oral tube with ?
NG tube with low intermittent suction setting
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A nurse has 4 different patients with all different acuities is contemplating
which one to see first. A good rule of thumb is....
The patient who is most difficult to arouse is the patient you should see first
A patient is tested for an STI, the nurse will instruct the patient to return for
retesting in ___ months
3-6 months
A HIV positive patient is admitted with pneumonia, the nurse expects the
patient to have what disease ?
AIDS
What is the criteria for a patient being diagnosed with aids
T - cell count of less than 200
A pap smear is done to detect what STD ?
HPV , instruct pt that symptoms can clear up
A newly positive STD patient should be encouraged by their nurse to do what
?
inform their sexual partner about their positive STD test result.
The nurse is told by the surgeon to help the pt sign the consent forms, why is
this not correct ?
Protocol states that the Nurse's responsibility is to teach the patient about the
surgery and anticipate their needs. Not to get the consent forms signed as that is
responsibility of the Doctor/Surgeon/HCP.
In an attempt to decrease the risk of pneumonia and DVTs the nurse will
inform the pt of the following interventions when the patient is aroused after
their surgery.
- up and out of bed
- cough & deep breathe
- teach about importance of finishing full antibiotic course
A nurse is working triage and is figuring out what patients to admit first, a
good rule of thumb is ...
if the pt is quiet, the closer they are to death
Aortic Dissection
- sudden sharp upper back pain
- seconds left to save pt !!!