NUR 211 Final Exam Questions With Complete Solutions
5 Ps related to neurovascualr dysfunction and venous alteration
assessments Correct Answer pallor, pain, paresthesia, paralysis,
pulse
acute hypoxia Correct Answer SUDDEN - causes? - obstructed
airway, pulmonary embolism, impaired ventilation (asthma,
pneumonia)
SX- anxious, sitting up, increased RR and HR, confusion,
behavior changes, nasal flaring - cyanosis is a late sign
air embolism Correct Answer prevention - keep system closed,
have pt hold breath during central line removal
SS- chest pain, dyspnea, tachycardia, hypotension, dizziness -
leads to stroke, MI, death
intervention- O2 supplement, turn pt on left side
albumin and pre albumin (levels and purpose) Correct Answer
albumin - normal (3.5-5.5) - maintains intravascular osmotic
pressure - keeps fluids inside of vessels
prealbumin - normal (15-36) - low levels are definitive of
malnutrition - regulate use of energy
alginate dressings indication Correct Answer absorb greater
amounts of drainage in full thickness wounds
an H+H diagnostic blood test Correct Answer hematocrit - %
of total blood volume made up by RBCs
MALE - 42-52% FEMALE - 37-47%
,= decreased levels are called anemia
hemoglobin - iron containing pigment of RBC
MALE - 14-18 FEMALE 12-16
antidiarrheal agents Correct Answer imodium, paregoric,
lomotil
-contain opiates to decrease intestinal muscle tone and slow
passage of contents
-may be habit forming
assessing sleep/sleep disorders Correct Answer clients
statements, partners statements, number of awakenings, duration
of sleep, how long to fall asleep, physical, sleep study
assessment of wounds Correct Answer anatomical location
using landmarks and directions, measurments, periwound and
edges,
best assessment of changes in fluid balance Correct Answer
daily weight
bulk forming laxatives Correct Answer metamucil, miralax -
mixes w one cup of water
-high fiber, absorbs water, least irritating
-can be used long term
cardiovascular changes related to immobility Correct Answer
orthostatic
thrombus formation - alterations in blood flow, damage to
vessels
,caring for central venous access device - central line Correct
Answer must have placement verification before use, sterile
dressing changes, routine heparin or NS flushes
changes in VS associated w FVD Correct Answer increased
temp, pulse increased and thready, decreased BP, narrowed
pulse pressure, orthostatic
changes in VS associated w FVE Correct Answer increase in
pulse (bounding), increase RR, increase BP, SOA
choosing location for peripheral IV Correct Answer choose
most distal site, avoid areas of flexion, use straight soft veins,
ask pt preference, dominant hand, masectomy pt?
chronic hypoxia Correct Answer long term - Causes? - COPD,
anemia, impaired ventilation, cardiac abnormalities
SX- fatigue, lethargy, clubbed fingers, barrel chest, SOA,
paroxysmal nocturnal dyspnea, orthopnea, activity intolerance
circulatory overload Correct Answer FVE - crackles and edema
hypernatremia or hyponatremia - confusion and seizures
hyperkalemia - cardiac dysrhythmias, muscle weakness
- reduce rate and notify provider
- recommend labs
classify wound - clean Correct Answer uninfected, minimal
inflammation, closed wound
-respiratory, alimentary, genital, and urinary tract not entered
, classify wound -clean contaminated wound Correct Answer
surgical wound where respiratory, alimentary, urinary, or genital
system has been entered
- no evidence of infection
classify wounds - dirty or infected wound Correct Answer
infected - purulent drainage, contains dead tissue
classify wounds- contaminated wound Correct Answer fresh
accidental or surgical wound, break in sterility, drainage from
GI tract
-evidence of inflammation
colon cancer screening at age 50 Correct Answer annual guiac
test
flexible sigmoidoscopy every 5 years
fecal occult blood test every 5 years w sigmoidoscopy
colonoscopy every 10 years
common side effects of opiods Correct Answer sedation,
constipation, N/V, pruritius, urinary retention, respiratory
depression
COPD and oxygenation Correct Answer -these pts have
adapted to a high level of CO2, so the CO2 sensitive receptors
do not function
-COPD pts stimulus to breathe is low O2, while normally it is
high CO2
-receptors in the aortic arch and carotid bodies are sensitive to
low O2 level causing increased ventilation when low O2
5 Ps related to neurovascualr dysfunction and venous alteration
assessments Correct Answer pallor, pain, paresthesia, paralysis,
pulse
acute hypoxia Correct Answer SUDDEN - causes? - obstructed
airway, pulmonary embolism, impaired ventilation (asthma,
pneumonia)
SX- anxious, sitting up, increased RR and HR, confusion,
behavior changes, nasal flaring - cyanosis is a late sign
air embolism Correct Answer prevention - keep system closed,
have pt hold breath during central line removal
SS- chest pain, dyspnea, tachycardia, hypotension, dizziness -
leads to stroke, MI, death
intervention- O2 supplement, turn pt on left side
albumin and pre albumin (levels and purpose) Correct Answer
albumin - normal (3.5-5.5) - maintains intravascular osmotic
pressure - keeps fluids inside of vessels
prealbumin - normal (15-36) - low levels are definitive of
malnutrition - regulate use of energy
alginate dressings indication Correct Answer absorb greater
amounts of drainage in full thickness wounds
an H+H diagnostic blood test Correct Answer hematocrit - %
of total blood volume made up by RBCs
MALE - 42-52% FEMALE - 37-47%
,= decreased levels are called anemia
hemoglobin - iron containing pigment of RBC
MALE - 14-18 FEMALE 12-16
antidiarrheal agents Correct Answer imodium, paregoric,
lomotil
-contain opiates to decrease intestinal muscle tone and slow
passage of contents
-may be habit forming
assessing sleep/sleep disorders Correct Answer clients
statements, partners statements, number of awakenings, duration
of sleep, how long to fall asleep, physical, sleep study
assessment of wounds Correct Answer anatomical location
using landmarks and directions, measurments, periwound and
edges,
best assessment of changes in fluid balance Correct Answer
daily weight
bulk forming laxatives Correct Answer metamucil, miralax -
mixes w one cup of water
-high fiber, absorbs water, least irritating
-can be used long term
cardiovascular changes related to immobility Correct Answer
orthostatic
thrombus formation - alterations in blood flow, damage to
vessels
,caring for central venous access device - central line Correct
Answer must have placement verification before use, sterile
dressing changes, routine heparin or NS flushes
changes in VS associated w FVD Correct Answer increased
temp, pulse increased and thready, decreased BP, narrowed
pulse pressure, orthostatic
changes in VS associated w FVE Correct Answer increase in
pulse (bounding), increase RR, increase BP, SOA
choosing location for peripheral IV Correct Answer choose
most distal site, avoid areas of flexion, use straight soft veins,
ask pt preference, dominant hand, masectomy pt?
chronic hypoxia Correct Answer long term - Causes? - COPD,
anemia, impaired ventilation, cardiac abnormalities
SX- fatigue, lethargy, clubbed fingers, barrel chest, SOA,
paroxysmal nocturnal dyspnea, orthopnea, activity intolerance
circulatory overload Correct Answer FVE - crackles and edema
hypernatremia or hyponatremia - confusion and seizures
hyperkalemia - cardiac dysrhythmias, muscle weakness
- reduce rate and notify provider
- recommend labs
classify wound - clean Correct Answer uninfected, minimal
inflammation, closed wound
-respiratory, alimentary, genital, and urinary tract not entered
, classify wound -clean contaminated wound Correct Answer
surgical wound where respiratory, alimentary, urinary, or genital
system has been entered
- no evidence of infection
classify wounds - dirty or infected wound Correct Answer
infected - purulent drainage, contains dead tissue
classify wounds- contaminated wound Correct Answer fresh
accidental or surgical wound, break in sterility, drainage from
GI tract
-evidence of inflammation
colon cancer screening at age 50 Correct Answer annual guiac
test
flexible sigmoidoscopy every 5 years
fecal occult blood test every 5 years w sigmoidoscopy
colonoscopy every 10 years
common side effects of opiods Correct Answer sedation,
constipation, N/V, pruritius, urinary retention, respiratory
depression
COPD and oxygenation Correct Answer -these pts have
adapted to a high level of CO2, so the CO2 sensitive receptors
do not function
-COPD pts stimulus to breathe is low O2, while normally it is
high CO2
-receptors in the aortic arch and carotid bodies are sensitive to
low O2 level causing increased ventilation when low O2
