NUR 342 Exam 1 Study Guide Questions With Complete
Solutions
adverse drug effects Correct Answers 1. Allergic Effect:
immune system response that occurs when the body
misinterprets the drug as a foreign substance and forms
antibodies against the drug
- Can happen immediately after administration or be delayed for
hours, days, weeks, etc.
- Symptoms can increase in severity each time the drug is
administered
- Common symptoms → rash, urticaria, diarrhea, fever, nausea,
vomiting
2. Anaphylactic reaction/Anaphylaxis: more serious, life
threatening allergic reaction characterized by respiratory
distress, sudden bronchospasm, and cardiovascular collapse
- Treated with vasopressors, bronchodilators, corticosteroids, O2
therapy, IV fluids, antihistamines
3. Drug Tolerance: when the body becomes accustomed to the
effects of a drug over a period of time; larger doses needed to
produce the same effects
Ex: morphine → when used consistently for a long period of
time, the body will become tolerant to the therapeutic effects
therefore person would need a higher dose of the drug to control
their pain
4. Toxic Effect: specific groups of symptoms related to drug
therapy that carry risk for permanent damage or death
,Can be caused by:
Cumulative effect → body cannot metabolize one dose of a drug
fully before another dose is given
- Drug is taken in more frequently than it is excreted leading to
an increase in concentration in the body
- Older adults at risk for this due to altered hepatic metabolism
and decreased renal clearance/excretion
5. Idiosyncratic Effect: "paradoxical effect"; an unusual
response to a drug; either an over-response, under-response, or
the opposite of the expected response
Airborne precautions Correct Answers · Private room with
monitored negative air pressure
· 6-12 air changes per hour, appropriate discharge of air outside
· Door closed
· Respirator (n95)
- Filters particles as small as 1 mcm
· Transport patient out of room only when necessary
Assessments and planning before moving patients Correct
Answers 1. Assessing:
See what can a patient handle, daily exercise levels
Nursing history:
Daily activity level
Endurance
Exercise and fitness goals
,Mobility problems
Physical or mental health alterations that affect mobility
2. Physical Assessment:
General ease of movement and gait
Alignment
Joint structure and function
Muscle mass, tone, and strength
Endurance
Planning:
Patient will:
· Identify personal benefits of regular exercise
· Demonstrate full range of joint motion (joint mobility)
· Demonstrate adequate muscle mass, tone and strength to
perform functional ADLs
· Be free from alterations in skin integrity
Show signs of adequate venous return
· Be free from contractures
Assessments required when patient is in restraints (freq, when
do you have to renew order) Correct Answers **Ensure orders
are current
Requires an order By MD, PA, APRN**
· Orders are time limited:
- Adults - 4 hours
- Children 9-17 - 2 hours
- Children under 9 - 1 hour
, **MD/LIP must evaluate within 1 hour(physical) or 24
hours(medical)**
Assessment of patient in restraints:
· Assess movement of patients extremity, sensation, capillary
refill, warmth, pulses etc.
· Assess the patient every 15 minutes with restraints placed for a
physical reason (i.e. fall risk)
· Assess the patient every 2 hours with restraints placed for a
medical reasons (i.e. pulling IV tubbing)
· Continuous supervision (1:1) if restraints are placed due to
violent behavior
What do I assess? CMS (circulation, motor, sensory)
· If safe, ensure a temporary release from restraints is provided
· At least every 2 hours
· Ensure toileting, hygiene and oral intake is offered regularly
**Can you fit two fingers underneath the restraint?
assessments to be made on immobility Correct Answers
Assessment to be made - used to help obtain data about the
patient's mobility and activity status
1. Nursing History (interview)
Daily activity level
Endurance
Exercise and fitness goals
Mobility problems
Physical or mental health alterations that affect mobility
Solutions
adverse drug effects Correct Answers 1. Allergic Effect:
immune system response that occurs when the body
misinterprets the drug as a foreign substance and forms
antibodies against the drug
- Can happen immediately after administration or be delayed for
hours, days, weeks, etc.
- Symptoms can increase in severity each time the drug is
administered
- Common symptoms → rash, urticaria, diarrhea, fever, nausea,
vomiting
2. Anaphylactic reaction/Anaphylaxis: more serious, life
threatening allergic reaction characterized by respiratory
distress, sudden bronchospasm, and cardiovascular collapse
- Treated with vasopressors, bronchodilators, corticosteroids, O2
therapy, IV fluids, antihistamines
3. Drug Tolerance: when the body becomes accustomed to the
effects of a drug over a period of time; larger doses needed to
produce the same effects
Ex: morphine → when used consistently for a long period of
time, the body will become tolerant to the therapeutic effects
therefore person would need a higher dose of the drug to control
their pain
4. Toxic Effect: specific groups of symptoms related to drug
therapy that carry risk for permanent damage or death
,Can be caused by:
Cumulative effect → body cannot metabolize one dose of a drug
fully before another dose is given
- Drug is taken in more frequently than it is excreted leading to
an increase in concentration in the body
- Older adults at risk for this due to altered hepatic metabolism
and decreased renal clearance/excretion
5. Idiosyncratic Effect: "paradoxical effect"; an unusual
response to a drug; either an over-response, under-response, or
the opposite of the expected response
Airborne precautions Correct Answers · Private room with
monitored negative air pressure
· 6-12 air changes per hour, appropriate discharge of air outside
· Door closed
· Respirator (n95)
- Filters particles as small as 1 mcm
· Transport patient out of room only when necessary
Assessments and planning before moving patients Correct
Answers 1. Assessing:
See what can a patient handle, daily exercise levels
Nursing history:
Daily activity level
Endurance
Exercise and fitness goals
,Mobility problems
Physical or mental health alterations that affect mobility
2. Physical Assessment:
General ease of movement and gait
Alignment
Joint structure and function
Muscle mass, tone, and strength
Endurance
Planning:
Patient will:
· Identify personal benefits of regular exercise
· Demonstrate full range of joint motion (joint mobility)
· Demonstrate adequate muscle mass, tone and strength to
perform functional ADLs
· Be free from alterations in skin integrity
Show signs of adequate venous return
· Be free from contractures
Assessments required when patient is in restraints (freq, when
do you have to renew order) Correct Answers **Ensure orders
are current
Requires an order By MD, PA, APRN**
· Orders are time limited:
- Adults - 4 hours
- Children 9-17 - 2 hours
- Children under 9 - 1 hour
, **MD/LIP must evaluate within 1 hour(physical) or 24
hours(medical)**
Assessment of patient in restraints:
· Assess movement of patients extremity, sensation, capillary
refill, warmth, pulses etc.
· Assess the patient every 15 minutes with restraints placed for a
physical reason (i.e. fall risk)
· Assess the patient every 2 hours with restraints placed for a
medical reasons (i.e. pulling IV tubbing)
· Continuous supervision (1:1) if restraints are placed due to
violent behavior
What do I assess? CMS (circulation, motor, sensory)
· If safe, ensure a temporary release from restraints is provided
· At least every 2 hours
· Ensure toileting, hygiene and oral intake is offered regularly
**Can you fit two fingers underneath the restraint?
assessments to be made on immobility Correct Answers
Assessment to be made - used to help obtain data about the
patient's mobility and activity status
1. Nursing History (interview)
Daily activity level
Endurance
Exercise and fitness goals
Mobility problems
Physical or mental health alterations that affect mobility
