PN3006 Midterm Exam: Questions With Solutions

PN3006 Midterm Exam: Questions With Solutions A nurse does water ax before administering IV, is bilateral crackles a precaution? - ANSWER -Yes, fluid in lungs Pack of red blood cells have been administered after 4 hours it is not done, what do u do? - ANSWER -Discard transfusion 4th day post op, surgical incision will be slightly reddened and swollen, without any drainage, is this abnormal or normal? - ANSWER -normal Z track technique for IM, must pull skin laterally before inserting the needle? - ANSWER -true Peripheral vascular disease, for this you are going to ax pulses bilateral to legs - ANSWER -true If anyone had a bolus amount of meds - ANSWER -Ax respiration distress Smoking increases the risk for infection due to affecting the cilia lining of upper air way. T/F - ANSWER -True Infusion. - ANSWER -Apply pressure Child is not cooperating with irrigation of wound. How would the nurse communicate with the child? - ANSWER -Use a doll how to irrigate wound instead of describing it to them What is the best nursing intervention related long term outcome? - ANSWER -providing well balance diet protein When the nurse is ax a wound after removing dressing, what does the nurse implement to reduce infection? - ANSWER -Remove dirty gloves and dawn new gloves When ur using a glass ampule, what needle do you use? - ANSWER Filter needle A nurses ax indicates that incision is red and purulent drainage, tenderness at site, temperature = 38.1, WBC is elevated - ANSWER Infection, contact patients status to physician A male patient, 5'10 and weighs 155 lbs, needs 2.2 mL IM of oil based medication, which needle/syringe should the nurse use to administer injection? - ANSWER -23 gauge, 1 inch, 3 mL syringe Patient has type I diabetes mellitus. The nurse teaches him SQ insulin admin, what does the nurse also include in patient-teacher teaching? - ANSWER -To eat after taking insulin to avoid hypoglycemia idiosyncratic reaction - ANSWER -An abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual patient. Where do you find an adult apical pulse? - ANSWER -Left 5th intercostal rib mid clavicular A patient initially weighs 200 lbs, but on the 2nd day of admission the patient weighed 209 lbs, what should the nurse evaluate the patient for? - ANSWER -Fluid retention In preparation for a rectal exam of non ambulatory patient w/ arthritis in both hips, patient exam in which position? - ANSWER -Sims position Subjective data - ANSWER -feelings, perceptions, reported symptoms After assessing the patient and using 2 ID needed to provide headache relief the nurse gives tylenol. What do you do after? - ANSWER reassess again after 30 mins Patient with high dose of opioid medication for severe pain, which assessment finding do you find due to opioid toxicity - ANSWER respiratory depression Nurse caring for patientt with peripheral IV being used intermittently for medications but not continuous infusion, what does that mean?what should the nurse do for cleaning this? - ANSWER -Flush with 0.9 saline and lock it The nurse completed a head to toe ax on patient. Which clinical sign does the nurse find? - ANSWER -Bilateral crackles The nurse instruct the patient to void or empty the urinary drainage collection container before administering a blood transfusion. T/F - ANSWER -True, due to fluid overload