Summary Yale University NURS 101 (NURS101) BOLEN LONG REVIEW NOTES Complete 2025/2026.

BOLEN LONG REVIEW NOTES - 5/30/24 o EXTRA o Which of the following patients require follow up?  Change in BP from 130/90 to 110/70 (BP change + or – 20) o (1) serous (clear and thin; may be present in a healthy, healing wound) o (2) serosanguineous (containing blood; may also be present in a healthy, healing wound) o (3) sanguineous (primarily blood) o (4) purulent (thick, white, and pus-like; may be o Would serosanguinous to sanguineous drainage be expected or unexpected?  Unexpected o Spina bifida and multiple surgeries increases the risk for  Latex allergy o Is gross hematuria with polycystic kidney disease expected or unexpected?  Unexpected o If mom has a heart rate of 180, the RN should lay her on  Her left side o It would require immediate follow up if  The FHR is consistently 132 during the 2nd stage of labor because this indicates LATE decelerations. o When should males do their monthly self-testicular exams?  After the shower o The nurse has instructed a client who regularly menstruates about performing self-breast examinations at home. Which of the following client statements indicates CORRECT understanding of the teaching:  I will perform my self breast examination 7 days after my period ends. o The patient with a newly implanted pacemaker can lift their arm above their head  In 4 weeks (during this time, they should not life anything > 10 pounds o Increased risk for cervical cancer  53-year-old who never had a HPV vaccine. o Stress management class: Primary, Secondary, or Tertiary prevention?  PRIMARY o The nurse is teaching a class on health promotion and illness prevention, which of the following actions b the nurse is an example of secondary prevention?  Performing monthly self-breast examinations. o Posterior fontanel should close by  The 8th week o Anterior fontanel should close by  18 months o Which action is priority for the patient with Histrionic personality disorder?  Establish a TRUSTING relationship. o Teach patients to get a colonoscopy at age 50.  Then every 10 years o Postmortem care:  Check if patient is an ORGAN donor, leave dentures in for family to see the patient, place peri pads under the pt. o New admit hx of PUD. Initial assessment BP 110/70, P = 96; coffee ground emesis; Hgb 10.8 Priority?  Insert NG tube o Which action should be completed first for the patient with PUD and signs of excessive bleeding?  Draw type and CROSS for admin of PRBCs o The nurse is talking with a newly hired nurse about peritoneal dialysis and how to recognize peritonitis. Which signs and symptoms should the nurse include in the Discussion? 1, 2, 4, 5  Fever,  Rebound abdominal tenderness,  Nausea and vomiting,  Cloudy or opaque outflow o Follow up:  It would require further teaching if a stroke patient said they should NOT tilt their head FORWARD to swallow if they are experiencing dysphagia. VP Shunt ○ Position child on unoperated side to prevent pressure ○ Keep child flat to prevent rapid reduction ICP ■ ICP increase(change in LOC, restless, ICP ) → elevate HOB 15-30 degrees ○ Assess s/s infection, irritability, headache, lack of appetite ■ VP shunt next action? ● Raise the HOB to at least 30 degrees. ○ Float OB nurse ■ Give patient that is 24 hours post op appendectomy. ○ Low sodium diet ■ Grilled salmon with broccoli ○ It would require immediate follow up if the transplant patient. ■ has an increase in temper from 99.5 to 100.3 over 4 hours because this can be a sign of REJECTION. ○ Send to PCP ■ 65 year old with low HDL and high LDL ○ End stage renal disease: creatinine 2.7 is expected or unexpected? ■ Expected ○ Why would a pt have a high LDL level on a correct diet? ■ Genetics ○ The patient with atherosclerosis should avoid. ■ eggs ○ A nurse is working in a community health clinic is assessing clients who are waiting to be seen, which client should the nurse have the primary health care provider see FIRST? ■ A 57-year-old with Graves’ disease with a temperature of 100.5 ○ For the patient taking ACE inhibitors, what class of diuretics should be avoided? ■ Potassium sparing ○ Hypothyroid SATA: ■ Dry skin ■ Brittle nails ■ Menorrhagia ○ Which two meds should be given for cardiogenic shock? ■ Digoxin ■ Dobutamine ● Should fluids be given to the patient with cardiogenic shock? ○ NO! ○ Which fruit should be avoided when taking statins? ■ Grapefruit ○ The nurse is caring for a client who has been prescribed a statin to treat hyperlipidemia. Which should the nurse check? ■ Liver enzymes ○ In the early stages of cirrhosis, should the patient increase or decrease protein? ■ Increase protein. ○ In the late stages of cirrhosis, should the patient increase or decrease protein? ■ Decrease protein. ○ A nurse is working on a med surg unit has just received hand off report on the following clients, the nurse should FIRST plan to assess the client who has: ■ Acute pancreatitis and is reporting development of pain on inspiration. ○ The home health nurse is visiting a client who has emphysema. Which of the following client statements would reflect a correct understanding of managing self-care activities? ■ “I usually will not talk when I am doing other activities such as walking”. ○ A nurse is caring for a patient who has a triple lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter? ■ Flush NS with 10 ml syringe after each use. ○ A nurse is administering a soap suds enema to a client, the client reports abdominal cramping shortly after. What actions should the nurse take? ■ Lower the bag ○ Which electrolyte imbalance is associated with SIADH? ■ Hyponatremia ○ What can a pt with hyperthyroidism wear to alleviate discomfort and provide protection due to exophthalmos? ■ Wear an eye patch ○ If a child is regressing back to bedwetting during a time of grief, is this expected or unexpected? ■ Expected ○ Before putting a tourniquet on an elderly patient ■ Wrap a washcloth around the arm to protect the skin. ○ Patient comes in the ED with hypothermia: ■ Warm the TRUNK before the extremities. ○ Pt with ASTHMA who takes labetalol. ■ Assess from bronchospasm/ low BP. ○ Pyloric stenosis ■ Projectile vomiting to be expected. ○ Intussusception ■ Jelly-like stools ● Place in knee to chest position. ○ A patient who is hyperventilating or having a panic attack would be in? ■ Respiratory Alkalosis ○ Timolol ■ Used to treat open angle glaucoma. ● Hold if HR is < 60. ● Interdisciplinary Care: ○ Cystic fibrosis with distended abdomen  Child abuse o Assessment with detailed history o Then we call Child abuse ● Nurse assess school-age child w/ left arm pain & several bruises on body. Action nurse takes 1st? ○ Obtain detailed history regarding how the bruising occurred. ● Support the child during a thorough physical assessment. ● Assess injuries. ● If shaken baby syndrome is suspected: monitor infant for a decrease in LOC. ○ → which can indicate ICP. ● Report a case of suspected abuse; nurses are legally required to report all cases of suspected child abuse to appropriate local or state agency. ○ THOROUGH ASSMT; injury from play is visibly different from abuse. ■ ⇒ call authorities. ● Place the child in an environment that is safe preventing further injury. ● Document information r/t suspected abuse in objective manner ● Assess parent’s strengths and weakness, normal coping mechanisms, and presence or absence of support systems. ● Refer family to appropriate support group. ● Priority: is patient stable? Call proper authorities.  Elder abuse o Dependent adults can’t fight for themselves. o Mandate calls  Which of the following is true about elder abuse?  ER nurse has the following 4 patients. Which client information requires reporting by the nurse to an outside agency? o 72 y/o who lives with daughter and has several stage 3 pressure ulcers.  Priority nursing actions* o Assess and treat wounds abuse. o Ensure that the victim is removed from the threatening environment. o Adhere to mandatory abuse reporting laws. o Notify the caseworker of the situation.o Document the occurrence, findings, actions taken, and the victi CONTINUED...........