NUR 445 Final Exam - Questions With Proven
Solutions
What is the nurses role while caring for a patient undergoing genetic
testing? Correct Answer - Obtain and assess family history
(assess risk of certain diseases, establish pattern of inheritance, ID
family members at risk and calculate risk)
Assess patients understanding of genetic info and factors r/t health
risks
Refer for risk assessment when a hereditary disease or disorder is
suspected
Determine if genetic testing has been performed and if other family
members are effected
educate patient and family about GINA passed in 2008
Obtain consent and provide support to patients
What interventions must a preoperative nurse complete prior to a
patient being taken to the OR? Correct Answer - Baseline head
to toe assessment
Medications: home med list and when last taken (beta blockers can
be taken up until day of, but anticoagulants may be held)
Obtain informed consent, assess for capability to consent,
witness/verify
Assess allergies and comorbid conditions
Assess family and genetic hx for complications with anesthesia, latex
allergy, malignant hyperthermia
Administer preanesthetic meds, maintain preop record,
transporting patient to surgical area, attending to family needs
Patient education: educate patient regarding surgical process
discharge plan, meds, resources, etc
What criteria must a patient meet for consent? Correct Answer -
18 years old (unless emancipated minor)
,Autonomous and informed
Competent patient: not cognitively impaired, mentally ill, or
neurologically incapacitated
What are potential complications that can occur during an
operation? Correct Answer - Anesthesia awareness
Anaphylaxis
Hypothermia
Malignant hyperthermia
What are priority assessments for a post op nurse? Correct
Answer - Patent airway and cardiovascular stability
VS
Pain relief
Control of nausea and vomiting
What discharge criteria does the patient need to meet, in order to be
discharged from the PACU? Correct Answer - Stable BP,
adequate respiratory function and O2 sat compared to baseline
Aldridge score between 7 and 10
What early assessment findings would make a nurse suspect a
patient has increased ICP? Correct Answer - Disorientation,
confusion, pupil changes, lethargy, weakness, headache
What are some late assessment findings that would make a nurse
suspect a patient has increased ICP? Correct Answer - VS
changes, projectile vomiting, loss of reflexes
what are some potential complications associated with increased
ICP? Correct Answer - Brain herniation
Diabetes Insipidus
syndrome of inappropriate antidiuretic hormone (SIADH)
, What are some assessment findings that would make the nurse
believe diabetes Insipidus has occurred? Correct Answer -
Excessive urine output
Tx: give fluids, monitor and replace electrolytes, synthetic
vasopressin
What are some assessment findings that would make the nurse
believe SIADH has occurred? Correct Answer - Fluid overload
s/s
Tx: give diuretics
What assessment findings make a nurse suspect a patient is having a
CVA? Correct Answer - Numbness or weakness of the face,
arm, leg - esp. unilaterally
Confusion or a change in mental status
Trouble speaking or understanding speech
Visual disturbances
Difficulty walking, dizziness, loss of balance
Sudden severe headache
What treatments should the nurse anticipate for an ischemic stroke:
Correct Answer - Recombinant t-PA if patient meets criteria. If
not t-PA, other anticoagulant therapy is initiated. Possible surgery to
correct issues that may have caused CVA
What treatments should the nurse anticipate for a hemorrhagic
stroke? Correct Answer - Bed rest for brain recovery, monitor
for re-bleeding, manage HTN and pain, surgical management
possible for evacuation of blood in the brain, coiling aneurysms to
prevent rupture. Monitor GSC and for changes in mental exam.
What assessments and nursing interventions are implemented
immediately post stroke? Correct Answer - NIH scales q hour,
q2hour, q 4 hour; CT scan, potentially TPA
Solutions
What is the nurses role while caring for a patient undergoing genetic
testing? Correct Answer - Obtain and assess family history
(assess risk of certain diseases, establish pattern of inheritance, ID
family members at risk and calculate risk)
Assess patients understanding of genetic info and factors r/t health
risks
Refer for risk assessment when a hereditary disease or disorder is
suspected
Determine if genetic testing has been performed and if other family
members are effected
educate patient and family about GINA passed in 2008
Obtain consent and provide support to patients
What interventions must a preoperative nurse complete prior to a
patient being taken to the OR? Correct Answer - Baseline head
to toe assessment
Medications: home med list and when last taken (beta blockers can
be taken up until day of, but anticoagulants may be held)
Obtain informed consent, assess for capability to consent,
witness/verify
Assess allergies and comorbid conditions
Assess family and genetic hx for complications with anesthesia, latex
allergy, malignant hyperthermia
Administer preanesthetic meds, maintain preop record,
transporting patient to surgical area, attending to family needs
Patient education: educate patient regarding surgical process
discharge plan, meds, resources, etc
What criteria must a patient meet for consent? Correct Answer -
18 years old (unless emancipated minor)
,Autonomous and informed
Competent patient: not cognitively impaired, mentally ill, or
neurologically incapacitated
What are potential complications that can occur during an
operation? Correct Answer - Anesthesia awareness
Anaphylaxis
Hypothermia
Malignant hyperthermia
What are priority assessments for a post op nurse? Correct
Answer - Patent airway and cardiovascular stability
VS
Pain relief
Control of nausea and vomiting
What discharge criteria does the patient need to meet, in order to be
discharged from the PACU? Correct Answer - Stable BP,
adequate respiratory function and O2 sat compared to baseline
Aldridge score between 7 and 10
What early assessment findings would make a nurse suspect a
patient has increased ICP? Correct Answer - Disorientation,
confusion, pupil changes, lethargy, weakness, headache
What are some late assessment findings that would make a nurse
suspect a patient has increased ICP? Correct Answer - VS
changes, projectile vomiting, loss of reflexes
what are some potential complications associated with increased
ICP? Correct Answer - Brain herniation
Diabetes Insipidus
syndrome of inappropriate antidiuretic hormone (SIADH)
, What are some assessment findings that would make the nurse
believe diabetes Insipidus has occurred? Correct Answer -
Excessive urine output
Tx: give fluids, monitor and replace electrolytes, synthetic
vasopressin
What are some assessment findings that would make the nurse
believe SIADH has occurred? Correct Answer - Fluid overload
s/s
Tx: give diuretics
What assessment findings make a nurse suspect a patient is having a
CVA? Correct Answer - Numbness or weakness of the face,
arm, leg - esp. unilaterally
Confusion or a change in mental status
Trouble speaking or understanding speech
Visual disturbances
Difficulty walking, dizziness, loss of balance
Sudden severe headache
What treatments should the nurse anticipate for an ischemic stroke:
Correct Answer - Recombinant t-PA if patient meets criteria. If
not t-PA, other anticoagulant therapy is initiated. Possible surgery to
correct issues that may have caused CVA
What treatments should the nurse anticipate for a hemorrhagic
stroke? Correct Answer - Bed rest for brain recovery, monitor
for re-bleeding, manage HTN and pain, surgical management
possible for evacuation of blood in the brain, coiling aneurysms to
prevent rupture. Monitor GSC and for changes in mental exam.
What assessments and nursing interventions are implemented
immediately post stroke? Correct Answer - NIH scales q hour,
q2hour, q 4 hour; CT scan, potentially TPA
