NURS 221 - Final Exam Questions with Correct Answers Verified by Experts| Latest Update
S/S of hyponatremia (body temperature, HR, pulse, BP, neurological, muscles, reflexes, GI)
Hypothermia, tachycardia, rapid thread pulse, hypotension, headache, confusion, lethargy,
muscle weakness, fatigue, decreased reflexes, seizures, coma, increased GI motility, GI
cramping, nausea, vomiting
S/S of hypernatremia (body temperature, HR, BP, neurological, muscles, reflexes, mucous
membranes, GI, body, urinary) Hyperthermia, tachycardia, orthostatic hypotension,
restlessness, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased
LOC, reduced to absent DTR's, thirst, dry mucous membranes, increased GI motility, abdominal
cramping, nausea, edema, oliguria
S/S of hypokalemia (body temperature, pulse, BP, muscles, reflexes, neurological, HR, GI)
Hyperthermia, weak irregular pulse, hypotension, respiratory distress, muscle weakness,
muscle cramping, decreased muscle tone, hypoactive reflexes, paresthesias, confusion, PVCs,
bradycardia, decreased GI motility
S/S of hyperkalemia (pulse, BP, neurological, muscles, reflexes, heart, GI) Slow irregular
pulse, hypotension, irritability, confusion, weakness, paresthesias, lack of reflexes, V fib,
increased GI motility, diarrhea, abdominal cramps, hyperactive bowel sounds
Which position should a patient be in for tracheal suction? Fowler's or high-Fowler's
What should the nurse do before tracheal suctioning? Obtain baseline vitals,
hyperoxygenate the patient with 100% SiO2
In the hospital, which type of asepsis should be practices during tracheal suctioning and care?
Surgical, sterile
What is the appropriate suction pressure for trach suctioning? 120-150 mmHg
,How long should trach suctioning be limited to? 10-15 seconds, max 5 minutes
What should the nurse do after trach suctioning to restore O2 levels? Administer 100% O2
Should a suction catheter for trach suctioning be reused for subsequent uses? No
What is the ego defense model? Refers to holding attitudes that protect our self-esteem or
that justify actions that make us feel guilty
What is the Neuman model? Focuses on the response of the patient system to actual or
potential environmental stressors and the use of primary, secondary, and tertiary nursing
prevention intervention for retention, attainment, and maintenance of patient system wellness
What should a student nurse do if a medication dosage does not seem right? Ask the nurse,
then the physician, then document
Describe 4-point crutch gait Gives stability to the patient but requires WEIGHT BEARING ON
BOTH LEGS; advance right crutch, move right leg forward, advance left crutch, move left foot
forward, etc.
Describe 3-point crutch gait Pt. bears all of the weight on one foot. Bears weight on both
crutches and then on the uninvolved leg and repeat the sequence. The affected leg does not
touch the ground during early phase of the three-point gait.
Describe 2-point crutch gait Requires partial weight bearing on each foot. The patient moves
a crutch at the same time as the opposing leg so the crutch movements are similar to arm
motion during normal walking.
Which route of med administration provides the fastest relief? IV
, What should the nurse do if a patient receiving an enema complains of cramping? Lower the
bag
What should a nurse do if a MD order does not make sense? Ask the MD or pharmacy
Mug of coffee volume 240 mL
Jello volume 120 mL
Ice cream volume 120 mL
Small glass volume 180 mL
Large glass volume 240 mL
mL to oz 30 mL=1 oz
mL to cc 1 mL=1 cc
What are some nursing interventions for stasis of pulmonary secretions? o Encourage
coughing
o Percussion - break up secretions
o Vibration - removes secretions and moves them to the center to be removed
o Postural drainage
Change position frequently
Should urine ever be withdrawn from the collection bag for specimen collection? No
S/S of hyponatremia (body temperature, HR, pulse, BP, neurological, muscles, reflexes, GI)
Hypothermia, tachycardia, rapid thread pulse, hypotension, headache, confusion, lethargy,
muscle weakness, fatigue, decreased reflexes, seizures, coma, increased GI motility, GI
cramping, nausea, vomiting
S/S of hypernatremia (body temperature, HR, BP, neurological, muscles, reflexes, mucous
membranes, GI, body, urinary) Hyperthermia, tachycardia, orthostatic hypotension,
restlessness, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased
LOC, reduced to absent DTR's, thirst, dry mucous membranes, increased GI motility, abdominal
cramping, nausea, edema, oliguria
S/S of hypokalemia (body temperature, pulse, BP, muscles, reflexes, neurological, HR, GI)
Hyperthermia, weak irregular pulse, hypotension, respiratory distress, muscle weakness,
muscle cramping, decreased muscle tone, hypoactive reflexes, paresthesias, confusion, PVCs,
bradycardia, decreased GI motility
S/S of hyperkalemia (pulse, BP, neurological, muscles, reflexes, heart, GI) Slow irregular
pulse, hypotension, irritability, confusion, weakness, paresthesias, lack of reflexes, V fib,
increased GI motility, diarrhea, abdominal cramps, hyperactive bowel sounds
Which position should a patient be in for tracheal suction? Fowler's or high-Fowler's
What should the nurse do before tracheal suctioning? Obtain baseline vitals,
hyperoxygenate the patient with 100% SiO2
In the hospital, which type of asepsis should be practices during tracheal suctioning and care?
Surgical, sterile
What is the appropriate suction pressure for trach suctioning? 120-150 mmHg
,How long should trach suctioning be limited to? 10-15 seconds, max 5 minutes
What should the nurse do after trach suctioning to restore O2 levels? Administer 100% O2
Should a suction catheter for trach suctioning be reused for subsequent uses? No
What is the ego defense model? Refers to holding attitudes that protect our self-esteem or
that justify actions that make us feel guilty
What is the Neuman model? Focuses on the response of the patient system to actual or
potential environmental stressors and the use of primary, secondary, and tertiary nursing
prevention intervention for retention, attainment, and maintenance of patient system wellness
What should a student nurse do if a medication dosage does not seem right? Ask the nurse,
then the physician, then document
Describe 4-point crutch gait Gives stability to the patient but requires WEIGHT BEARING ON
BOTH LEGS; advance right crutch, move right leg forward, advance left crutch, move left foot
forward, etc.
Describe 3-point crutch gait Pt. bears all of the weight on one foot. Bears weight on both
crutches and then on the uninvolved leg and repeat the sequence. The affected leg does not
touch the ground during early phase of the three-point gait.
Describe 2-point crutch gait Requires partial weight bearing on each foot. The patient moves
a crutch at the same time as the opposing leg so the crutch movements are similar to arm
motion during normal walking.
Which route of med administration provides the fastest relief? IV
, What should the nurse do if a patient receiving an enema complains of cramping? Lower the
bag
What should a nurse do if a MD order does not make sense? Ask the MD or pharmacy
Mug of coffee volume 240 mL
Jello volume 120 mL
Ice cream volume 120 mL
Small glass volume 180 mL
Large glass volume 240 mL
mL to oz 30 mL=1 oz
mL to cc 1 mL=1 cc
What are some nursing interventions for stasis of pulmonary secretions? o Encourage
coughing
o Percussion - break up secretions
o Vibration - removes secretions and moves them to the center to be removed
o Postural drainage
Change position frequently
Should urine ever be withdrawn from the collection bag for specimen collection? No
