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Exam (elaborations)

NUR 185 Final Exam Term 4

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NUR 185 Final Exam Term 4

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NUR 185 Final Exam Term 4

1.Patient with Congestive Heart Failure (CHF), what lab value would you
pay attention to?: Potassium (K+ normal value 3.5-5)
2.Ventilator Care - Care Coordination may include...: For mechanically
ven- tilated patients, care providers may include primary care
physicians, pulmonary specialists, hospitalists, respiratory therapists,
and nurses
3.Patient with stroke and right sided vision loss. You plan to do which of
the following?: Teach the patient to scan the environment
4.Patient with bowel tumor. Which diagnostic test would confirm the
malig- nancy?: Biopsy
5.Patient getting Antineoplastic , chemo therapy. What would you include
in their plan of care?: Consult the physicians before getting
immunizations
6.Patient has upper GI bleeding and is in moderate distress. What is your
first priority?: Obtain and evaluate vital signs
7.You have a patient with pulmonary edema about to be discharged.
What would you tell them to manage and prevent complications?: Daily
weights
8.You have given a patient diphenhydramine Benadryl and then educate
the patient on this medication. Which statement indicates a need for
further teaching?: I can still take my sleeping pill with my Benadryl
9.The nurse is caring for patient with terminal cancer and close to death.
What is the priority intervention for this patient?: Provide emotional
support for loved ones
10. Patient with chronic vertigo. Teaching them about preventions of
exacerba- tions or injury. What would you educate the patient on?: Turn
your head slowly to minimize vertigo.
11.Teaching a patient how to use a walker. What statement would the nurse
question?: Be certain there is a 45 degree angle of flexion at the elbow
to ensure adequate length of the walker
12.You have a patient from the OR following hip replacement. Patient is in
bed in high-fowlers. Skin is pale, cold, and clammy. What actions would you
take at this time?: Check the blood pressure.
13.You have 4 patients in long-term care facility. Which patient would be
priority?: 29 year old patient with down syndrome. 1 week post op
temperature of 101, pulse of 110, and shivering.
14.You have a patient on the coumadin 3MG a day. INR today is 1.2 (low).
What order would you carry out?: Give 5MG coumadin today to offset
the imbalance.


, NUR 185 Final Exam Term 4

15.Caring for diabetic patient who just took shower. HR is 70, skin is warm
and dry. You take their Blood Sugar and it is 42. What would you do?: Go
get a new glucose test and recheck.






, NUR 185 Final Exam Term 4

16.You have a patient that just vomited coffee ground emesis. 350 ML on
the floor, indicative of GI bleed, on the cardiac floor on heparin drip. What
are you going to do?: Stop the heparin drip, give vitals, and provide
emotional support (one answer)
17.A patient has started on a new med and developed hives and
angioedema. This is their 3rd dose of medication and states "I did have
some itching with the second dose". What would the nurse do now?: Give
the patient a dose of Epinephrine (epi) Intramuscular shot stat per
physician order.
18.What are burn patients at high risk for?: High risk for sepsis / infection,
fluid volume deficit
19.Anytime you are at risk for infections: Tetanus is good for up to 10 year
20.You have a patient getting gentamicin, also know as geromycin, via IV.
What lab from this morning are you going to be concerned about?
(ototoxic, nephrotoxic, and neurotoxic): Creatinine of 5.1
21.What acronym would you use for a fire extinguisher?: PASS: Pull,
AIM, Squeeze, Sweep
22.You are giving med to a G-tube patient. What would concern you
the most?: Purulent drainage
23. Nurse notices a trashcan with papers caught on fire.You will do what
action first?: Grab an ABC fire extinguisher and aim at the base of the
fire.
24.Patient admitted to ED with chest pain. They have several coronary
artery risk factors. What will you implement?: EKG within 10 minutes and
give chewable aspirin if they are not allergic.
25.You gave a patient morphine 1 hour ago. You are most concerned
about which assessment?: Blood Pressure (BP) of 94/60, pulse
oximeter (O2) of 88, patient is lethargic.
26.You have a patient who had an Myocardial Infarction (MI). Which lab
values are of greatest concern to the nurse?: Sodium of 133 and
magnesium of 1.3
27. You go into a patient's room and there is a fire in the corner. The
ambulatory patient is asleep. What are you going to do?: Wake up the
patient up and get them out of the room as quickly as possible.
28.Patient in the ER burned by the fire. You are most concerned about
which piece of assessment data?: Blood Pressure of 80 over 50 (80/50)
and pulse is 120
29.Patient is getting 1L of Lactated Ringers (LR) to infuse over 8 hours,
what would you set up the pump at?: 125 ml/hr

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