NURSING 400 FINAL EXAM COMBINED STU
WITH CORRECT ANSWERS
Dysphagia c- cCORRECT cANS✔✔inability cto cswallow cor cdifficulty cin cswallowing
2 ckey cpoints cabout cDysphagia c- cCORRECT cANS✔✔1. c30 cmins cprior cto cmeal ctime, cthe cpt cne
cdegree cunless cits ccontraindicated
2. cMonitor cfor cpossibility cof caspiration
-s/s cof caspiration
-Coughing
-Wheezing
-Redness cof cface
-Decrease cO2 csat
2 ckey cpoints cabout cNasogastric cTube c- cCORRECT cANS✔✔Used cfor cpt cwho csuffers cfrom cdys
Residual cvolume cmust calways cbe cchecked cq4h cd/t crisk cfor caspiration c*** cif cthere cis ca clarge ca
cthat cmeans cpt cis cnot cdigesting cthe cfood c- cinform cMD**
Nasogastric cTube cSupplies c- cCORRECT cANS✔✔Nasogastric ctube
Irrigation ctray c- c60 cml csyringe
A cbottle cof csterile cwater
lubricant
NGT cinsertion c- cCORRECT cANS✔✔1. cMeasure cthe ctube cfrom cthe cnose cto cthe cback cof cthe ce
cbottom cof cthe cxiphoid cprocess
2. cMark cthe ctube c(sharpie)
3. cHave cthe cpatient cswallow cwhile cinserting cthe ctube c(with cor cwithout cice cchips)
NGT cplacement c- cCORRECT cANS✔✔1. cOnce cthe cNGT cis cinserted, caspirate c30 cmL cof cair
2. cPlace cthe cstethoscope cover cthe cstomach cand clisten cto cthe c"wooooosh" csound cas cyou cinjec
3. cIf cnecessary, cget can corder cfor cx cray cfor cproper cplacement.
,7 cRules cabout cBody cmechanics c- cCORRECT cANS✔✔-Always cbend cthe cknee cand chave ca cwi
-Always cpoint cyour ctoes cto cthe cdirection cyou're cgoing
-When ctransferring ca cpatient cto ca cchair cor cwheelchair, chave cthem chold con cto cyour cshoulders c
cin cbetween ctheir clegs.
-Always ccount c(1-2-3) cout cloud cand ctell cthem chow cto cposition cor cmove
themselves.
a. cIf cthe cpatient cis cweaker con cone cside, chave cthem cput ctheir cweight con cthe cstronger cside cbe
b. cTurn cyour centire cbody crather cthan cpivoting cto cavoid churting cyour cback
-When cre cpositioning cthe cpatient, cyou chas calways cmake csure cto cavoid churting cyour cwrists
-Make csure cthe cbed cis cat cyour chip clevel. c
-If cthe cpatient cis ctoo cheavy, cask cfor chelp.
How cdo cwe cmeasure csyringe cgauge csizes? c- cCORRECT cANS✔✔THE cSMALLER cTHE cNUMB
cDIAMETER c(GAUGE) cOF cNEEDLE
IV csite cinspection c- cCORRECT cANS✔✔look catthe cIV ccatheter cinsertion csite cfor credness, cswel
cindicate cirritation, cinflammation, cinfection, cor cthrombus cformation. c... cAssess cthe ccondition cof c
cdressing. cThe cdressing cshould cbe cclean, cdry, cand cadhere csecurely cto cthe cskin caround cthe cIV
Intravenous csites c- cCORRECT cANS✔✔-Common csites:
Dorsal carea cof cthe chands
Forearm
-Antecubital cFossa
Uncommon csites
Dorsal carea cof cfeet c(needs can corder)
Cephalic c(infants)
Intravenous csyringe clength c- cCORRECT cANS✔✔Neonate cand cInfants:
19 cmm c(<1 cinch)
Child cand cOlder cAdult:
1 cinch
Adults:
1-1 c¼ cinches
Intravenous cguages c- cCORRECT cANS✔✔Neonate cand cInfants:
24-26 cG
Child cand cOlder cAdults:
22 cG
Adults:
18, c20, cand c22 cG
Intravenous cangle c- cCORRECT cANS✔✔*** cAngle cdepends cupon cwhere cthe cIV cinsertion csite c
,(Parenteral croutes cof cmedication cadministration)
Intramuscular c- cCORRECT cANS✔✔Injected cin cthe cmuscle
Faster conset cthan cintradermal cand csubQ
(Parenteral croutes cof cmedication cadministration)
Intravenous c- cCORRECT cANS✔✔Injected cin cthe cvein
Fastest cabsorption cwhich calso cmeans cfastest creaction cto cmedication
(Parenteral croutes cof cmedication cadministration) c(7)
Transdermal c- cCORRECT cANS✔✔1. cApplied ctopically con cthe cskin cusing ca cpatch cthat ccontain
2. cRemove cold cpatch cand cwipe cof cremnants cof cmedication
3. cClean cand cdry cthe carea
4. cApply cpatch con cdifferent clocation c(sites cmust cbe crotated cto cavoid cskin cirritation)
5. cIf cthe cpt cis chairy, ctrim cthe chair
6. cLabel cthe cpatch cwith cdate, ctime, cand cyou cinitials
7. cMost ccommon cpatch cused: cNitroglycerin c- ca cvasodilator cused cto cprevent cangina c(chest cpai
cArtery cDisease)
Urinary ccatheterization cpreparation c- cCORRECT cANS✔✔Doctor's corder cis cneeded cfor call ccath
Ask cfor clatex cand ciodine callergies
Gather cappropriate cPPE csupplies
Clean cthe cgenital carea cprior cto cthe cprocedure
Assess cthe cgenitalia cfor cany clesions, cswelling, cand cskin cbreakdown
Adjust cthe cbed cto cappropriate cheight
Vital csigns c- cCORRECT cANS✔✔are cindicators cof cphysiological cfunctioning cperson's c
temperature, cpulse, crespiration cand cblood cpressure c
T, cP, cR cand cBlood cPressure ctaken cevery c4 chours cin chospitalized cpatients
Vital csign cfacts: c- cCORRECT cANS✔✔Changes cin cvital csigns cmay cindicate, cor cin csome ccases
cand cacid-base cimbalances.
Elevated cbody ctemp: cmay cbe cthe cresult cof cdehydration cor ca ccause cof cincreased cbody cfluid clo
Tachycardia cis can cearly csign cof chypovolemia c(abnormal cdecrease cin cthe cvolume cof cblood cpla
Pulse cvolume cwill cdecrease cin cFVD cand cincrease cin cFVE. cIrregular cpulse crhythms cmay coccur
cChanges cin cresp crate cand cdepth cmay ccause crespiratory cacid-base cimbalances cor cindicate ca c
cmetabolic cacidosis cor calkalosis.
BP: csensitive cmeasure cfor cdetecting cblood cvolume cchanges cmay cfall csignificantly cwith cFVD can
cwith cFVE. cPostural cor corthostatic chypotension cmay calso coccur cwith cFVD cand chypovolemia.
, Pulse cbeats/min: c60-100
Respirations cbreaths/min: c15-25
Blood cPressure cmm cHg: c95/57
Adolescent cBlood cpressure c(TPRBp) c- cCORRECT cANS✔✔Temperature: c35.8-37.5C* c(oral cF* c
Pulse cbeats/min: c55-95
Respirations cbreaths/min: c12-18
Blood cPressure cmm cHg: c102/61
Adult cBlood cpressure c(TPRBp) c- cCORRECT cANS✔✔Temperature: c35.8-37.5C* c(oral cF*96.4-99
Pulse cbeats/min: c60-100
Respirations cbreaths/min: c12-20
Blood cPressure cmm cHg: c120/80
(Temperature)
Oral c- cCORRECT cANS✔✔When cselecting cthe coral csite, cthe cpatient cmust cbe cable cto cclose chi
cprobe.
If ca cpatient chas chad ceither chot cor ccold cfood cor cfluids cor chas cbeen csmoking cor cchewing cgum,
cis cto cwait c15 cto c30 cmins cto callow cthe coral ctissues cto creturn cto cnormal ctemperature. cMouth cb
cresults.
Oral ctemperatures cshould cnot cbe ctaken cin cpeople cwith cdiseases cof cthe coral ccavity, cin cthose cw
cor cmouth cor cwhen cthere cis crisk cof cseizures.
The cprobe cmust cremain cin cthe csublingual cpocket cfor cthe cfull cperiod cof cmeasurement
(Temperature)
Tympanic c- cCORRECT cANS✔✔Insert cthe cprobe csnugly cinto cthe cexternal cear cusing cgentle cbu
cthermometer ctoward cthe cpatient's cjaw cline. c
Pull cthe cpinna cup cand cback cto cstraighten cthe cear ccanal cin can cadult.
If ca cpatient chas can cearache, cdo cnot cuse cthe caffected cear cto ctake ca ctympanic ctemperature. cT
cmay ccause csevere cdiscomfort. c
Assess cthe cpatient cfor csignificant cear cdrainage cor ca cscarred ctympanic cmembrane c(not cgood)
An cear cinfection cor cthe cpresence cof cearwax cin cthe ccanal cwill cnot csignificantly caffect ca ctympan
If cthe cpatient chas cbeen csleeping cwith cthe chead cturned cto cone cside, ctake ca ctympanic ctempera
cmay cbe cincreased con cthe cside cthat cwas cagainst cthe cpillow, cespecially cif cit cis ca cplastic-covere
(Temperature)
Axillary c- cCORRECT cANS✔✔Place cthe cprobe cin cthe ccenter cof cthe caxilla; chold cthe cpatient's ca
cthe cmeasurement cis ccomplete
WITH CORRECT ANSWERS
Dysphagia c- cCORRECT cANS✔✔inability cto cswallow cor cdifficulty cin cswallowing
2 ckey cpoints cabout cDysphagia c- cCORRECT cANS✔✔1. c30 cmins cprior cto cmeal ctime, cthe cpt cne
cdegree cunless cits ccontraindicated
2. cMonitor cfor cpossibility cof caspiration
-s/s cof caspiration
-Coughing
-Wheezing
-Redness cof cface
-Decrease cO2 csat
2 ckey cpoints cabout cNasogastric cTube c- cCORRECT cANS✔✔Used cfor cpt cwho csuffers cfrom cdys
Residual cvolume cmust calways cbe cchecked cq4h cd/t crisk cfor caspiration c*** cif cthere cis ca clarge ca
cthat cmeans cpt cis cnot cdigesting cthe cfood c- cinform cMD**
Nasogastric cTube cSupplies c- cCORRECT cANS✔✔Nasogastric ctube
Irrigation ctray c- c60 cml csyringe
A cbottle cof csterile cwater
lubricant
NGT cinsertion c- cCORRECT cANS✔✔1. cMeasure cthe ctube cfrom cthe cnose cto cthe cback cof cthe ce
cbottom cof cthe cxiphoid cprocess
2. cMark cthe ctube c(sharpie)
3. cHave cthe cpatient cswallow cwhile cinserting cthe ctube c(with cor cwithout cice cchips)
NGT cplacement c- cCORRECT cANS✔✔1. cOnce cthe cNGT cis cinserted, caspirate c30 cmL cof cair
2. cPlace cthe cstethoscope cover cthe cstomach cand clisten cto cthe c"wooooosh" csound cas cyou cinjec
3. cIf cnecessary, cget can corder cfor cx cray cfor cproper cplacement.
,7 cRules cabout cBody cmechanics c- cCORRECT cANS✔✔-Always cbend cthe cknee cand chave ca cwi
-Always cpoint cyour ctoes cto cthe cdirection cyou're cgoing
-When ctransferring ca cpatient cto ca cchair cor cwheelchair, chave cthem chold con cto cyour cshoulders c
cin cbetween ctheir clegs.
-Always ccount c(1-2-3) cout cloud cand ctell cthem chow cto cposition cor cmove
themselves.
a. cIf cthe cpatient cis cweaker con cone cside, chave cthem cput ctheir cweight con cthe cstronger cside cbe
b. cTurn cyour centire cbody crather cthan cpivoting cto cavoid churting cyour cback
-When cre cpositioning cthe cpatient, cyou chas calways cmake csure cto cavoid churting cyour cwrists
-Make csure cthe cbed cis cat cyour chip clevel. c
-If cthe cpatient cis ctoo cheavy, cask cfor chelp.
How cdo cwe cmeasure csyringe cgauge csizes? c- cCORRECT cANS✔✔THE cSMALLER cTHE cNUMB
cDIAMETER c(GAUGE) cOF cNEEDLE
IV csite cinspection c- cCORRECT cANS✔✔look catthe cIV ccatheter cinsertion csite cfor credness, cswel
cindicate cirritation, cinflammation, cinfection, cor cthrombus cformation. c... cAssess cthe ccondition cof c
cdressing. cThe cdressing cshould cbe cclean, cdry, cand cadhere csecurely cto cthe cskin caround cthe cIV
Intravenous csites c- cCORRECT cANS✔✔-Common csites:
Dorsal carea cof cthe chands
Forearm
-Antecubital cFossa
Uncommon csites
Dorsal carea cof cfeet c(needs can corder)
Cephalic c(infants)
Intravenous csyringe clength c- cCORRECT cANS✔✔Neonate cand cInfants:
19 cmm c(<1 cinch)
Child cand cOlder cAdult:
1 cinch
Adults:
1-1 c¼ cinches
Intravenous cguages c- cCORRECT cANS✔✔Neonate cand cInfants:
24-26 cG
Child cand cOlder cAdults:
22 cG
Adults:
18, c20, cand c22 cG
Intravenous cangle c- cCORRECT cANS✔✔*** cAngle cdepends cupon cwhere cthe cIV cinsertion csite c
,(Parenteral croutes cof cmedication cadministration)
Intramuscular c- cCORRECT cANS✔✔Injected cin cthe cmuscle
Faster conset cthan cintradermal cand csubQ
(Parenteral croutes cof cmedication cadministration)
Intravenous c- cCORRECT cANS✔✔Injected cin cthe cvein
Fastest cabsorption cwhich calso cmeans cfastest creaction cto cmedication
(Parenteral croutes cof cmedication cadministration) c(7)
Transdermal c- cCORRECT cANS✔✔1. cApplied ctopically con cthe cskin cusing ca cpatch cthat ccontain
2. cRemove cold cpatch cand cwipe cof cremnants cof cmedication
3. cClean cand cdry cthe carea
4. cApply cpatch con cdifferent clocation c(sites cmust cbe crotated cto cavoid cskin cirritation)
5. cIf cthe cpt cis chairy, ctrim cthe chair
6. cLabel cthe cpatch cwith cdate, ctime, cand cyou cinitials
7. cMost ccommon cpatch cused: cNitroglycerin c- ca cvasodilator cused cto cprevent cangina c(chest cpai
cArtery cDisease)
Urinary ccatheterization cpreparation c- cCORRECT cANS✔✔Doctor's corder cis cneeded cfor call ccath
Ask cfor clatex cand ciodine callergies
Gather cappropriate cPPE csupplies
Clean cthe cgenital carea cprior cto cthe cprocedure
Assess cthe cgenitalia cfor cany clesions, cswelling, cand cskin cbreakdown
Adjust cthe cbed cto cappropriate cheight
Vital csigns c- cCORRECT cANS✔✔are cindicators cof cphysiological cfunctioning cperson's c
temperature, cpulse, crespiration cand cblood cpressure c
T, cP, cR cand cBlood cPressure ctaken cevery c4 chours cin chospitalized cpatients
Vital csign cfacts: c- cCORRECT cANS✔✔Changes cin cvital csigns cmay cindicate, cor cin csome ccases
cand cacid-base cimbalances.
Elevated cbody ctemp: cmay cbe cthe cresult cof cdehydration cor ca ccause cof cincreased cbody cfluid clo
Tachycardia cis can cearly csign cof chypovolemia c(abnormal cdecrease cin cthe cvolume cof cblood cpla
Pulse cvolume cwill cdecrease cin cFVD cand cincrease cin cFVE. cIrregular cpulse crhythms cmay coccur
cChanges cin cresp crate cand cdepth cmay ccause crespiratory cacid-base cimbalances cor cindicate ca c
cmetabolic cacidosis cor calkalosis.
BP: csensitive cmeasure cfor cdetecting cblood cvolume cchanges cmay cfall csignificantly cwith cFVD can
cwith cFVE. cPostural cor corthostatic chypotension cmay calso coccur cwith cFVD cand chypovolemia.
, Pulse cbeats/min: c60-100
Respirations cbreaths/min: c15-25
Blood cPressure cmm cHg: c95/57
Adolescent cBlood cpressure c(TPRBp) c- cCORRECT cANS✔✔Temperature: c35.8-37.5C* c(oral cF* c
Pulse cbeats/min: c55-95
Respirations cbreaths/min: c12-18
Blood cPressure cmm cHg: c102/61
Adult cBlood cpressure c(TPRBp) c- cCORRECT cANS✔✔Temperature: c35.8-37.5C* c(oral cF*96.4-99
Pulse cbeats/min: c60-100
Respirations cbreaths/min: c12-20
Blood cPressure cmm cHg: c120/80
(Temperature)
Oral c- cCORRECT cANS✔✔When cselecting cthe coral csite, cthe cpatient cmust cbe cable cto cclose chi
cprobe.
If ca cpatient chas chad ceither chot cor ccold cfood cor cfluids cor chas cbeen csmoking cor cchewing cgum,
cis cto cwait c15 cto c30 cmins cto callow cthe coral ctissues cto creturn cto cnormal ctemperature. cMouth cb
cresults.
Oral ctemperatures cshould cnot cbe ctaken cin cpeople cwith cdiseases cof cthe coral ccavity, cin cthose cw
cor cmouth cor cwhen cthere cis crisk cof cseizures.
The cprobe cmust cremain cin cthe csublingual cpocket cfor cthe cfull cperiod cof cmeasurement
(Temperature)
Tympanic c- cCORRECT cANS✔✔Insert cthe cprobe csnugly cinto cthe cexternal cear cusing cgentle cbu
cthermometer ctoward cthe cpatient's cjaw cline. c
Pull cthe cpinna cup cand cback cto cstraighten cthe cear ccanal cin can cadult.
If ca cpatient chas can cearache, cdo cnot cuse cthe caffected cear cto ctake ca ctympanic ctemperature. cT
cmay ccause csevere cdiscomfort. c
Assess cthe cpatient cfor csignificant cear cdrainage cor ca cscarred ctympanic cmembrane c(not cgood)
An cear cinfection cor cthe cpresence cof cearwax cin cthe ccanal cwill cnot csignificantly caffect ca ctympan
If cthe cpatient chas cbeen csleeping cwith cthe chead cturned cto cone cside, ctake ca ctympanic ctempera
cmay cbe cincreased con cthe cside cthat cwas cagainst cthe cpillow, cespecially cif cit cis ca cplastic-covere
(Temperature)
Axillary c- cCORRECT cANS✔✔Place cthe cprobe cin cthe ccenter cof cthe caxilla; chold cthe cpatient's ca
cthe cmeasurement cis ccomplete
