NSG 122 FUNDAMENTAL FINAL EXAM ACTUAL QUESTIONS
AND SOLUTIONS RATED A+
✔✔Cheyne Stokes Respirations - ✔✔Signs of impending death: Noisy, irregular, or
Cheyne-Stokes respirations
Cheyne-Stokes respiration is an abnormal pattern of breathing characterized by
progressively deeper, and sometimes faster, breathing followed by a gradual decrease
that results in a temporary stop in breathing called an apnea
✔✔Hypocalcemia Assessment - ✔✔Hypocalcemia refers to a calcium deficit in ECF
(serum calcium <8.9 mg/dL, ionized calcium <4.5 mg/dL). Common causes related to a
calcium deficit involve inadequate calcium intake, impaired calcium absorption, and
excessive calcium loss. Manifestations of hypocalcemia include numbness and tingling
of fingers, mouth, or feet; tetany; muscle cramps; and seizures.
✔✔Z-Track Injection - ✔✔Use the Z-track technique for intramuscular injections to
prevent leakage of medication into the needle track, thus minimizing discomfort
Many of the drugs given intramuscularly can cause irritation to subcutaneous tissues
when backflow into the tissues occurs along the injection track. Therefore, the Z-track
technique is recommended for all intramuscular injections (particularly nonvaccine
injections) to ensure that medication does not leak back along the needle track and into
the subcutaneous tissue
✔✔Insomnia Stress - ✔✔Insomnia is characterized by difficulty falling asleep,
intermittent sleep, or difficulty maintaining sleep, despite adequate opportunity and
circumstances to sleep
Many cases of insomnia are related to disruptions in circadian rhythms. This sleep
disorder can also occur during periods of stress; in situations involving some change in
the normal environment such as shift work; as a result of pain, discomfort, or limited
mobility; and as a result of the side effects of medications
Identify stress-relieving rituals that enable the patient to fall asleep more easily
✔✔Sleep & Exercise - ✔✔Behavior therapy includes maintaining regular sleep-wake
times, avoiding naps, keeping to a regular exercise routine, and avoiding caffeine,
nicotine, and stimulating activities within several hours of bedtime
✔✔Log Rolling - ✔✔Frequently, a patient cannot turn in bed without assistance. Nurses
need to use their knowledge of correct alignment to turn the patient from the back onto
the side, from the back onto the abdomen, and from the abdomen onto the back
Mastering this turning technique helps nurses adhere to an every-2-hour turn schedule
for a patient experiencing decreased mobility.
✔✔ROM Exercises - ✔✔Engaging in routine tasks—such as bathing, eating, dressing,
and writing—helps use muscle groups that keep many joints in effective range of motion
, Unless contraindicated, encourage active, active-assistive, or passive range-of-motion
exercises regularly and include them in the patient's care plan. In active exercise, the
patient independently moves joints through their full range of motion (isotonic exercise).
In active-assistive exercise, the nurse may provide minimal support, whereas in passive
exercise, the patient is unable to move independently, and the nurse moves each joint
through its range of motion. Both active and passive exercises improve joint mobility
and increase circulation to the affected part, but only active exercise increases muscle
mass, tone, and strength and improves cardiac and respiratory functioning.
✔✔Correct Walker Use - ✔✔Wear nonskid shoes or slippers.
When rising from a seated position, use the chair arms for support. Once standing,
place one hand at a time on the walker and move forward into it.
Begin by pushing the walker forward, keeping the back upright. Place one leg inside the
walker, keeping the walker in place. Then, step forward with the remaining leg into the
walker, keeping the walker still. Repeat the process by moving the walker forward
again.
Caution the patient to avoid pushing the walker out too far in front and leaning over it.
Patients should always step into the walker, rather than walking behind it, staying
upright as they move.
Never attempt to use a walker on stairs.
✔✔Colostomy Gas - ✔✔A colostomy permits formed feces in the colon to exit through
the stoma (the opening of the ostomy attached to the skin)
If you have a colostomy or ileostomy, you may have noticed gas in your pouch, which
happens as your bowel begins to function after surgery. The amount of gas varies.
However, if you've always had excessive gas, you'll probably still have it after your
surgery, but in your pouch. Gas can be caused by the foods you eat.
✔✔Constipation Interventions - ✔✔Listen to bowel sounds, Laxatives
A combination of high-fiber foods (20 to 35 g of fiber), 60 to 80 oz (1.8 to 2.4 L) of fluid
daily, and exercise has been shown to be effective in controlling constipation in patients
with deficiencies in dietary intake of fiber and/or fluid and reduced amounts of exercise
✔✔Assessment of Feces - ✔✔Assess volume, color, odor, consistency, shape, and any
constituents
✔✔PEG Feedings - ✔✔Placement of a tube into the stomach can be accomplished by a
surgeon or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or a
surgically (open or laparoscopically) placed gastrostomy tube. PEG tube insertion is
often used because, unlike a traditional, surgically placed gastrostomy tube, it usually
does not require general anesthesia. Use of a PEG tube or other type of gastrostomy
tube requires an intact, functional GI tract. Insertion of a PEG tube involves local
anesthesia, passage of an endoscope into the stomach, a small incision or stab wound
through the skin of the abdomen, pushing a cannula through the small incision, insertion
of a guide wire or suture material through the cannula, and introduction and placement
of the PEG tube through one of several method
AND SOLUTIONS RATED A+
✔✔Cheyne Stokes Respirations - ✔✔Signs of impending death: Noisy, irregular, or
Cheyne-Stokes respirations
Cheyne-Stokes respiration is an abnormal pattern of breathing characterized by
progressively deeper, and sometimes faster, breathing followed by a gradual decrease
that results in a temporary stop in breathing called an apnea
✔✔Hypocalcemia Assessment - ✔✔Hypocalcemia refers to a calcium deficit in ECF
(serum calcium <8.9 mg/dL, ionized calcium <4.5 mg/dL). Common causes related to a
calcium deficit involve inadequate calcium intake, impaired calcium absorption, and
excessive calcium loss. Manifestations of hypocalcemia include numbness and tingling
of fingers, mouth, or feet; tetany; muscle cramps; and seizures.
✔✔Z-Track Injection - ✔✔Use the Z-track technique for intramuscular injections to
prevent leakage of medication into the needle track, thus minimizing discomfort
Many of the drugs given intramuscularly can cause irritation to subcutaneous tissues
when backflow into the tissues occurs along the injection track. Therefore, the Z-track
technique is recommended for all intramuscular injections (particularly nonvaccine
injections) to ensure that medication does not leak back along the needle track and into
the subcutaneous tissue
✔✔Insomnia Stress - ✔✔Insomnia is characterized by difficulty falling asleep,
intermittent sleep, or difficulty maintaining sleep, despite adequate opportunity and
circumstances to sleep
Many cases of insomnia are related to disruptions in circadian rhythms. This sleep
disorder can also occur during periods of stress; in situations involving some change in
the normal environment such as shift work; as a result of pain, discomfort, or limited
mobility; and as a result of the side effects of medications
Identify stress-relieving rituals that enable the patient to fall asleep more easily
✔✔Sleep & Exercise - ✔✔Behavior therapy includes maintaining regular sleep-wake
times, avoiding naps, keeping to a regular exercise routine, and avoiding caffeine,
nicotine, and stimulating activities within several hours of bedtime
✔✔Log Rolling - ✔✔Frequently, a patient cannot turn in bed without assistance. Nurses
need to use their knowledge of correct alignment to turn the patient from the back onto
the side, from the back onto the abdomen, and from the abdomen onto the back
Mastering this turning technique helps nurses adhere to an every-2-hour turn schedule
for a patient experiencing decreased mobility.
✔✔ROM Exercises - ✔✔Engaging in routine tasks—such as bathing, eating, dressing,
and writing—helps use muscle groups that keep many joints in effective range of motion
, Unless contraindicated, encourage active, active-assistive, or passive range-of-motion
exercises regularly and include them in the patient's care plan. In active exercise, the
patient independently moves joints through their full range of motion (isotonic exercise).
In active-assistive exercise, the nurse may provide minimal support, whereas in passive
exercise, the patient is unable to move independently, and the nurse moves each joint
through its range of motion. Both active and passive exercises improve joint mobility
and increase circulation to the affected part, but only active exercise increases muscle
mass, tone, and strength and improves cardiac and respiratory functioning.
✔✔Correct Walker Use - ✔✔Wear nonskid shoes or slippers.
When rising from a seated position, use the chair arms for support. Once standing,
place one hand at a time on the walker and move forward into it.
Begin by pushing the walker forward, keeping the back upright. Place one leg inside the
walker, keeping the walker in place. Then, step forward with the remaining leg into the
walker, keeping the walker still. Repeat the process by moving the walker forward
again.
Caution the patient to avoid pushing the walker out too far in front and leaning over it.
Patients should always step into the walker, rather than walking behind it, staying
upright as they move.
Never attempt to use a walker on stairs.
✔✔Colostomy Gas - ✔✔A colostomy permits formed feces in the colon to exit through
the stoma (the opening of the ostomy attached to the skin)
If you have a colostomy or ileostomy, you may have noticed gas in your pouch, which
happens as your bowel begins to function after surgery. The amount of gas varies.
However, if you've always had excessive gas, you'll probably still have it after your
surgery, but in your pouch. Gas can be caused by the foods you eat.
✔✔Constipation Interventions - ✔✔Listen to bowel sounds, Laxatives
A combination of high-fiber foods (20 to 35 g of fiber), 60 to 80 oz (1.8 to 2.4 L) of fluid
daily, and exercise has been shown to be effective in controlling constipation in patients
with deficiencies in dietary intake of fiber and/or fluid and reduced amounts of exercise
✔✔Assessment of Feces - ✔✔Assess volume, color, odor, consistency, shape, and any
constituents
✔✔PEG Feedings - ✔✔Placement of a tube into the stomach can be accomplished by a
surgeon or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or a
surgically (open or laparoscopically) placed gastrostomy tube. PEG tube insertion is
often used because, unlike a traditional, surgically placed gastrostomy tube, it usually
does not require general anesthesia. Use of a PEG tube or other type of gastrostomy
tube requires an intact, functional GI tract. Insertion of a PEG tube involves local
anesthesia, passage of an endoscope into the stomach, a small incision or stab wound
through the skin of the abdomen, pushing a cannula through the small incision, insertion
of a guide wire or suture material through the cannula, and introduction and placement
of the PEG tube through one of several method
