Grossmont College Nursing 120 Exam 2 Questions With
Complete Solutions
2 important questions to assess bowel elimination and possible
problems Correct Answers "When was your last BM?"
"Are you passing gas?"
6 QSEN Competencies Correct Answers Pt.-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
Abdominal assessment: Auscultation Correct Answers Listen
for bowel sounds in all quadrants (clockwise motion)
Listen for clicks/gurgles → motility & peristalsis
5-7 sounds/15 seconds each quadrant
Can be hypoactive (diminished sounds), hyperactive (intense c
frequency), or absent & infrequent
*Most recent meal/full bladder may affect exam*
Abdominal assessment: Inspection Correct Answers Assess for
contour of abdomen - noting masses, scars, or areas of distention
or protrusion
Abdominal assessment: Palpation Correct Answers Watch for
nonverbal comm. for pain
Note muscular resistance, tenderness, enlargement of organs, or
masses
*Palpate painful areas last*
,Acute Pain Correct Answers Rapid in onset & varies in
intensity from mild to severe
Short duration, up to 6 months
Addiction Correct Answers Pattern of compulsive opioid use
for means other than pain control
Adrenergic agonist
Albuterol
(Proventil) Correct Answers Action: Binds to B2-adrenergic
receptors in airway smooth muscle, relaxing airways →
bronchodilation
Indication: Opens airway to treat acute bronchospasm
Adverse Rxn: PARADOXICAL BRONCHOSPASM,
nervousness, restlessness, tremor, chest pain, palpitations,
tachycardia
RN Considerations: Assess O2, RR, HR, lung sounds; Observe
for paradoxical bronchospasm
Effectiveness: Prevention/relief of bronchospasm, ↑O2, ↓RR,
clearer lung sounds
Age related changes affecting oxygenation in older adults
Correct Answers ↓ elasticity of alveoli
↓ rate/depth of breathing
Use of accessory muscles
Dryer mucus membranes
,↓ CO & perfusion to extremities
Age-related changes for older adult c pain Correct Answers
Communication difficulties
Denial of pain
Altered physiological response
American Nurses Association Code of Ethics for Nurses Correct
Answers Nurse practices c compassion & respect for the
inherent dignity, worth, & uniqueness of every individual
1° commitment is to the pt.
Promotes, advocates for, & strives to protect the health, safety &
rights of the pt.
Anticholinergic
Ipratropium
(Atrovent) Correct Answers Action: Inhibits cholenergic
receptors in bronchial smooth muscle & produce local
bronchodilation
Indication: Maintenance therapy of reversible airway obstruction
due to COPD
Adverse Rxn: CNS irritation, GI upset
RN Considerations: Assess for allergy to atropine; Assess
respiratory status (rate, breath sounds, degree of dyspnea, pulse)
Effectiveness: ↓dyspnea, clearer lung sounds
Anticholinergic
, Oxybutynin
(Ditropan) Correct Answers Action: Inhibits action of ACh @
postganglionic receptors on smooth muscle in GU tract; ↑
bladder capacity, delayed desire to void.
Frequent urination, urgency, urge incontinence, overactive
bladder
Adverse Rxn: ANAPHYLAXIS, ANGIOEDEMA, dizziness,
drowsiness, constipation, dry mouth, nausea, urinary retention
RN Considerations: Monitor voiding pattern, I/O, bladder
distention
Effectiveness: Relief of bladder spasm, urinary frequency,
urgency & incontinence
Antidiarrheal
Loperamide
(Imodium) Correct Answers Action: Inhibits peristalsis by
direct effect on nerves in intestinal muscle wall; ↓ fecal vol, ↑
fecal viscosity and bulk; Relief of diarrhea
Indication: Therapy of acute diarrhea; Chronic diarrhea
associated c inflammatory bowel disease
Adverse Rxn: Drowsiness, constipation
RN Considerations: Assess frequency & consistency of stools &
bowel sounds a/p Rx, assess fluid & electrolyte balance & skin
turgor for dehydration, teach pt. Rx may cause drowsiness
Complete Solutions
2 important questions to assess bowel elimination and possible
problems Correct Answers "When was your last BM?"
"Are you passing gas?"
6 QSEN Competencies Correct Answers Pt.-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
Abdominal assessment: Auscultation Correct Answers Listen
for bowel sounds in all quadrants (clockwise motion)
Listen for clicks/gurgles → motility & peristalsis
5-7 sounds/15 seconds each quadrant
Can be hypoactive (diminished sounds), hyperactive (intense c
frequency), or absent & infrequent
*Most recent meal/full bladder may affect exam*
Abdominal assessment: Inspection Correct Answers Assess for
contour of abdomen - noting masses, scars, or areas of distention
or protrusion
Abdominal assessment: Palpation Correct Answers Watch for
nonverbal comm. for pain
Note muscular resistance, tenderness, enlargement of organs, or
masses
*Palpate painful areas last*
,Acute Pain Correct Answers Rapid in onset & varies in
intensity from mild to severe
Short duration, up to 6 months
Addiction Correct Answers Pattern of compulsive opioid use
for means other than pain control
Adrenergic agonist
Albuterol
(Proventil) Correct Answers Action: Binds to B2-adrenergic
receptors in airway smooth muscle, relaxing airways →
bronchodilation
Indication: Opens airway to treat acute bronchospasm
Adverse Rxn: PARADOXICAL BRONCHOSPASM,
nervousness, restlessness, tremor, chest pain, palpitations,
tachycardia
RN Considerations: Assess O2, RR, HR, lung sounds; Observe
for paradoxical bronchospasm
Effectiveness: Prevention/relief of bronchospasm, ↑O2, ↓RR,
clearer lung sounds
Age related changes affecting oxygenation in older adults
Correct Answers ↓ elasticity of alveoli
↓ rate/depth of breathing
Use of accessory muscles
Dryer mucus membranes
,↓ CO & perfusion to extremities
Age-related changes for older adult c pain Correct Answers
Communication difficulties
Denial of pain
Altered physiological response
American Nurses Association Code of Ethics for Nurses Correct
Answers Nurse practices c compassion & respect for the
inherent dignity, worth, & uniqueness of every individual
1° commitment is to the pt.
Promotes, advocates for, & strives to protect the health, safety &
rights of the pt.
Anticholinergic
Ipratropium
(Atrovent) Correct Answers Action: Inhibits cholenergic
receptors in bronchial smooth muscle & produce local
bronchodilation
Indication: Maintenance therapy of reversible airway obstruction
due to COPD
Adverse Rxn: CNS irritation, GI upset
RN Considerations: Assess for allergy to atropine; Assess
respiratory status (rate, breath sounds, degree of dyspnea, pulse)
Effectiveness: ↓dyspnea, clearer lung sounds
Anticholinergic
, Oxybutynin
(Ditropan) Correct Answers Action: Inhibits action of ACh @
postganglionic receptors on smooth muscle in GU tract; ↑
bladder capacity, delayed desire to void.
Frequent urination, urgency, urge incontinence, overactive
bladder
Adverse Rxn: ANAPHYLAXIS, ANGIOEDEMA, dizziness,
drowsiness, constipation, dry mouth, nausea, urinary retention
RN Considerations: Monitor voiding pattern, I/O, bladder
distention
Effectiveness: Relief of bladder spasm, urinary frequency,
urgency & incontinence
Antidiarrheal
Loperamide
(Imodium) Correct Answers Action: Inhibits peristalsis by
direct effect on nerves in intestinal muscle wall; ↓ fecal vol, ↑
fecal viscosity and bulk; Relief of diarrhea
Indication: Therapy of acute diarrhea; Chronic diarrhea
associated c inflammatory bowel disease
Adverse Rxn: Drowsiness, constipation
RN Considerations: Assess frequency & consistency of stools &
bowel sounds a/p Rx, assess fluid & electrolyte balance & skin
turgor for dehydration, teach pt. Rx may cause drowsiness
