NR 341 EXAM 2 (FINAL) STUDY
GUIDE QUESTIONS AND
CORRECT DETAILED ANSWERS
ABG interpretation - correct answer- i. pH 7.35-
7.45
iv. PaCO2 35-45 mm Hg
v. HCO3− 22-26 mEq/L (mmol/L)
Acute pancreatitis - correct answer-
inflammation of the pancreas
acute reaction - correct answer- in the first 6
months after transplantation. This type of rejection is
usually a cell-mediated immune response by the
recipient's lymphocytes, which have been activated
against the donated (foreign) tissue or organ (Fig. 13-12).
In addition to cell-mediated rejection, another type of
acute rejection occurs when the recipient develops
antibodies to the transplanted organ (humoral rejection).
,Addison's disease - correct answer- occurs
when the adrenal glands do not produce enough of the
hormones cortisol or aldosterone
Addison's disease interventions - correct answer-
Promote fluid balance, monitor fluid deficit, prevent
hypoglycemia. Mineralcorticoid hormone need to
maintain electrolyte balance
Addison's disease treatment - correct answer-
Chronic steroids (glucocorticoids)
life long
Anaphylactic reaction - correct answer- severe
reaction occurring immediately after exposure to a drug;
characterized by respiratory distress and vascular collapse
Anaphylactic reaction interventions - correct
answer- 1. Administer epinephrine, 0.3 mL of a
1;1000 solution, Sub-Q for adults or 0.01 mg/kg of 1;1000
Sub-Q for pediatric patients.
,2. Massage the site to speed absorption rate. Repeat the
dose every 15-20 minutes, as appropriate.
3. Notify the prescriber and/or primary caregiver and
discontinue the drug.
4. Be aware that prevention is the best treatment.
Counsel patients with known allergies to wear Medic-
Alert identification and, if appropriate, to carry an
emergency epinephrine kit.
Assessment method for CSF leakage - correct
answer- The first method is to test the leaking fluid
with a Dextrostix or Tes-Tape strip to determine whether
glucose is present. CSF gives a positive reading for
glucose. If blood is present in the fluid, testing for glucose
is unreliable because blood also contains glucose. In this
event, look for the halo or ring sign
Autonomic dysreflexia - correct answer-
(potentially life threatening emergency!) HOB elevate 90
, degrees, loosen constrictive clothing, assess for full
bladder or bowel impaction, (trigger) administer
antihypertensives (may cause stroke, MI, seizure)
Autonomic Dysreflexia interventions & prevention -
correct answer- • Raise the person to a sitting
position.
• Remove the noxious stimulus (fecal impaction, kinked
urinary catheter, tight clothing).
• Call the HCP if above actions do not relieve the signs and
symptoms.
3. Measures to decrease the incidence of autonomic
hyperreflexia
• Maintain regular bowel function.
• Use a local anesthetic to prevent autonomic
hyperreflexia if manual rectal stimulation is used to
promote bowel function.
Autonomic dysreflexia symptoms - correct
answer- 1. Signs and symptoms
GUIDE QUESTIONS AND
CORRECT DETAILED ANSWERS
ABG interpretation - correct answer- i. pH 7.35-
7.45
iv. PaCO2 35-45 mm Hg
v. HCO3− 22-26 mEq/L (mmol/L)
Acute pancreatitis - correct answer-
inflammation of the pancreas
acute reaction - correct answer- in the first 6
months after transplantation. This type of rejection is
usually a cell-mediated immune response by the
recipient's lymphocytes, which have been activated
against the donated (foreign) tissue or organ (Fig. 13-12).
In addition to cell-mediated rejection, another type of
acute rejection occurs when the recipient develops
antibodies to the transplanted organ (humoral rejection).
,Addison's disease - correct answer- occurs
when the adrenal glands do not produce enough of the
hormones cortisol or aldosterone
Addison's disease interventions - correct answer-
Promote fluid balance, monitor fluid deficit, prevent
hypoglycemia. Mineralcorticoid hormone need to
maintain electrolyte balance
Addison's disease treatment - correct answer-
Chronic steroids (glucocorticoids)
life long
Anaphylactic reaction - correct answer- severe
reaction occurring immediately after exposure to a drug;
characterized by respiratory distress and vascular collapse
Anaphylactic reaction interventions - correct
answer- 1. Administer epinephrine, 0.3 mL of a
1;1000 solution, Sub-Q for adults or 0.01 mg/kg of 1;1000
Sub-Q for pediatric patients.
,2. Massage the site to speed absorption rate. Repeat the
dose every 15-20 minutes, as appropriate.
3. Notify the prescriber and/or primary caregiver and
discontinue the drug.
4. Be aware that prevention is the best treatment.
Counsel patients with known allergies to wear Medic-
Alert identification and, if appropriate, to carry an
emergency epinephrine kit.
Assessment method for CSF leakage - correct
answer- The first method is to test the leaking fluid
with a Dextrostix or Tes-Tape strip to determine whether
glucose is present. CSF gives a positive reading for
glucose. If blood is present in the fluid, testing for glucose
is unreliable because blood also contains glucose. In this
event, look for the halo or ring sign
Autonomic dysreflexia - correct answer-
(potentially life threatening emergency!) HOB elevate 90
, degrees, loosen constrictive clothing, assess for full
bladder or bowel impaction, (trigger) administer
antihypertensives (may cause stroke, MI, seizure)
Autonomic Dysreflexia interventions & prevention -
correct answer- • Raise the person to a sitting
position.
• Remove the noxious stimulus (fecal impaction, kinked
urinary catheter, tight clothing).
• Call the HCP if above actions do not relieve the signs and
symptoms.
3. Measures to decrease the incidence of autonomic
hyperreflexia
• Maintain regular bowel function.
• Use a local anesthetic to prevent autonomic
hyperreflexia if manual rectal stimulation is used to
promote bowel function.
Autonomic dysreflexia symptoms - correct
answer- 1. Signs and symptoms
