NUR 242 Final Exam Review
Exam 1: Correct Answer:
Cane: Correct Answer: -Appropriate height (at wrist level when arm is at side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*
At risk for falls due to: Correct Answer: incontenience
Transferring pt to WC: Correct Answer: -Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
Safe pt handling: Correct Answer: -Keep pt directly in front of you and as close as possible to prevent
back injuries
Skin integrity: Correct Answer: -dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
Pressure Ulcer stages: Correct Answer: *Stage 2- skin is not intact; open or fluid blister*
Wet-to-damp wound care: Correct Answer: mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as well
Informed consent: Correct Answer: -surgeon is responsible for having consent signed
-Pt who can not sign can sign with an "X" but must be witnessed by two people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
Pre-OP: Correct Answer: -Report these to surgeon:
-increased PT/INR/aPTT/Creatinine
-Verify operative permit is signed
-Side rails up, bed down, call light within reach
Intra-OP: Correct Answer: -Pts are lifted into position onto the OR table to prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile supplies immediately before the
start of the procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes
,Post-OP: Correct Answer: -in PACU, nurse immediately assess pt airway, LOC
-RR <10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal
Malignant hyperthermia: Correct Answer: -life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
Pain Management: Correct Answer: *Pain management referral for pts in chronic pain unrelieved*
-Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon as possible
-Use FACES scale in pts with dementia
PCA Pump: Correct Answer: -Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
If incision opens: Correct Answer: -cover with wet sterile gauze
-Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
IV: Correct Answer: -20G 1-1.5" needle is adequate for most therapies
-Huber needle should be placed at 90 degree angle to access port (chemo pt)
TPN: Correct Answer: - Check each bag twice
-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available
-If TPN not administered on time, do not increase the rate
-Change IV tubing q24 hours when new bag is hung
-Dressing change around IV site changed 2 48-72 hours
Sickle Cell: Correct Answer: -Pain is the most common problem
-Requires large doses of opioid analgesics
-Hydrate with NS IV fluids, encourage oral fluids without caffeine
-Administer O2
-Remove restrictive clothing, No BP with external cuff
-Sickle Cell crisis: pain meds and IV fluids
Vitamin B12 Deficiency: Correct Answer: -Smooth, beefy red tongue
MRSA: Correct Answer: -Sleep in separate beds until infection clears
-Wash clothes in HOT water
Standard precautions: Correct Answer: -Hand hygiene
-Gloves
, Contact precautions: Correct Answer: -Private room
-Wear gloves when entering room
-Wash hands with soap and water
-Dedicated equipment
Airborne Precautions: Correct Answer: -Private room with negative airflow
-Keep door closed
-N95 respirator
*Pt wear surgical mask when leaving room for labs/procedure*
Droplet precautions: Correct Answer: -Private room preferred
-If not, may share a room with pt having same active infection
-Surgical mask when working WITHIN 3 FEET OF PT
-Pt to wear surgical mask when leaving room
Psoriasis: Correct Answer: Treat with UV light but NOT A TANNING BED
Skin Cancer: Correct Answer: -Avoid sun exposure from 11-3pm
-A=Asymmetry
-B=border
-C=color
-D=diameter
-E=evolving
-Examine the body monthly for changes
Exam 2: Correct Answer:
The nurse is teaching a client who has been prescribed alprazolam. Which of the following statements
by the nurse would be appropriate to make? Correct Answer: You should inform your primary health
care provider (PHCP) before taking any herbal supplement.
The nurse is caring for a client who is scheduled to have a minor procedure under conscious sedation.
Which of the following medications should the nurse anticipate will be prescribed? Correct Answer:
Propofol
The nurse is caring for a client who is receiving epidural analgesia. Which of the following findings would
indicate an adverse effect? Correct Answer: Hypotension
The nurse is planning care for a surgical client who has been prescribed morphine sulfate every four
hours for pain. The nurse should recognize which of the following as a priority for the client? Correct
Answer: Monitor respiratory rate and pattern
The nurse is performing an admission assessment on a client who has been in a motor vehicle accident
(MVA). The client states, "I am in bad pain." The nurse should first Correct Answer: ask the client to rate
the pain on a scale of 0 to 10.
Exam 1: Correct Answer:
Cane: Correct Answer: -Appropriate height (at wrist level when arm is at side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*
At risk for falls due to: Correct Answer: incontenience
Transferring pt to WC: Correct Answer: -Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
Safe pt handling: Correct Answer: -Keep pt directly in front of you and as close as possible to prevent
back injuries
Skin integrity: Correct Answer: -dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
Pressure Ulcer stages: Correct Answer: *Stage 2- skin is not intact; open or fluid blister*
Wet-to-damp wound care: Correct Answer: mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as well
Informed consent: Correct Answer: -surgeon is responsible for having consent signed
-Pt who can not sign can sign with an "X" but must be witnessed by two people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
Pre-OP: Correct Answer: -Report these to surgeon:
-increased PT/INR/aPTT/Creatinine
-Verify operative permit is signed
-Side rails up, bed down, call light within reach
Intra-OP: Correct Answer: -Pts are lifted into position onto the OR table to prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile supplies immediately before the
start of the procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes
,Post-OP: Correct Answer: -in PACU, nurse immediately assess pt airway, LOC
-RR <10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal
Malignant hyperthermia: Correct Answer: -life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
Pain Management: Correct Answer: *Pain management referral for pts in chronic pain unrelieved*
-Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon as possible
-Use FACES scale in pts with dementia
PCA Pump: Correct Answer: -Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
If incision opens: Correct Answer: -cover with wet sterile gauze
-Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
IV: Correct Answer: -20G 1-1.5" needle is adequate for most therapies
-Huber needle should be placed at 90 degree angle to access port (chemo pt)
TPN: Correct Answer: - Check each bag twice
-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available
-If TPN not administered on time, do not increase the rate
-Change IV tubing q24 hours when new bag is hung
-Dressing change around IV site changed 2 48-72 hours
Sickle Cell: Correct Answer: -Pain is the most common problem
-Requires large doses of opioid analgesics
-Hydrate with NS IV fluids, encourage oral fluids without caffeine
-Administer O2
-Remove restrictive clothing, No BP with external cuff
-Sickle Cell crisis: pain meds and IV fluids
Vitamin B12 Deficiency: Correct Answer: -Smooth, beefy red tongue
MRSA: Correct Answer: -Sleep in separate beds until infection clears
-Wash clothes in HOT water
Standard precautions: Correct Answer: -Hand hygiene
-Gloves
, Contact precautions: Correct Answer: -Private room
-Wear gloves when entering room
-Wash hands with soap and water
-Dedicated equipment
Airborne Precautions: Correct Answer: -Private room with negative airflow
-Keep door closed
-N95 respirator
*Pt wear surgical mask when leaving room for labs/procedure*
Droplet precautions: Correct Answer: -Private room preferred
-If not, may share a room with pt having same active infection
-Surgical mask when working WITHIN 3 FEET OF PT
-Pt to wear surgical mask when leaving room
Psoriasis: Correct Answer: Treat with UV light but NOT A TANNING BED
Skin Cancer: Correct Answer: -Avoid sun exposure from 11-3pm
-A=Asymmetry
-B=border
-C=color
-D=diameter
-E=evolving
-Examine the body monthly for changes
Exam 2: Correct Answer:
The nurse is teaching a client who has been prescribed alprazolam. Which of the following statements
by the nurse would be appropriate to make? Correct Answer: You should inform your primary health
care provider (PHCP) before taking any herbal supplement.
The nurse is caring for a client who is scheduled to have a minor procedure under conscious sedation.
Which of the following medications should the nurse anticipate will be prescribed? Correct Answer:
Propofol
The nurse is caring for a client who is receiving epidural analgesia. Which of the following findings would
indicate an adverse effect? Correct Answer: Hypotension
The nurse is planning care for a surgical client who has been prescribed morphine sulfate every four
hours for pain. The nurse should recognize which of the following as a priority for the client? Correct
Answer: Monitor respiratory rate and pattern
The nurse is performing an admission assessment on a client who has been in a motor vehicle accident
(MVA). The client states, "I am in bad pain." The nurse should first Correct Answer: ask the client to rate
the pain on a scale of 0 to 10.
