NRS 204 Spring 2023 Final Exam
Patient comes in with 2nd and 3rd degree burns over 60% of the body and is conscious. What level of
triage would they be classified? - ANS Black
What level C PPE equipment would the nurse use if a patient has been exposed to an unknown
substance? - ANS Air purified Respirator
A patient with Bell's palsy refuses to eat while others are present because of embarrassment about
drooling. The best response by the nurse to the patient's behavior is to _______________. - ANS
Respect their privacy especially at meal times
What is the priority to document after a tonic clonic seizure? - ANS the time ( duration ) observation
(what happened during the seizure, and the postictal state (how pt is once seizure is over).
After a pt has had a stroke (brain attack), what is important to teach the patient to do? - ANS
Consistently use adaptive equipment. EX: built up utensils, things to help get dressed, shower rails.
Begin it as soon as possible.
When a patient is undergoing Chemotherapy treatment, what labs would you report to the HCP? - ANS
Abnormal levels. Ex: WBC 17000
A patient has mestatic cancer and is receiving chemotherapy. What medication can the nurse give the
patient 1 hour prior to help ease treatment? - ANS Antiemetic. for nausea EX: Zofran, Compazine
Phenergan
A patient is having an allergic reaction to a skin test and is experiencing dizziness, difficulty breathing,
and shortness of breath. What can the nurse administer to the patient? - ANS Epinephrine 0.3mL
(adrenaline) EpiPen
,A patient is going into shock. What can the nurse do to prevent or reduce complications? - ANS
Understand mechanism, recognize subtle and obvious signs of shock, and do a rapid assessment.
A patient is scheduled for an endarterectomy and askes you what it is, how would you explain the
procedure? - ANS Surgical removal of plaque from the carotid artery when a patient has CAD.
Pt at risk for airway occlusion and hematoma in the airway.
A patient is having hemiparesis with dysarthria is having TIA's. What should the nurse expect the pt to
be given to help them? - ANS TPA (tissue plasminogen Activator) to break up blood clots
The nurse asks his patient to stick his tongue out and say "Ahh" and move the tongue from side to side.
What is this assessing? - ANS Cranial nerve XII hypoglossal nerve.
A patient has a blast injury from working with dynamite or something loud :) What does the nurse
expect the patient to have damaged? - ANS Tympanic membrane
A patient has been diagnosed with retinal detachment. How did the patient describe the vision issue to
the nurse? - ANS Like a curtain veil was pulled over the view and flashing lights seen.
Not going to have loss of color of vision.
Not going to have numbness around the eye.
Not going to have colored halos.
What time period should be allowed between administration of two different eye drop medications? -
ANS 5 min.
, A new staff member has been hired to feel a supervisory roll, who would be the best type of mentor for
the new employee? - ANS Someone who has leadership experience and experience with
communication.
What impacts the ethical decision making made in an ethics committee? - ANS Complexity of issues in a
high technological society.
A patient has had a brain injury and is on Desmopressin. What is a positive outcome of the medication? -
ANS Decreased urinary output
A patient with myasthenia gravis who is taking a cholinesterase inhibitor has to be monitored for a
cholinergic crisis. What are the s/s to monitor for? - ANS muscle weakness and increased salivation
A patient is given antihistamine. What side effects should the patient monitor for? - ANS Dry mouth and
drowsiness
A patient has a family history of of breast Cancer and has Bracca gene and has chosen to have a bilateral
mastectomy. This is considered what type of surgery? - ANS prophylactic
A patient with myasthenia gravis should be educated that they should do what to help from being tired?
- ANS Frequent rest periods and schedule diagnostic procedures in the morning when they are not as
tired.
A nurse is taking care of a patient with Gillian Barre syndrome with a risk for decline in vital capacity.
What should the nurse be prepared to assist with? - ANS Intubation
A patient who has had a hemorrhagic stroke has been admitted to the ICU. The patient's family should
be educated about what change that will be necessary? - ANS Patients environment will have to be
modified. Ex. hosp. bed, shower bars installed, w/c ramp.
Patient comes in with 2nd and 3rd degree burns over 60% of the body and is conscious. What level of
triage would they be classified? - ANS Black
What level C PPE equipment would the nurse use if a patient has been exposed to an unknown
substance? - ANS Air purified Respirator
A patient with Bell's palsy refuses to eat while others are present because of embarrassment about
drooling. The best response by the nurse to the patient's behavior is to _______________. - ANS
Respect their privacy especially at meal times
What is the priority to document after a tonic clonic seizure? - ANS the time ( duration ) observation
(what happened during the seizure, and the postictal state (how pt is once seizure is over).
After a pt has had a stroke (brain attack), what is important to teach the patient to do? - ANS
Consistently use adaptive equipment. EX: built up utensils, things to help get dressed, shower rails.
Begin it as soon as possible.
When a patient is undergoing Chemotherapy treatment, what labs would you report to the HCP? - ANS
Abnormal levels. Ex: WBC 17000
A patient has mestatic cancer and is receiving chemotherapy. What medication can the nurse give the
patient 1 hour prior to help ease treatment? - ANS Antiemetic. for nausea EX: Zofran, Compazine
Phenergan
A patient is having an allergic reaction to a skin test and is experiencing dizziness, difficulty breathing,
and shortness of breath. What can the nurse administer to the patient? - ANS Epinephrine 0.3mL
(adrenaline) EpiPen
,A patient is going into shock. What can the nurse do to prevent or reduce complications? - ANS
Understand mechanism, recognize subtle and obvious signs of shock, and do a rapid assessment.
A patient is scheduled for an endarterectomy and askes you what it is, how would you explain the
procedure? - ANS Surgical removal of plaque from the carotid artery when a patient has CAD.
Pt at risk for airway occlusion and hematoma in the airway.
A patient is having hemiparesis with dysarthria is having TIA's. What should the nurse expect the pt to
be given to help them? - ANS TPA (tissue plasminogen Activator) to break up blood clots
The nurse asks his patient to stick his tongue out and say "Ahh" and move the tongue from side to side.
What is this assessing? - ANS Cranial nerve XII hypoglossal nerve.
A patient has a blast injury from working with dynamite or something loud :) What does the nurse
expect the patient to have damaged? - ANS Tympanic membrane
A patient has been diagnosed with retinal detachment. How did the patient describe the vision issue to
the nurse? - ANS Like a curtain veil was pulled over the view and flashing lights seen.
Not going to have loss of color of vision.
Not going to have numbness around the eye.
Not going to have colored halos.
What time period should be allowed between administration of two different eye drop medications? -
ANS 5 min.
, A new staff member has been hired to feel a supervisory roll, who would be the best type of mentor for
the new employee? - ANS Someone who has leadership experience and experience with
communication.
What impacts the ethical decision making made in an ethics committee? - ANS Complexity of issues in a
high technological society.
A patient has had a brain injury and is on Desmopressin. What is a positive outcome of the medication? -
ANS Decreased urinary output
A patient with myasthenia gravis who is taking a cholinesterase inhibitor has to be monitored for a
cholinergic crisis. What are the s/s to monitor for? - ANS muscle weakness and increased salivation
A patient is given antihistamine. What side effects should the patient monitor for? - ANS Dry mouth and
drowsiness
A patient has a family history of of breast Cancer and has Bracca gene and has chosen to have a bilateral
mastectomy. This is considered what type of surgery? - ANS prophylactic
A patient with myasthenia gravis should be educated that they should do what to help from being tired?
- ANS Frequent rest periods and schedule diagnostic procedures in the morning when they are not as
tired.
A nurse is taking care of a patient with Gillian Barre syndrome with a risk for decline in vital capacity.
What should the nurse be prepared to assist with? - ANS Intubation
A patient who has had a hemorrhagic stroke has been admitted to the ICU. The patient's family should
be educated about what change that will be necessary? - ANS Patients environment will have to be
modified. Ex. hosp. bed, shower bars installed, w/c ramp.
