NUR 436 Final Exam WITH WELL
ANSWERED QUESTIONS
What is the Parkland formula used for? - CORRECT ANSWERS ✔✔To
calculate the fluid replacement in a burn injury patient
Parkland formula - CORRECT ANSWERS ✔✔Volume of Lactated Ringers
solution = 4 mL x total body surface area of burn (%) x body weight (kg); first
half over 8 hours, second half over 16 hours
What symptoms may indicate an adverse reaction to blood products? -
CORRECT ANSWERS ✔✔Nausea or vomiting, burning along infusion line,
facial swelling, abdominal cramping, significant back pain, chills, diarrhea,
chest pain, headache, dry and flushed skin, hematuria, temp increase, pallor,
laryngeal/pharyngeal edema, hypertension, tachycardia, severe apprehension,
tachypnea, shock, difficulty breathing, severe bilateral pulmonary edema,
bleeding/oozing from IV site/wound
What are the immediate nursing actions if a patient displays signs of an
adverse blood transfusion reaction? - CORRECT ANSWERS ✔✔1. Stop
transfusion immediately
2. Remove blood product tubing, connect 0.9% NS tubing to patient's IV site,
and begin 0.9% NS infusion
3. Do NOT leave patient alone
4. Continue monitoring patient's assessment and VS
, 5.Notify blood bank - they will tell you what labs to draw from patient and
paperwork to bring to blood blank
6. Administer any meds ordered by provider for adverse transfusion reaction
7. Discuss with HCP how frequently they want VS following reaction
8. Chart VS, reactions symptoms, and interventions
Diagnostic criteria for sepsis - CORRECT ANSWERS ✔✔Altered mental
status, fever, tachycardia, hyperglycemia, hypothermia, hypotension,
significant edema, tachypnea, elevated prolactin level, hyperlactatemia, arterial
hypoxemia, acute oliguria, increase in serum creatinine, thrombocytopenia
DKA priority assessment - CORRECT ANSWERS ✔✔1. Physical assessment
with focused neuro and LOC
2. IV access and draw labs: CMP, CBC, VBG, blood glucose, hemoglobin A1C
3. Urine sample for analysis and ketones
4. Assess degree of dehydration
5. Baseline EKG
How is pediatric pain assessed? - CORRECT ANSWERS ✔✔FLACC scale,
FACES scale, numeric pain scale
Signs of IV site infiltration - CORRECT ANSWERS ✔✔Swelling, compartment
syndrome, tight skin, cool to touch, numbness, burning/pain, impaired blood
circulation
ANSWERED QUESTIONS
What is the Parkland formula used for? - CORRECT ANSWERS ✔✔To
calculate the fluid replacement in a burn injury patient
Parkland formula - CORRECT ANSWERS ✔✔Volume of Lactated Ringers
solution = 4 mL x total body surface area of burn (%) x body weight (kg); first
half over 8 hours, second half over 16 hours
What symptoms may indicate an adverse reaction to blood products? -
CORRECT ANSWERS ✔✔Nausea or vomiting, burning along infusion line,
facial swelling, abdominal cramping, significant back pain, chills, diarrhea,
chest pain, headache, dry and flushed skin, hematuria, temp increase, pallor,
laryngeal/pharyngeal edema, hypertension, tachycardia, severe apprehension,
tachypnea, shock, difficulty breathing, severe bilateral pulmonary edema,
bleeding/oozing from IV site/wound
What are the immediate nursing actions if a patient displays signs of an
adverse blood transfusion reaction? - CORRECT ANSWERS ✔✔1. Stop
transfusion immediately
2. Remove blood product tubing, connect 0.9% NS tubing to patient's IV site,
and begin 0.9% NS infusion
3. Do NOT leave patient alone
4. Continue monitoring patient's assessment and VS
, 5.Notify blood bank - they will tell you what labs to draw from patient and
paperwork to bring to blood blank
6. Administer any meds ordered by provider for adverse transfusion reaction
7. Discuss with HCP how frequently they want VS following reaction
8. Chart VS, reactions symptoms, and interventions
Diagnostic criteria for sepsis - CORRECT ANSWERS ✔✔Altered mental
status, fever, tachycardia, hyperglycemia, hypothermia, hypotension,
significant edema, tachypnea, elevated prolactin level, hyperlactatemia, arterial
hypoxemia, acute oliguria, increase in serum creatinine, thrombocytopenia
DKA priority assessment - CORRECT ANSWERS ✔✔1. Physical assessment
with focused neuro and LOC
2. IV access and draw labs: CMP, CBC, VBG, blood glucose, hemoglobin A1C
3. Urine sample for analysis and ketones
4. Assess degree of dehydration
5. Baseline EKG
How is pediatric pain assessed? - CORRECT ANSWERS ✔✔FLACC scale,
FACES scale, numeric pain scale
Signs of IV site infiltration - CORRECT ANSWERS ✔✔Swelling, compartment
syndrome, tight skin, cool to touch, numbness, burning/pain, impaired blood
circulation
