EXAM QUESTIONS AND 100% CORRECT
Fluid resuscitation *in burns* - what determines it effectiveness - ANSWER-
B - B B B B B B B B B
monitor urinary output & *30-50 mL/hr to determine effectiveness* - *CORRECT*
B B B B B B B B B B
-*granulation tissue is used to determine if WOUND HEALING is effective*
B B B B B B B B B B
-
monitor *lung sounds* because *PNEUMONIA is a complication of burns* & clear lung sound
B B B B B B B B B B B B B
s ensure that the pt has not had FVE.
B B B B B B B B
-
monitor *O2 sat* because respiratory problems are a complication of burns. *O2 sat should b
B B B B B B B B B B B B B B
e within 95%-100%*
B B
nursing interventions - herpes zoster - ANSWER-
B - B B B B B
*keep linens off of affected areas* by using a bed cradle so that the pt doesn't experience pain
B B B B B B B B B B B B B B B B B
due to linens rubbing against the lesions - *CORRECT*
B B B B B B B B B
-
*standard precautions* should be initiated for healthy pts, but *airborne and contact precauti
B B B B B B B B B B B B
ons need to be initiated for pts who are immunocompromised and has herpes zoster*
B B B B B B B B B B B B B
-*COOL compresses* should be applied to affected areas.
B B B B B B B
nursing interventions - THA (Total Hip Arthroplasty) - ANSWER-
B - B B B B B B B
*keep an ADDuction pillow between the client's legs* to prevent the hips from dislocating afte
B B B B B B B B B B B B B B
r surgery - *CORRECT*
B B B
-*neurovascular checks* on the extremity every *2 TO 4 HOURS* B B B B B B B B B
, -
have the client use an incentive spirometer EVERY 2 HOURS as well as DEEP BREATHING and C
B B B B B B B B B B B B B B B B
OUGHING to prevent ATELECTASIS* B B B
-
*the pt should be encouraged to participate in early ambulation* to keep mobility intact and t
B B B B B B B B B B B B B B B
o *prevent DVTs*
B B
nursing interventions - alzheimer's pt (restful sleep) - ANSWER-
B - B B B B B B B
*offer a small snack at bedtime*, like a glass of milk or carbs as part of bedtime routine to help
B B B B B B B B B B B B B B B B B B B
the pt relax and prepare for sleep - *CORRECT*
B B B B B B B B B
-don't encourage stimulating activities as it will make the client alert near bedtime
B B B B B B B B B B B B
-don't encourage napping as it will make it more difficult for the pt to sleep when it is bedtime
B B B B B B B B B B B B B B B B B B
-do not offer caffeine as it is a stimulant and can interfere w/ sleep
B B B B B B B B B B B B B
understanding of (discharge) teaching - mechanical mitral valve replacement - ANSWER-
B B B B B B B B B B
-
remind client *notify dentist of the procedure* so that *ANTIBIOTIC THERAPY can be initiated
B B B B B B B B B B B B B B
to reduce risk of an endocardial infarction*
B B B B B B
-
*avoid taking any aspirin or NSAID medications because the medication increase risk of bleedi
B B B B B B B B B B B B B
ng post-op. pt should be on long-term anticoagulant regimen*
B B B B B B B B
-pt should use a soft-bristled tooth brush to reduce the risk of bleeding
B B B B B B B B B B B B
Fluid resuscitation *in burns* - what determines it effectiveness - ANSWER-
B - B B B B B B B B B
monitor urinary output & *30-50 mL/hr to determine effectiveness* - *CORRECT*
B B B B B B B B B B
-*granulation tissue is used to determine if WOUND HEALING is effective*
B B B B B B B B B B
-
monitor *lung sounds* because *PNEUMONIA is a complication of burns* & clear lung sound
B B B B B B B B B B B B B
s ensure that the pt has not had FVE.
B B B B B B B B
-
monitor *O2 sat* because respiratory problems are a complication of burns. *O2 sat should b
B B B B B B B B B B B B B B
e within 95%-100%*
B B
nursing interventions - herpes zoster - ANSWER-
B - B B B B B
*keep linens off of affected areas* by using a bed cradle so that the pt doesn't experience pain
B B B B B B B B B B B B B B B B B
due to linens rubbing against the lesions - *CORRECT*
B B B B B B B B B
-
*standard precautions* should be initiated for healthy pts, but *airborne and contact precauti
B B B B B B B B B B B B
ons need to be initiated for pts who are immunocompromised and has herpes zoster*
B B B B B B B B B B B B B
-*COOL compresses* should be applied to affected areas.
B B B B B B B
nursing interventions - THA (Total Hip Arthroplasty) - ANSWER-
B - B B B B B B B
*keep an ADDuction pillow between the client's legs* to prevent the hips from dislocating afte
B B B B B B B B B B B B B B
r surgery - *CORRECT*
B B B
-*neurovascular checks* on the extremity every *2 TO 4 HOURS* B B B B B B B B B
, -
have the client use an incentive spirometer EVERY 2 HOURS as well as DEEP BREATHING and C
B B B B B B B B B B B B B B B B
OUGHING to prevent ATELECTASIS* B B B
-
*the pt should be encouraged to participate in early ambulation* to keep mobility intact and t
B B B B B B B B B B B B B B B
o *prevent DVTs*
B B
nursing interventions - alzheimer's pt (restful sleep) - ANSWER-
B - B B B B B B B
*offer a small snack at bedtime*, like a glass of milk or carbs as part of bedtime routine to help
B B B B B B B B B B B B B B B B B B B
the pt relax and prepare for sleep - *CORRECT*
B B B B B B B B B
-don't encourage stimulating activities as it will make the client alert near bedtime
B B B B B B B B B B B B
-don't encourage napping as it will make it more difficult for the pt to sleep when it is bedtime
B B B B B B B B B B B B B B B B B B
-do not offer caffeine as it is a stimulant and can interfere w/ sleep
B B B B B B B B B B B B B
understanding of (discharge) teaching - mechanical mitral valve replacement - ANSWER-
B B B B B B B B B B
-
remind client *notify dentist of the procedure* so that *ANTIBIOTIC THERAPY can be initiated
B B B B B B B B B B B B B B
to reduce risk of an endocardial infarction*
B B B B B B
-
*avoid taking any aspirin or NSAID medications because the medication increase risk of bleedi
B B B B B B B B B B B B B
ng post-op. pt should be on long-term anticoagulant regimen*
B B B B B B B B
-pt should use a soft-bristled tooth brush to reduce the risk of bleeding
B B B B B B B B B B B B