NUR 242 FINAL EXAMINATION / MOST RECENT
VERSION, 2025 – 2026 / SHARP QUESTIONS AND
STRONG ANSWERS / ALREADY RATED A+ / 100%
SOLVED / GUARANTEED SUCCESS
EXAM 1:
Cane:
-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:
incontenience
Transferring pt to WC:
-Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
Safe pt handling:
-Keep pt directly in front of you and as close as possible to
prevent back injuries
Skin integrity:
-dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
Pressure Ulcer stages:
Stage 2- skin is not intact; open or fluid blister
Wet-to-damp wound care:
,mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as
well
Informed consent:
-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:
-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:
-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:
-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:
-life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
Pain Management:
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:
-Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
If incision opens:
-cover with wet sterile gauze
, -Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
IV:
-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:
- 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:
-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:
-Smooth, beefy red tongue
VERSION, 2025 – 2026 / SHARP QUESTIONS AND
STRONG ANSWERS / ALREADY RATED A+ / 100%
SOLVED / GUARANTEED SUCCESS
EXAM 1:
Cane:
-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:
incontenience
Transferring pt to WC:
-Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
Safe pt handling:
-Keep pt directly in front of you and as close as possible to
prevent back injuries
Skin integrity:
-dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
Pressure Ulcer stages:
Stage 2- skin is not intact; open or fluid blister
Wet-to-damp wound care:
,mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as
well
Informed consent:
-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:
-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:
-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:
-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:
-life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
Pain Management:
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:
-Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
If incision opens:
-cover with wet sterile gauze
, -Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
IV:
-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:
- 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:
-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:
-Smooth, beefy red tongue
