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NUR 445: Exam 3 Review (#2) Questions and Answers with
Complete Solutions UPDATED!!!
When weaning patient off the ventilator, what are signs that
shows the patient is not ready to come off the ventilator?
- Not able to breath on their own or above the ventilator.
- Uncomfortable/not settling well.
- Patient is not breathing within a 12-20 rate.
A patient is getting ready to go to MRI. How does the nurse
prepare the patient?
- Get consent form signed.
- Educate about the procedure.
- Inform the client to remain still while in the machine.
- Take away all metal objects (including cell phones, jewelry).
- Patient should be NPO (4-6 hours)
Regarding the MRI procedure, what are three important nursing
considerations?
- Assess the patient’s ability to remain still during the
procedure because movement of the head causes decreased
clarity (artifact) of the images, which could obscure an
abnormality.
- A pregnancy test should be performed prior to scanning a
woman of childbearing age so that appropriate precautions
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may be applied depending on the stage of pregnancy and in
consultation with a radiologist.
- Patients must be screened for metal that may be embedded
in and around the eyes (metal workers and welders) or in any
other part of the body, including joint implants, cardiac stents,
pacemakers, and other implanted devices. If the patient has a
history of working with metal, x-rays may be requested by a
radiologist to locate or rule out the existence of metal
fragments. During MRI, implanted metal can heat up, causing
tissue damage.
What neuro assessment findings would indicate the patient's
condition is worsening?
Change in LOC
What are two early signs of increased intracranial pressure
(ICP)?
- Progressive confusion
- Increasing lethargy
Increased ICP is detected by performing...
A serious of neurological assessments including the elements of
wakefulness, arousal, cranial nerves, and motor function.
What is the MOST sensitive indicator of ICP?
A decrease in level of consciousness.
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Remember: In order to detect subtle changes in level of
consciousness, it is imperative to establish an accurate baseline
of functioning from which to judge deterioration.
A patient that is on a ventilator is receiving 100% O2. If the O2
drops from 100% to 80%, what should the nurse do?
Assess the tubing, something may be blocking the air coming in.
A patient is experiencing septic shock. What is an early sign that
the patient is going into acute respiratory distress syndrome
(ARDS)?
Increase respirations.
Name one indication for lung compliance, specifically with
ARDS.
Surfactant therapy.
A patient is experiencing Guillain barre syndrome (GBS). What
are three signs and symptoms that indicate that the patient is in
respiratory distress?
- Increase respiration
- Use of accessory muscles
- Buildup of mucus A c
What are five contraindications for TPA (tissue plasma activator-
clot buster)?
NUR 445: Exam 3 Review (#2) Questions and Answers with
Complete Solutions UPDATED!!!
When weaning patient off the ventilator, what are signs that
shows the patient is not ready to come off the ventilator?
- Not able to breath on their own or above the ventilator.
- Uncomfortable/not settling well.
- Patient is not breathing within a 12-20 rate.
A patient is getting ready to go to MRI. How does the nurse
prepare the patient?
- Get consent form signed.
- Educate about the procedure.
- Inform the client to remain still while in the machine.
- Take away all metal objects (including cell phones, jewelry).
- Patient should be NPO (4-6 hours)
Regarding the MRI procedure, what are three important nursing
considerations?
- Assess the patient’s ability to remain still during the
procedure because movement of the head causes decreased
clarity (artifact) of the images, which could obscure an
abnormality.
- A pregnancy test should be performed prior to scanning a
woman of childbearing age so that appropriate precautions
,2|Page
may be applied depending on the stage of pregnancy and in
consultation with a radiologist.
- Patients must be screened for metal that may be embedded
in and around the eyes (metal workers and welders) or in any
other part of the body, including joint implants, cardiac stents,
pacemakers, and other implanted devices. If the patient has a
history of working with metal, x-rays may be requested by a
radiologist to locate or rule out the existence of metal
fragments. During MRI, implanted metal can heat up, causing
tissue damage.
What neuro assessment findings would indicate the patient's
condition is worsening?
Change in LOC
What are two early signs of increased intracranial pressure
(ICP)?
- Progressive confusion
- Increasing lethargy
Increased ICP is detected by performing...
A serious of neurological assessments including the elements of
wakefulness, arousal, cranial nerves, and motor function.
What is the MOST sensitive indicator of ICP?
A decrease in level of consciousness.
, 3|Page
Remember: In order to detect subtle changes in level of
consciousness, it is imperative to establish an accurate baseline
of functioning from which to judge deterioration.
A patient that is on a ventilator is receiving 100% O2. If the O2
drops from 100% to 80%, what should the nurse do?
Assess the tubing, something may be blocking the air coming in.
A patient is experiencing septic shock. What is an early sign that
the patient is going into acute respiratory distress syndrome
(ARDS)?
Increase respirations.
Name one indication for lung compliance, specifically with
ARDS.
Surfactant therapy.
A patient is experiencing Guillain barre syndrome (GBS). What
are three signs and symptoms that indicate that the patient is in
respiratory distress?
- Increase respiration
- Use of accessory muscles
- Buildup of mucus A c
What are five contraindications for TPA (tissue plasma activator-
clot buster)?
