Nur185 exam test 1with answers already gradeA+ passing
points
Nurse admits patient to med surg unit. Resp rate of 38. Patient using chest muscles to breathe,
pulse ox of 87 on room air, pink frothy sputum. What intervention would you implement first? -
answers✔✔O2 at 2 Liters/Min
Caring for pt. who is intubated and receiving mechanical ventilation. What action by the nurse
would decrease the patient's incidence of developing ventilator associated pneumonia? -
answers✔✔Put head of bed at 30-45 degrees.
The nurse is administering acetylcysteine (muca-mist) as nebulizer treatment to patient. Which
should the nurse have available for adverse effect on the patient? - answers✔✔Suction
equipment
Patient coming in with SOB and resp. rate of 32. ABG results PH 7.3 (acid), Co2-50 Bicarb-28,
PO2-70
Resp. Acidosis, what orders do you anticipate carrying out? - answers✔✔Apply O2 and give
med-neb treatment.
You have 4 patients in a long term care facility. Which would you check first? - answers✔✔COPD
patient with resp rate of 30, O2 of 87 and on 3 Liters of O2 complaining of dyspnea.
Caring for newly intubated patient getting mechanical ventilation. Pt.'s wife was not at hosp.
when this occurred. Wife appears angry and states "What have you all done to him?" What
would be your response as a nurse? - answers✔✔Explain to the patient why the patient had to
be intubated, continue to update patient's wife on condition and plan of care, I'm sorry that you
walked in on him like that, I understand this must have been very frightening.
, Patient has SOB, edema in legs and face and has the following labs: BUN-95 (high), Creatinine of
9.2, Potassium of 6.0 (high). What are you going to do - answers✔✔Give Kexolate, prepare the
patient a central line for dialysis. Cardiac monitoring.
Working with a UAP, what task can be delegated? - answers✔✔Instill non-prescription eye
drops in patient's eyes.
Nurse is caring for patient who had total knee replacement yesterday. Patient up in chair stating
he feels good. Pain is 3/10. Resp. 16, pulse is 75, bp is 110/78. Pulse ox 88 reading is after
incentive spirometer. What actions would you take at this time? - answers✔✔Move pulse ox to
another finger on the other hand and recheck.
Vancomycin - answers✔✔Nephrotoxic (meaning it can really damage the kidney's) and Ototoxic
(temp. hearing loss) Can be given IV, orally, or via enema. pharmacy is usually involved with this
medication.
Lomotil - answers✔✔mix of 2 different drugs (atropine-can dry up fluids or for bradycardia &
diphenoxylate can raise the BP/HR and lower the urinary output). Monitor BP and HR. Monitor
urinary output.
Caring for patient with hx of diarrhea. Weight loss, bloating, run labs on them. Which to report
potassium-5.1 WBC 10.8 Sodium 146 Hgb-9.1. ? - answers✔✔HgB
Patient with dx of colorectal cx. Colostomy tomorrow. Pt. says "What's the use I am just going to
die anyway?" What is your response? - answers✔✔Ask the patient to tell you more about these
feelings.
Patient getting chemo for colon cancer. Has C-diff getting vanco. What is most important -
answers✔✔Hearing Loss
points
Nurse admits patient to med surg unit. Resp rate of 38. Patient using chest muscles to breathe,
pulse ox of 87 on room air, pink frothy sputum. What intervention would you implement first? -
answers✔✔O2 at 2 Liters/Min
Caring for pt. who is intubated and receiving mechanical ventilation. What action by the nurse
would decrease the patient's incidence of developing ventilator associated pneumonia? -
answers✔✔Put head of bed at 30-45 degrees.
The nurse is administering acetylcysteine (muca-mist) as nebulizer treatment to patient. Which
should the nurse have available for adverse effect on the patient? - answers✔✔Suction
equipment
Patient coming in with SOB and resp. rate of 32. ABG results PH 7.3 (acid), Co2-50 Bicarb-28,
PO2-70
Resp. Acidosis, what orders do you anticipate carrying out? - answers✔✔Apply O2 and give
med-neb treatment.
You have 4 patients in a long term care facility. Which would you check first? - answers✔✔COPD
patient with resp rate of 30, O2 of 87 and on 3 Liters of O2 complaining of dyspnea.
Caring for newly intubated patient getting mechanical ventilation. Pt.'s wife was not at hosp.
when this occurred. Wife appears angry and states "What have you all done to him?" What
would be your response as a nurse? - answers✔✔Explain to the patient why the patient had to
be intubated, continue to update patient's wife on condition and plan of care, I'm sorry that you
walked in on him like that, I understand this must have been very frightening.
, Patient has SOB, edema in legs and face and has the following labs: BUN-95 (high), Creatinine of
9.2, Potassium of 6.0 (high). What are you going to do - answers✔✔Give Kexolate, prepare the
patient a central line for dialysis. Cardiac monitoring.
Working with a UAP, what task can be delegated? - answers✔✔Instill non-prescription eye
drops in patient's eyes.
Nurse is caring for patient who had total knee replacement yesterday. Patient up in chair stating
he feels good. Pain is 3/10. Resp. 16, pulse is 75, bp is 110/78. Pulse ox 88 reading is after
incentive spirometer. What actions would you take at this time? - answers✔✔Move pulse ox to
another finger on the other hand and recheck.
Vancomycin - answers✔✔Nephrotoxic (meaning it can really damage the kidney's) and Ototoxic
(temp. hearing loss) Can be given IV, orally, or via enema. pharmacy is usually involved with this
medication.
Lomotil - answers✔✔mix of 2 different drugs (atropine-can dry up fluids or for bradycardia &
diphenoxylate can raise the BP/HR and lower the urinary output). Monitor BP and HR. Monitor
urinary output.
Caring for patient with hx of diarrhea. Weight loss, bloating, run labs on them. Which to report
potassium-5.1 WBC 10.8 Sodium 146 Hgb-9.1. ? - answers✔✔HgB
Patient with dx of colorectal cx. Colostomy tomorrow. Pt. says "What's the use I am just going to
die anyway?" What is your response? - answers✔✔Ask the patient to tell you more about these
feelings.
Patient getting chemo for colon cancer. Has C-diff getting vanco. What is most important -
answers✔✔Hearing Loss
