HONDROS NUR 160 EXAM 2
QUESTIONS WITH COMPLETE
ANSWERS
Nursing Interventions for hypovolemic shock - Answer- monitor vitals, behavior, output,
assess pt, notify MD, raise legs, push fluids, give meds as prescribed, pt may need O2
and they may need to be tipped on head
evisceration - Answer- when an organ is sticking up out of a wound that has opened
Dehiscense - Answer- When a wound has opened up, most often d/t force (cough)
What to do for dehiscense - Answer- put pillow on abdomen when coughing, semi-high
fowler's, cover with sterile, moist dressing and notify MD
Pain meds - Answer- start low, go slow
Physiological signs of pain - Answer- Red, sweating,crying, irritated, fetal position
How to help with pt pain - Answer- try non- pharmacological interventions first, when
nothing works-ask someone else, go through chain of command
at risk for urinary retention - Answer- post-surgical, men with large prostates, TBI,
stroke, paralyzed
Nursing interventions for urinary retention - Answer- i&o, push fluids, run water, stick
hands in warm water, bladder scan-see how much is in there (if at or more than 200,
call someone), pt will need straight cath at that point, when straight cathed, if you get to
1000, clamp it off and go back later.
DVT signs and symptoms - Answer- unilateral swelling, redness, hot, painful, pulseless,
cannot move toes or very little, pale below where clot is
Prevention of DVT - Answer- early and frequent ambulation, TED hose
Safety with DVT - Answer- immobilize, call MD, you do not move the pt,
Bowel Obstruction - Answer- bloating, abdominal pain, nausea, vomiting, constipation
, Nursing Interventions for Bowel Obstruction - Answer- auscultate bowel sounds
(5min/quadrant), look, listen, feel, get pt moving, coughing and deep breathing, ZERO
bowel sound sis an emergency, notify MD
Prednisone - Answer- decreases inflammation
Causes of Respiratory Alkalosis - Answer- Hyperventilation, Obesity, Anxiety
Causes of Respiratory Acidosis - Answer- asthma, COPD, pulmonary edema, sedation
Causes of Metabolic Alkalosis - Answer- Gastric Acid loss (NG suction), diuretics
Causes of Metabolic Acidosis - Answer- Diarrhea, diabetes, renal failure, alcohol
How to treat ABG issues - Answer- Treat the cause
Tx for Respiratory Alkalosis - Answer- Breathe into Brown paper bag, relaxation, anti-
anxiety meds
Tx for Respiratory acidosis - Answer- Clear airway, assist with ventilation
Tx for Metabolic alkalosis - Answer- Anti-emetics, replace fluids and electrolytes
Tx for Metabolic acidosis - Answer- sodium bicarb
Ventilation - Answer- Action of inspiration and exhalation of air, O2 into and out of lungs
Transport - Answer- Physical movement of O2 from alveoli to cells for use and the
physical movement of CO2 from cells to lungs for removal
Perfusion - Answer- the action of passing through barriers
Ventilation issue - Answer- COPD
Perfusion issue - Answer- Pneumonia
Transport issue - Answer- CHF
Early sign of hypoxia - Answer- restlessness
late sign of hypoxia - Answer- cyanosis
crackles - Answer- fluid in lungs
SOB with activity - Answer- COPD: first SOB with activity, then SOB at rest
QUESTIONS WITH COMPLETE
ANSWERS
Nursing Interventions for hypovolemic shock - Answer- monitor vitals, behavior, output,
assess pt, notify MD, raise legs, push fluids, give meds as prescribed, pt may need O2
and they may need to be tipped on head
evisceration - Answer- when an organ is sticking up out of a wound that has opened
Dehiscense - Answer- When a wound has opened up, most often d/t force (cough)
What to do for dehiscense - Answer- put pillow on abdomen when coughing, semi-high
fowler's, cover with sterile, moist dressing and notify MD
Pain meds - Answer- start low, go slow
Physiological signs of pain - Answer- Red, sweating,crying, irritated, fetal position
How to help with pt pain - Answer- try non- pharmacological interventions first, when
nothing works-ask someone else, go through chain of command
at risk for urinary retention - Answer- post-surgical, men with large prostates, TBI,
stroke, paralyzed
Nursing interventions for urinary retention - Answer- i&o, push fluids, run water, stick
hands in warm water, bladder scan-see how much is in there (if at or more than 200,
call someone), pt will need straight cath at that point, when straight cathed, if you get to
1000, clamp it off and go back later.
DVT signs and symptoms - Answer- unilateral swelling, redness, hot, painful, pulseless,
cannot move toes or very little, pale below where clot is
Prevention of DVT - Answer- early and frequent ambulation, TED hose
Safety with DVT - Answer- immobilize, call MD, you do not move the pt,
Bowel Obstruction - Answer- bloating, abdominal pain, nausea, vomiting, constipation
, Nursing Interventions for Bowel Obstruction - Answer- auscultate bowel sounds
(5min/quadrant), look, listen, feel, get pt moving, coughing and deep breathing, ZERO
bowel sound sis an emergency, notify MD
Prednisone - Answer- decreases inflammation
Causes of Respiratory Alkalosis - Answer- Hyperventilation, Obesity, Anxiety
Causes of Respiratory Acidosis - Answer- asthma, COPD, pulmonary edema, sedation
Causes of Metabolic Alkalosis - Answer- Gastric Acid loss (NG suction), diuretics
Causes of Metabolic Acidosis - Answer- Diarrhea, diabetes, renal failure, alcohol
How to treat ABG issues - Answer- Treat the cause
Tx for Respiratory Alkalosis - Answer- Breathe into Brown paper bag, relaxation, anti-
anxiety meds
Tx for Respiratory acidosis - Answer- Clear airway, assist with ventilation
Tx for Metabolic alkalosis - Answer- Anti-emetics, replace fluids and electrolytes
Tx for Metabolic acidosis - Answer- sodium bicarb
Ventilation - Answer- Action of inspiration and exhalation of air, O2 into and out of lungs
Transport - Answer- Physical movement of O2 from alveoli to cells for use and the
physical movement of CO2 from cells to lungs for removal
Perfusion - Answer- the action of passing through barriers
Ventilation issue - Answer- COPD
Perfusion issue - Answer- Pneumonia
Transport issue - Answer- CHF
Early sign of hypoxia - Answer- restlessness
late sign of hypoxia - Answer- cyanosis
crackles - Answer- fluid in lungs
SOB with activity - Answer- COPD: first SOB with activity, then SOB at rest
