NUR 2243 – Final Exam Study Guide | Advanced Medical-Surgical
Nursing | Comprehensive Review of Clinical Concepts and Practice
Autonomic Dysreflexia - correct answer - caused by SCI
- 1st assessment is bladder distension
S/sx of autonomic dysreflexia - correct answer - pounding headache
- diaphoresis
- bradycardia
- HTN (systolic BP can reach 300)
when the trigger/stimuli resolves the s/sx will resolve
Hepatitis A is caused by - correct answer fecal-oral contamination, usually food
ex: contaminated seafood not fully cooked, fruit/veggies overseas washed with contaminated
water
Hepatitis B is caused by - correct answer unprotected sex, needle sticks (IV drug user), blood
transfusion
Who is most at risk for Hep B infection? - correct answer 20 year old with multiple sexual
partners
Hepatitis C is caused by - correct answer blood contact with infected person; cannot be spread
casually
Hep C treatment - correct answer ribavirin; take a long time to work so med compliance is key,
teach to use pill organizer
Pt present with hypotension, bradycardia, and dizziness, what would you anticipate
administering? - correct answer atropine; pt has symptomatic bradycardia
Primary manifestations of diabetes - correct answer 3 P's: polyuria, polyphagia, polydipsia
Pt presents to the ED bleeding profusely from a head wound. What is the first action the nurse
should take? - correct answer don gloves/PPE
Manifestations of cirrhosis - correct answer - ascites, edema, elevated ammonia levels,
proteinuria, low albumin, esophageal varices
- tx for ammonia is lactulose; diarrhea is expected
, Cirrhosis pt with ascites may experience what pulmonary problem? - correct answer SOB, too
much fluid in peritoneal cavity
A pt with cirrhosis has developed esophageal varices. What is the nurse's priority - correct
answer - maintain airway
- monitor for s/sx of hemorrhage
Teaching pt with cirrhosis - correct answer - low sodium to reduce ascites
- watch protein levels to avoid high concentrations of ammonia and hepatic encephalopathy
S/sx of hyperthermia - correct answer sweaty red skin, tachypnea, tachycardia
Murmur is best heard on - correct answer right side of sternal border
PVC strip - correct answer dips after PQRS, occurs before next beat
Teaching for heart failure pt - correct answer - restrict salt in diet
- check weight at same time every day
V-tach - correct answer - unstable tx: synchronous SHOCK (cardioversion), CPR, O2,
- stable tx: O2
- 150-250 BPM
- can lead to cardiac arrest
V-fib - correct answer - tx: asynchronous SHOCK(defib), CPR, O2, antidysrhythmics
- chaotic rapid rhythm
- fatal if not treated in 3-5 mins!
Normal Sinus Rhythm (NSR) - correct answer ECG of a healthy heart shows an organized,
uniform rhythm; 60-100 BPM
Pt with heart failure is prescribed enalapril (Vasotec), what would be the primary teaching? -
correct answer no salt substitutes; enalapril is potassium sparing so extra potassium can cause
hyperkalemia
Subcutaneous emphysema is an indication that - correct answer air is escaping into the chest
wall from a damaged lung
A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the
patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority? -
correct answer O2 sat, call rapid if pt unstable
Nursing | Comprehensive Review of Clinical Concepts and Practice
Autonomic Dysreflexia - correct answer - caused by SCI
- 1st assessment is bladder distension
S/sx of autonomic dysreflexia - correct answer - pounding headache
- diaphoresis
- bradycardia
- HTN (systolic BP can reach 300)
when the trigger/stimuli resolves the s/sx will resolve
Hepatitis A is caused by - correct answer fecal-oral contamination, usually food
ex: contaminated seafood not fully cooked, fruit/veggies overseas washed with contaminated
water
Hepatitis B is caused by - correct answer unprotected sex, needle sticks (IV drug user), blood
transfusion
Who is most at risk for Hep B infection? - correct answer 20 year old with multiple sexual
partners
Hepatitis C is caused by - correct answer blood contact with infected person; cannot be spread
casually
Hep C treatment - correct answer ribavirin; take a long time to work so med compliance is key,
teach to use pill organizer
Pt present with hypotension, bradycardia, and dizziness, what would you anticipate
administering? - correct answer atropine; pt has symptomatic bradycardia
Primary manifestations of diabetes - correct answer 3 P's: polyuria, polyphagia, polydipsia
Pt presents to the ED bleeding profusely from a head wound. What is the first action the nurse
should take? - correct answer don gloves/PPE
Manifestations of cirrhosis - correct answer - ascites, edema, elevated ammonia levels,
proteinuria, low albumin, esophageal varices
- tx for ammonia is lactulose; diarrhea is expected
, Cirrhosis pt with ascites may experience what pulmonary problem? - correct answer SOB, too
much fluid in peritoneal cavity
A pt with cirrhosis has developed esophageal varices. What is the nurse's priority - correct
answer - maintain airway
- monitor for s/sx of hemorrhage
Teaching pt with cirrhosis - correct answer - low sodium to reduce ascites
- watch protein levels to avoid high concentrations of ammonia and hepatic encephalopathy
S/sx of hyperthermia - correct answer sweaty red skin, tachypnea, tachycardia
Murmur is best heard on - correct answer right side of sternal border
PVC strip - correct answer dips after PQRS, occurs before next beat
Teaching for heart failure pt - correct answer - restrict salt in diet
- check weight at same time every day
V-tach - correct answer - unstable tx: synchronous SHOCK (cardioversion), CPR, O2,
- stable tx: O2
- 150-250 BPM
- can lead to cardiac arrest
V-fib - correct answer - tx: asynchronous SHOCK(defib), CPR, O2, antidysrhythmics
- chaotic rapid rhythm
- fatal if not treated in 3-5 mins!
Normal Sinus Rhythm (NSR) - correct answer ECG of a healthy heart shows an organized,
uniform rhythm; 60-100 BPM
Pt with heart failure is prescribed enalapril (Vasotec), what would be the primary teaching? -
correct answer no salt substitutes; enalapril is potassium sparing so extra potassium can cause
hyperkalemia
Subcutaneous emphysema is an indication that - correct answer air is escaping into the chest
wall from a damaged lung
A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the
patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority? -
correct answer O2 sat, call rapid if pt unstable
