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7/29/2019 Comp Review
1/5
final
when you have a pt with a cast what is your priority= circulation, movementand
sensation... assesscirculationby pulse checkmovementby movingfingerschecksensationby
askingif they can feel anything
when you have a child with a arm cast what is priority >checkperipheralpulsesin affected
area
invasion of client privacy.. what would be a good example of violating patient privacy-
a client was brought to er after serious accident needs to go to a procedure needs an
informed accident who do you go to ? never a friendonly closefamily member
you are doing rounds, in planning client rounds, which client will you collect the data
first? look for a pt who will fall into categoryof ABC-- ABCis priority
You have a patient who came from surgery the initial nursing action is= (immediately
after post op) your action is ABC(infectiondoesntset in until 72 hrs do not answerthat)
your pt has sever headache he was given analgesic how does it give pain release=
gait control mechanism
Bilroth I- gastro dudenostomy II- gastro jujenostomy If they have has abdominal
surgery what will they come back with? NGT(inorder to removeexcessair you needto add
NGTfor first 24-48 hrs after surgery*whichof the physicianordersdo you question?Never
irrigatea NGTstatuspost abdomensurgery
you have a pt w/ acute gastritis, which medication that you find on your pt chart is
contraindicated = NSAIDS(irritate to stomachIbuprofen,aspirin, steroids)
acid base- ph-7.35-7.45
paCO2= 35-45 Respiratory pa O2= 80-100%
HCO3= 22-28 GI/Kidney (metabolic)
(21-26)
UGIT- NGT/Vomiting > left with metabolic alkalosis (if it comes out your mouth
alkalosis)
LGIT- Diarrhea > left with acidosis (comes from your anus is acidosis)
Respiratory Acidosis > COPD= Asthma, bronchitis, Pulmonary EmphysemaTrap CO2= CO2+H2O> H2CO3- Resp acidosis
Chronicbronchitis usually stays with the pt
Hyperventilate (RR^ deep rapid)
Hypoventilate (RR down shallow)
Which diet do you not give to COPD pts?- Carbohydrates
7/29/2019 Comp Review
2/5
A pt has fat embolis (from fracture of long bone) clot that has moved... DX: CXR if fat
embolis goes into lungs it is called pulmonary fat embois
Osteoarthritis- degenerative;older population;unilateral; pain=restpain goesaway
RA- inflammatory- no specific age; elderly pts; autoimmune condition; symmetrical;
pain-rest pain still there labs: ^ESR (inflammatory condition) measures how fast RBS
move; positive rheumatoid factor Herniated slip disk (intervertebral disk) If a pt with a known herniated disk c/o rt/lt
buttocks pain is a result of? musclespasmon herniateddisk
computation: dr orders medication
0=7.5 mg IM BID
S= 10mg/mL
7.5X 1ml = 0.75 ml
10
when you have a pt with AKA= what type of dressing= compressiondressingwhat is
immediatenursinginterventionif dressingcomesoff? Rewrapcompressionstocking
Compartment syndrome= increased pressure in a muscle compartment= Fasciotomy=
opening into fascia do muscles decrease in size decrease in edema > wound care=
moist sterile normal saline dressing
When giving a flu vaccine first question to ask = ask if they are allergic to eggs
pulmonary emphysema- CO2 maximum of 2 liters to patients
Systemic lupus- s/sx- butterfly rash; polymyalgia (muscle pain); polyarthalgia (joint
pain)
If a pt fractures a leg what kind of acute pain will he have= nonseceptive pain- pain 6
months or less
what do you do with a cast -- elevate the leg to release edema and swelling; how long
do you allow for cast to dry 24-48 hrs; NI- tap on cast for itching or apply cold
compresses
GI: liver cirrhoses - crackles- pulmonary overload- no flat veins; no increase urine
output; no rapid pulse
nurse plan of care knowing which of the following american asian- they believe in Yin
and Yang
albuterol- bronchodilator; tachycardia; asthma; respiratory distress
COPD (resp. acidosis) when you have a pt ventilator dependent alarm is going on >
What is initial NI when trying to trouble shoot for ventilator that keeps alarming- Use
ambubag for patient - ventilator not working
Osteoarthritis- pain in the joints; dull aching pain
young female pt going for cxr- are you pregnant
when you are assisting client going for pulmonary angiogram? are you allergic to sea
food
what manifestation to indicate you are allergic to contrast medium? Respiratory
distress
7/29/2019 Comp Review
3/5
if you have a pt w/ a fx and cant feel anything on lt finger and slow capillary refill and
decrease pulses what do you do first? Call physician because it is life threatening
If a pt has pulmonary TB what are not manifestations? Mark all that apply- no stridor,
no fever; non productive cough, chills, anorexia, wt loss, night sweats
if you have a pt who went for ORIF of hip- when trying to turn pt do not cross legs use
abduction pillow (away from mid-line)
compartment syndrome- from a severe fx pt asks how did he develop compartment
syndrome? Swelling in muscle unable to expand. increase pressure
pt w/ multiple trauma admitted to hosp w/ fx and placed a cast, in positioning leg w/
cast what do you do? elevate legs continuosly for 24 hours to decrease presence of
edema
what is this diformity- pt goes to er for lower leg, injured leg looks shorter and smaller
than other leg; painful and ecchymosis? Contusion fracture
SPrain- joint
STrain- muscle
skin traction- use bandages
skeletal traction- pins goes into bones
Pt asking nurse why do you need box extension traction (example of skin traction)
before going too surgery, what is the purpose? to decreasemusclespasms
pt w/ pulmonary TB- DX = sputum culture-
Imodium- anti-diarrrhea
Pt has chest tube- monitor for Subcutaneous emphysema> crepitus secondary to
emphysema> refers to air
pt went for sx, pt diet changed from NPO to clear liquids, what should pt have before
giving clear liquids? bowel sounds; normal BS is 4-32 pt went for EGD, what is highest priority for this client? GAG reflex (any procedure that
goes through the throat)
if a pt goes for chemo what is sx: nausea, anemia, neutropenia, depressed bone
marrow= decreased RBC, WBC, Platelets, (-penia is decreased) which of the
following will you not expect for chemotherapy
if your patient has chronic gastritis (stomach) what do you have to absorb vitamin B12
(decrease b12=pernicious anemia) ? IF (intrensic factor)
what is your NI priority if your patient has multiple myeloma (bone marrow)? increase
fluid intake (proper hydration)
characteristic myeloma- dumping syndrome- rapid emptying of stomach contents from duodenum; what are
manifestations= pale; sweating;pallor(no dry skin, bradycardia, no double vision)
What are you going to tell pt after a CT scan w/ dye? warmflushingsensationas you
inject into body,fluids will not be restricted, not painful, test does not take 2-3 hrs
pt w/ acute pancreatitis what 2 enzymes will be affected? Amylase and Lipase; what
position do you avoid= supine (flat)
7/29/2019 Comp Review
4/5
Zantac (ranitidine) what is best time to give Zantac? At bed time
pt on prolonged bed rest to prevent GI complication? fluids if not contraindicated
Respiratory complication on prolonged bed rest?
youre taking care of a pt what do you do to monitor
Prilosec- medications for GERD Pt has taking meds for 4 wks how would you know if
pt has received optimal intended effect? preventheart burn
TENS unit- transcutaneouselectrical nervestimulation; which statement from pt does he
need more teaching? Needles need to be inserted into skin
You have an older female pt that you would like to join group therapy in facility what
nursing action would you consider doing first before going to that group? Changediaper
pt went for pneumoectomy what is >> pink frothysputum(pulmonaryedema)
anaphylaxis- severe allergic reaction- what is priority for severe allergic reaction=
airway
Decrease immune system- infectionprevention
pt has Lupus defined as inflammatorycollagen if the dr orders you to give an IM injection of 400,000 units H/S=300,000 units per mm
how many mL do you give
when inserting NGT position in high fowlers(90 degree)
if pt had AKA RT leg how would you position pt?
w/ pt has evicersation - sterile saline dressing,assessfor shock, call nurseinstruct pt to
remaincalmand quiet, preparept for sx
if your clients doesnt speak english and has pain what chart does he use to describe
pain? WongBaker
mark all that apply- a pt went for surgery you are monitoring for signs of complication
which of the following would you expect to find in an immediate post op pt?less than 3 capillaryrefill; homanssign (-); hypoactiveBS;
if vital sign of pt comes back from sx and bp is 100/60 p: 90 resp: 20 bpm what do you
do? Nothing- normalranges
lung infection turns into- pneumonia
chest compression- 1/2-2 inchesfor adults
what lab results will tell you a sx needs to be rescheduled? HGB
incentive spirometer teaching that pt doesnt understand- I can use in any positionI want
pt is verbally abusive and confused; has headache and asking for analgesic nurse
says she cannot: says she was going to put in restraints: what is that considered:
Abuse
Ethnocentrism- tendency to view your culture as the best; stem: which statement is
lack of understanding?
hypercalcemia- when you have increased high calcium levels - muscleweakness
how would u know client is benefitting from platelet transfusion- decreasedbleeding
chills and rashes-
7/29/2019 Comp Review
5/5
prevent DVT on pulmonary embolism- ROMexercises
a piece of lungs removed what are expected findings when pt has chest tube
draining? middlejar fluctuatingup and down;if you have 50cc-100 is normalof draining-
dressingyou use is occlusive- petrolatumdressing;drainiagesystemshouldbe under bed; no
bubbling-leak in system;whenyou removechest tube tell pt to hold breath(valsalva)
when you have medication PRN what does it mean= as needed
if pt has cancer pain how do you give ? aroundthe clock
broth, jello, tea (clear liquid is anything u can see through)
when feeding a GT patient place in - fowlersposition
if pt has ucer and taking tums how do you know pt - heart burn is gone
Zolfran-anit nausesand anti vomiting
A pt w/ GERDpprescribedReglan- 30 minutesbeforeeach meal
Bisulfan (Myeleran) drug of choice for Leukemia; Give Allaperinol(anti-gout) medication
pt has NGT low suction- pt has metabolicakalosis
in gastroesophagia disease- which substances will increase lower dysophagia spincterpressure? non-fat milk (do not give fatty acids, tea, or coffee)
pancreatitis- what is major complication in paralytic ileus? do not havegas
what is associated w/ Crohn's disease? malabsorption
why do you stage lung cancer? to identify best treatment
If you are giving pt Kayexalade (K to K) drug of choice to bring downpotassiumlevel
(chooselowestpotassiumlevel)
If you are supervising nursing student who is doing suctioning how do you know if
student is performing it wrong: whenyou notice she is applyingsuctionuponinsertion
Aspirin toxic- ringing in the airs
Always remember HCT %= women normal level 42-46 male is 48-53;When you aredehydrated (hct increases)? 48