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TERM 2 FINAL UNITEKCOLLEGE EXAM QUESTIONS AND ANSWERS
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What does stage 1 pressure ulcer look like? what to do to help in that area? - Correct Answers -stage 1 localized area of skin , typically bony prominence, that is intact with non-blanchable redness. Turn the patient every 2 hours/ avoid full lateral position because it puts direct pressure on the trochanteric region stage II - Correct Answers -presents clinically as an abrasion , blister or SHALLOW crater What intervention is most appropriate to prevent respiratory complications resulting from immobility? What should you do to the patient? What is the immobilized patient at risk for? - Correct Answers -Pneumonia-ask the patient to cough, deep breathe, reposition at least every 2 hours What causes constipation in patients who have pressure injuries? - Correct Answers --I never constipated i take gentle laxatives every night -Immobility, dehydration, poor diet a nurse is instructing a patient on performing isometric exercise. what instruction should the nurse include? - Correct Answers -contract the muscle for several seconds, then relax the muscle for a few second and contract it again What dietary supplement would the pt need to be given who has pernicious anemia? - Correct Answers -Vitamin B What are the signs and symptoms of hypoglycemia? - Correct Answers -confusion Antidote for heparin? - Correct Answers -Protamine Sulfate Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) what signs would they exhibit above 800? - Correct Answers -Severe dehydration and hypernatremia caused by hyperglycemia. Polyuria and Polydipsia Patient has erythema around the sacrum area due to immobility. What is the nurses first priority? - Correct Answers -Reposition the patient
When differentiating between delirium and dementia in a pt, what would a pt with dementia exhibit? - Correct Answers -Forgets things relatively quickly and is unable to learn new things Mother of a child asks if their child can get chickenpox more than once. What kind of immunity would be most accurate? - Correct Answers -Active acquired immunity What should you administer after a pt experience anaphylaxis? - Correct Answers - oxygen Best way to prevent communicable diseases? - Correct Answers -Hand Washing What do we call different animals that carry germs? - Correct Answers -Vector What is the nursing priority for a patient who is immunocompromised? - Correct Answers -Protect them from infection or illness What illnesses would require you to take airborne precautions? - Correct Answers -TB, measles, Varicella, Contact precaution illnesses? - Correct Answers -Would infection Respiratory Infection Kidney infection Impetigo Viral Conjunctiva Cdiff What does the impetigo look like? - Correct Answers -a honey colored crust over a thin- walled vesicle You are giving blood to a patient and they start to have terrible chills. What should be the first course of action? - Correct Answers -Stop IV and notify provider immediately What is the best for a nurse to offer when encouraging a patient after a tonsillectomy to increase fluid intake? - Correct Answers -Flavored popsicles to suck What position do we need to have the patient in to perform thoracentesis? - Correct Answers -Sitting on the side of the bed bent over the bedside table What to do when your patient O2 sat is 85%. What action are you going to take? - Correct Answers -Semi Fowlers position What kind of medication is Propranolol? What is common side effect of the medication? - Correct Answers -Beta Blocker Orthostatic Hypotension Hypotension, Bradycardia, Dizzy, lightheaded, tired
How long should the nurse be inside the room when they first administer blood transfusion? - Correct Answers -the first 15 minutes What are the priority actions BEFORE starting blood transfusions? - Correct Answers - Pts temperature; Get CONSENT What is the most appropriate action when you are giving two or more units of blood? - Correct Answers -Have the second bag of blood sent back for storage if the blood will take longer than 30 minutes to diffuse for the first bag. Clinical finding patient will present when they are in Diabetic Keto Acidosis?(DKA) - Correct Answers -Fruity/Acetone breath What is the mechanism of action Heparin? - Correct Answers -Prevents the formation of blood clots Which position enhances cerebral blood flow to counteract the symptoms of compensatory shock? - Correct Answers -Trendelenburg Pt with cervical spine injury, is suffering from hypotension. What is it a sign of? A nurse is caring for a patient who has a cervical spine injury and assesses progressive hypotension. What does it signify? - Correct Answers -Neurological Shock What are the four types of shock? - Correct Answers -Hypovolemic, cardiogenic, obstructive, vasogenic or distributive shock Pt comes to the ER with abdominal laceration or wound, what to do with exposed bowels? - Correct Answers -Reinforce dressing with saline dressing What does the acronym SAMPLE stand for? - Correct Answers -S - symptoms A - Allergies M - Medications (current) P - Past illness/pregnancy L - Last oral intake E - Events related to injury What lab needs to be monitored when a pt takes Lasix (diuretic)? - Correct Answers -K+ (Hypokalemia) is a big risk for Lasix Educational tips for a pt who is going home with Warfarin/Coumadin? - Correct Answers -Shaving with an electric razor What is the most effective diagnostic test that can be done to be monitored for warfarin or coumadin? - Correct Answers -APTT
Nurse teaching a pt, what is important to include in teaching about Simvastatin? - Correct Answers -Take medication in the evening A nurse documents and reports the presence of foul, bulky stool in a pt with cystic fibrosis (CF). What does this finding indicate about the pt? - Correct Answers -Is not adequately food A nurse is designing a teaching plan for a patient with AIDS. What should be included relative to food preparation precautions? (Select all that apply.) - Correct Answers -- Check expiration dates on frozen foods