B260 Final Exam Questions With Complete Solutions: Nursing Fundamentals, Exams of Nursing

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B260 Final Exam Questions With Complete Solutions Acceptance Correct Answer incorporates loss into their life acute hemolytic reaction Correct Answer incompatibility to antibodies, causes RBC breakdown s/s: chills, fever, flank pain, hypotension, flushing acute pain Correct Answer self-limiting, identifiable cause, protective addiction Correct Answer compulsive drug craving and use, despite adverse consequences air embolism Correct Answer air entering the vein

• SOB, chest pain, tachycardia, cough, decreased BP
• if happens: stop infusion, lay pt in recovery position airborne precautions Correct Answer used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei
• gown, gloves, respirator, face shield, negative pressure room handwashing
• TB, SARS, Measles, Chickenpox analyze/diagnose Correct Answer analyze cues & prioritize hypothesis
• use data to determine what needs to be done

anaphylactic reaction Correct Answer reaction to blood proteins s/s: anxiety, itching, wheezing, shock Anger Correct Answer expresses resistance or anger at God or others for situation ascending stairs with crutches Correct Answer - weight is placed on crutch

• weight is transferred from crutches to unaffected leg on stairs
• crutches are aligned with unaffected leg on stairs
• strong leg next to railing assessment Correct Answer recognize clues
• gather and organize data Bargaining Correct Answer postpones awareness of loss by trying to prevent it from happening barrier restraint Correct Answer barriers that limit movement Bevel of needle Correct Answer should always be facing up when inserted into the skin bipap Correct Answer 2 pressure settings
• 21-100% O Body defenses against infection Correct Answer skin, mouth, eyes, respiratory tract urinary tract, GI tract, vaginal tract

bowel diversion Correct Answer temporary or permanent artificial opening in the abdominal wall (stoma) bowel elimination interventions Correct Answer - routine schedule

• antidiarrheals
• laxatives
• enema
• positioning
• skin integrity cancer pain Correct Answer acute and chronic carminative edema Correct Answer gas reduces distension
• varies check for NG tube placement Correct Answer first is xray
• next is aspirating gastric contents chemical restraint Correct Answer any drug that is used for discipline or convenience and not required to treat medical symptoms chest tube Correct Answer removes air and fluids from pleural space
• negative pressure
• no kinks, secure and airtight chronic pain Correct Answer constant/recurring

clear liq diet Correct Answer any liquids you can see through clinical judgement Correct Answer outcome of critical thinking

• requires several steps to make decisions clinical thinking Correct Answer systemic and logical
• cognitive process
• involves analysis and interpretation of data CO2 is an Correct Answer acid comfort measures for terminally ill pts Correct Answer skin care, oral care, artificial tears, keep pt calm and comfortable, antiemetics, laxative, barrier creams, position for comfort, raise HOB, manage pain common bowel problems Correct Answer constipation, diarrhea, incontinence, flatulence, hemorrhoids, impaction common hospital infections Correct Answer urinary tract, surgical sites, respiratory tract, blood stream common urinary problems Correct Answer - retention
• UTI
• incontinence
• diversion contact precautions Correct Answer practices used to prevent spread of disease by direct or indirect contact
• gloves, gown, handwashing -MRSA & VRE

cpap Correct Answer 1 continuous pressure setting

• 21-100% O debridement Correct Answer removal of nonviable/necrotic tissue wet to moist dressings deep tissue injury Correct Answer Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear dehiscence Correct Answer partial or total separation of wound layers Denial Correct Answer cannot accept the loss
• form of protection Depression Correct Answer realizes full impact of the loss descending stairs with crutches Correct Answer - body weight is on unaffected leg
• body weight is transferred to crutches
• unaffected leg is aligned on stairs with crutches
• affected leg next to railing diabetic diet Correct Answer balanced intake of protein, fats, and carbohydrates disinfection Correct Answer eliminated many/all microorganisms besides bacterial spores

dressing changes Correct Answer - change when out of date and PRN

• clean or sterile technique
• clean from inside wound to outside wound
• give pain meds before droplet precautions Correct Answer used for patients known or suspected to be infected with pathogens transmitted by large particle droplets expelled during coughing, sneezing, talking, or laughing
• gown, gloves, face mask/respirator, face sheild, hand washing -Rubella, flue, RSV, pertussis, meningococcal meningitis dysphagia died Correct Answer pureed food, thickened liquids effects of immobility Correct Answer constipation, depression, atelectasis, clots, DVT, orthostatic hypotension, skin breakdown, muscle atrophy, incontinence enema admin Correct Answer - clean technique
• pt on left side
• explain procedure and lengtht of time to retain solution enteral tube nutrition Correct Answer provides nutrients into GI tract
• for patients who can't swallow
• potential for aspiration
  • HOB at least 30 degrees

eschar Correct Answer thick layer of dead, dry tissue that covers a wound bed evaluation Correct Answer evaluate outcomes

• did it work or no, what can be changed to work better evisceration Correct Answer protrusion of organs through an incision extravasation of IV Correct Answer infiltration with a drug that damages skin tissue
• edema, cool to touch, pallor, painful exudate Correct Answer fluid, cells, other substances that have been discharged from cells or blood vessels factors that affect bowel elimination Correct Answer medications, age, diet, physical activity, surgery, lifestyle habits, positioning during defecation factors that affect oxygenation Correct Answer diet, hydration, exercise, smoking, substance abuse, stress, environment factors that affect urinary elimination Correct Answer age, pregnancy, diet, immobility, psychosocial factors, pain, surgical procedures, medications fall prevention methods Correct Answer -Rounding -Wrist-bands/socks -Bed low/wheels locked -Gait belts

-BSC

-Assess condition/correct use of ambulatory aids -Assess environment febrile nonhemolytic reaction Correct Answer sensitivity to specific blood components s/s: sudden chills, fever, headache fire safety Correct Answer Rescue Alarm Contain Extinguish Pull Aim Squeeze Sweep four point gait Correct Answer used when both legs can bear some weight; right foot, left crutch, left crutch, right foot full liquid diet Correct Answer any liquid gluten free diet Correct Answer Eliminates wheat, oats, rye, barley and their derivatives granulation tissue Correct Answer healthy tissue HCO3 is a Correct Answer base

helping pt. mobility Correct Answer - assess strength, VS, environment

• non-skid shoes/socks
• gait belt
• assistance to sit, wait 1-2 min
• use of assistive devices hemodialysis Correct Answer the process by which waste products are filtered directly from the patient's blood
• if pt has advanced Renal Failure/ESRD or severe fluid/electrolyte imbalances hemorrhage Correct Answer s/s: swelling, distension, outright bleeding interventions: apply pressure, notify MD hemovac Correct Answer Closed wound drainage system connected to a suction often used for mastectomy and total knee/hip replacement high fiber diets Correct Answer whole grains, raw and dried fruits hospice care Correct Answer provide comfort, dignity, and personal growth
• available in home/hospital/etc
• no curative treatments given
• aids and supports pt and family

how long can blood be given Correct Answer up until 4 hours, even if not completely administered how long do you stay with a patient when blood is being administered Correct Answer 15 minutes

• take vitals before admin, 15 minutes after admin, and after blood is finished how to prevent air embolism from occurring Correct Answer - prime tubing carefully
• check tubing for bubbles
• change bags before they run dry hypertonic (fleet) enema Correct Answer constipation hypertonic
• can cause dehydration hyperventilation Correct Answer the condition of taking abnormally fast, deep breaths caused by: anxiety, infection, COPD hypoventilation Correct Answer decreased rate or depth of air movement into the lungs caused by: atelectasis, neuromuscular disorders, trauma immobility interventions Correct Answer - active and passive ROM
• optimal nutrition
• repositioning

• skin assessments
• deep breathing
• analgesics, anti-inflammatory meds
• assistive devices impaired skin integrity interventions Correct Answer positioning ambulation specialty beds bathing impaired skin integrity risk factors Correct Answer - friction
• moisture
• shear implementation Correct Answer take action
• start implementing solutions to solve the problems infection Correct Answer s/s: purulent drainage, fever, erythema, pain interventions: antibiotics, irrigation/cleaning infection prevention interventions Correct Answer bathing, dressing changes, remove contaminated items, remove contaminated sharps, keep environment clean and dry infiltration of IV Correct Answer Fluid goes into interstitial skin
• edema, cool to touch, pallor,

inhalation Correct Answer - crush meds

• inhale the meds through chamber
• immediate onset
• rinse mouth immediately after use intramuscular injection Correct Answer - 90 degree angle
• aspirate for blood return
• faster than SubQ, slower than IV
• z-track IV insertion procedure Correct Answer -apply tourniquet proximally to chosen site -put on gloves -cleanse site with alcohol and allow to dry -hold patients hand securely and use thumb to retract the skin and secure the vein -puncture vein at a 15-20 degree angle -when blood appears in the chamber, lower the needle to almost parallel to skin -press retraction button and remove assembly -apply pressure to vein and release tourniquet -nonclosed system: secure hub to catheter and start IV fluids -closed system: flush with saline IV push Correct Answer - fast onset - immediate
• flush before and after med admin IVPB Correct Answer - shorter onset, longer duration
• plateau level easier to reach
• bypasses first pass effect
• hang primary below secondary

JP drain Correct Answer suction drain with tubing inside the body and a bulb reservoir which, when squeezed empty, applies suction and pulls fluid out of the body

• used in thoracic or abdominal surgery Kubler Ross stages of grief Correct Answer 1. Denial

2. Anger
3. Bargaining
4. Depression
5. Acceptance localized infection Correct Answer an infection that is limited to a specific location in the body s/s: welling, redness, heat of area low cholesterol diet Correct Answer no more than 300 mg/day of dietary cholesterol low residue diet Correct Answer eliminates or limits foods that are high in bulk and fiber low sodium Correct Answer varies in sodium allow per day mechanical soft diet Correct Answer pureed foods medical aseptic technique Correct Answer clean, reduce number of organisms present medication edema Correct Answer treatment varies

• watch for contraindications for medication

medication errors Correct Answer - Report all medication errors

• Patient safety is top priority when an error occurs
• Documentation is required
• nurse must complete incident report metabolic acidosis signs and symptoms Correct Answer Kussmaul respirations, headache, confusion, tachycardia, N/V metabolic alkalosis signs and symptoms Correct Answer N/V, muscle twitching, tremors, seizures/coma, headache mild allergic reaction Correct Answer sensitivity to plasma proteins s/s: flushing, itching, hives most important action to prevent infection Correct Answer handwashing nasal cannula Correct Answer delivers up to 6L/min
• 24-44% O neuropathic pain Correct Answer nerve pain NG tube Correct Answer - flush with 30-60 ml of water before and after admin
• flush with 15-30 ml between meds
• never mix medications

NG tube measurement Correct Answer tip of nose to earlobe to xiphoid process NG tube: dobhoff, small bore Correct Answer enteral feeding NG tube: larger bore Correct Answer lavage (clear out cavity) NG tube: salem sump Correct Answer decompression NG tube: sengstaken blakemore Correct Answer compression nociceptive pain Correct Answer tissue/organ/part of body non-rebreather Correct Answer 10-15 L/min

• 80-98% O reservoir bag must be inflated nonpharmacological pain interventions Correct Answer - positioning
• massage
• thermotherapy
• distraction
• music
• therapeutic touch normal range for CO2 Correct Answer 35- normal range for HCO3 Correct Answer 21-28 mEq/L normal range for pH Correct Answer 7.35-7.

normal saline enema Correct Answer constipation isotonic

• safest now med order Correct Answer when a med is needed right away, but not STAT 30-60 min Nursing process Correct Answer - Assessment
• Analize/Diagnose
• Planning
• Implementation
• Evaluation oil retention edema Correct Answer constipation lubrication
• retain for several hours oral/enteral route Correct Answer subinguinal, buccal
• convenience v. tolerance
• easy to give
• pt has to be able to swallow and self administer
• slower affect
• 1st pass effect oxygenation interventions Correct Answer - HOB at semi fowlers
• incentive spirometry
• deep breathing and coughing
• hydration
• airway maintenance

pain Correct Answer taken from patients report pain assessment Correct Answer - numerical

• nonverbal
• visual analog
• Wong-Baker Faces
• FLACC (2mo-7 years) -Cries (infants palliative care Correct Answer help patients and families achieve best possible quality of life
• keeps pts comfortable
• can have this when pursuing curative treatments parenteral nutrition Correct Answer nourishment provided via IV therapy
• change tubing q24 hrs
• hang bag for only 24hrs
• filter solution if needed
• do not try to catch up with missed doses partial rebreather Correct Answer 10-15 L/min
• 60-90% O reservoir bag must be inflated Penrose drain Correct Answer a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing peritoneal dialysis Correct Answer the lining of the peritoneal cavity acts as the filter to remove waste from the blood

• if pt has advanced Renal Failure/ESRD or severe fluid/electrolyte imbalances phlebitis Correct Answer inflammation of the vein
• redness up the vein, painful physical dependence Correct Answer a physiological need for a drug, marked by unpleasant withdrawal symptoms when the drug is discontinued physical restraint Correct Answer manual methods that keep a patient from moving his/her arms, legs, body or head freely planning Correct Answer generate solutions
• come up with ideas to fix problems prescription med order Correct Answer med is taken outside hospital PRN med order Correct Answer given when pt requires it protective environment Correct Answer Focuses on clients w/ transplants or gene therapy
• positive airflow room
• workers wear mask, gowns, gloves
• NO fresh flowers/plants respiratory acidosis signs and symptoms Correct Answer anxiety, SOB, confusion, lethargy, flushed skin, tremors

respiratory alkalosis signs and symptoms Correct Answer lightheaded, dizzy, confusion, numbness in extremities restraint use Correct Answer - clinically justified

• based on face-to-face assessment
• must be reordered q24 as needed
• ongoing pt monitoring q 2hrs (toileting, ROM, food, hydration) rights of medication administration Correct Answer - right client
• right drug
• right dose
• right route
• right time
• right assessment
• right documentation
• right to refuse
• right education
• right evaluation risk factors for immobility Correct Answer age, diagnosis, pain, procedures, stability, trauma, pregnancy risk factors for infection Correct Answer age, immunocompromised, transplants, indwelling devices, surgery, medications seclusion restraint Correct Answer placing pt by themself to prevent harm to self or others

signs of dysphagia Correct Answer - coughing, changing in voice after swallowing, pocketing food, uncoordinated speech simple face mask Correct Answer delivers 5-10 L/min

• 35-60% O single med order Correct Answer given one time for specific reason slough Correct Answer stringy substance attached to wound bed soap suds enema Correct Answer constipation stimulates peristalsis
• castile soap ONLY
• caution with pregnancy and older adults stage 1 pressure injury Correct Answer unblanchable redness stage 2 pressure injury Correct Answer partial thickness skin loss with exposed dermis stage 3 pressure injury Correct Answer full thickness skin loss stage 4 pressure ulcer Correct Answer Full-thickness tissue loss with exposed bone, muscle, or tendon standard precautions Correct Answer wear gloves when coming into contact with blood, body fluid, non-intact skin, and mucous membranes

standing/routine med order Correct Answer Administered until the dosage is changed or another medication is prescribed STAT med order Correct Answer given immediately in an emergency (w/in 30 min) sterilization Correct Answer eliminates all microorganisms and spores subcutaneous injection Correct Answer - bypasses 1st pass effect,

• faster than oral, slower than IM/IV
• 45-90 degree angle for injection, pinch skin Suppository Correct Answer - vaginal or rectal
• bypasses first pass effect
• goes straight to problem area
• lubricate suppository surgical asepsis principles Correct Answer 1. A sterile object remains sterile only when touched by another sterile object.

2. Only sterile objects may be placed on a sterile field.
3. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated.
4. A sterile object or field becomes contaminated by prolonged exposure to air.
5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.
6. Fluid flows in the direction of gravity.

7. The edges of a sterile field or container are considered to be contaminated. surgical aseptic technique Correct Answer sterile, absence of pathogenic microorganisms swing through gait Correct Answer crutches forward, lift both feet and swing forward

• place weight on both feet to swing crutches forward again systemic infection Correct Answer an infection throughout the body s/s: fever, N/V, organ failure, leukocytosis, malaise tap water enema Correct Answer constipation hypotonic
• can cause fluid overload three point gait Correct Answer Both crutches and involved leg advance together Uninvolved leg follows Uses two canes/crutches or a walker tolerance Correct Answer the diminishing effect with regular use of the same dose of a drug, requiring the user to take larger and larger doses before experiencing the drug's effect Topical Correct Answer - put on problem area
• localized affect
• noninvasive

Trach care Correct Answer - q4 hours

• document
• make sure equipment fits properly trach suctioning Correct Answer sterile technique
• hyper oxygenate pt
• insert catheter without suction
• gently rotate cath with suction while pulling out
• only suction for 10-15 seconds Transdermal Correct Answer - prolonged systemic affects
• bypasses 1st pass
• rotate sites tunnelling Correct Answer tract of injury occurring in any direction from surface or edge of wound two-point gait Correct Answer One crutch and opposite extremity move together followed by opposite crutch and extremity undermining Correct Answer area of tissue injury beneath intact skin around the margins of wound unstageable pressure ulcer Correct Answer base of ulcer covered by slough and/or eschar in the wound bed urinary catheter insertion Correct Answer - sterile
• closed drainage system
• perineal hygiene
• cath care

• education venturi mask Correct Answer 4-15 L/min
• 24-60% what is blood hung with? Correct Answer normal saline only what to do if infiltration occurs Correct Answer - aspirate catheter to remove as much fluid as possible
• elevate arm
• apply compress