Foundations of Nursing 2 Final Exam Questions With
Complete Solutions
3 sections of a pleuravac and the purpose of each: Correct
Answers -collection chamber (collects drainage)
-water-seal chamber (one way valve)
-suction control chamber (promotes drainage)
3 types of bleeding Correct Answers -Capillary
-Venous
-Arterial
4 landmarks for IM injections: Correct Answers Deltoid
Vastus Lateralis
Ventrogluteal
Dorsogluteal
5 Rights of med admin: Correct Answers Right patient (check
name, ID band, MR #)
Right Dose (drug guide, have math checked)
Right Medication
Right Route (IV fastest, IM, sub-Q, oral , rectal, intradermal)-
not interchangeable- need MD order
Right Time: (30 minutes before and after scheduled time)
A wound drain is emptied: Correct Answers Emptied every 4-8
hours and drainage recorded on I&O sheet.
Appearance of normal and abnormal stoma Correct Answers
Normal Stoma: should be pink, moist, "beefy red", surrounding
,skin- no redness or ulcerations, should be outside skin like half
an inch
Abnormal Stoma: pale, black, or blue stoma is ischemic
Best position for suppositories: Correct Answers Left sims
Chest tubes: #?-#? French catheter is inserted for air or serous
drainage; #? to #? is inserted for serous, thick or purulent
drainage. Correct Answers #16 - 20 French catheter is inserted
for air or serous drainage;
#28 - 40 is inserted for serous, thick or purulent drainage.
Cuff purpose: Correct Answers -The cuff is a balloon inflated
with air to maintain a seal between the trach tube and the
patient's trachea
-A cuffed trach tube is used during mechanical ventilation, with
BiPap, and bagging - Prevents air from moving through the
upper airway and prevents speech
-A pilot balloon outside the trach tube indicates status of cuff
inflation (inflated or deflated)
Describe the penrose drain: Correct Answers -Hollow, open-
ended rubber tube
-Allows fluid to drain via capillary action onto absorbent
dressing
-Not sutured
-Commonly placed to drain abscesses
-Change dressing frequently to prevent skin irritation
-Held in place by a safety pin on outside of wound to prevent
drain from slipping back into incision.
, Describe the T tube: Correct Answers -Placed in Common Bile
Duct after removal of gallbladder
-Tube drains bile while surgical site is healing
-End looks like a "T" p. 414 Taylor skills
-Make sure tubing not kinked.
-Don't contaminate drain spout -wipe with sterile gauze and re-
seal.
-May be clamped with a rubber band after meals to divert bile
into duodenum to aid in digestion.
Diameter of nasal trumpet should be: Correct Answers
Diameter should be slightly smaller than diameter of nostril
Enemas - how to manage cramping: Correct Answers If cramps
or pain, stop flow, have patient take deep breaths and restart at a
slower rate
Examples of vesicants (3) Correct Answers chemotherapy
some antibiotics
potassium chloride
Febrile Non-Hemolytic Reaction vs.
Acute Hemolytic Reaction Correct Answers *Febrile Non-
Hemolytic Reaction*
-Caused by antibodies to donor leukocytes that remain in the
unit of blood
-90% of transfusion reactions (most common)
-Greater risk if multiple transfusions (develop antibodies) & RH
negative women who have borne RH positive children
-Chills, fever elevation of 1 degree or more that begins 2 or
more hours after transfusion started
Complete Solutions
3 sections of a pleuravac and the purpose of each: Correct
Answers -collection chamber (collects drainage)
-water-seal chamber (one way valve)
-suction control chamber (promotes drainage)
3 types of bleeding Correct Answers -Capillary
-Venous
-Arterial
4 landmarks for IM injections: Correct Answers Deltoid
Vastus Lateralis
Ventrogluteal
Dorsogluteal
5 Rights of med admin: Correct Answers Right patient (check
name, ID band, MR #)
Right Dose (drug guide, have math checked)
Right Medication
Right Route (IV fastest, IM, sub-Q, oral , rectal, intradermal)-
not interchangeable- need MD order
Right Time: (30 minutes before and after scheduled time)
A wound drain is emptied: Correct Answers Emptied every 4-8
hours and drainage recorded on I&O sheet.
Appearance of normal and abnormal stoma Correct Answers
Normal Stoma: should be pink, moist, "beefy red", surrounding
,skin- no redness or ulcerations, should be outside skin like half
an inch
Abnormal Stoma: pale, black, or blue stoma is ischemic
Best position for suppositories: Correct Answers Left sims
Chest tubes: #?-#? French catheter is inserted for air or serous
drainage; #? to #? is inserted for serous, thick or purulent
drainage. Correct Answers #16 - 20 French catheter is inserted
for air or serous drainage;
#28 - 40 is inserted for serous, thick or purulent drainage.
Cuff purpose: Correct Answers -The cuff is a balloon inflated
with air to maintain a seal between the trach tube and the
patient's trachea
-A cuffed trach tube is used during mechanical ventilation, with
BiPap, and bagging - Prevents air from moving through the
upper airway and prevents speech
-A pilot balloon outside the trach tube indicates status of cuff
inflation (inflated or deflated)
Describe the penrose drain: Correct Answers -Hollow, open-
ended rubber tube
-Allows fluid to drain via capillary action onto absorbent
dressing
-Not sutured
-Commonly placed to drain abscesses
-Change dressing frequently to prevent skin irritation
-Held in place by a safety pin on outside of wound to prevent
drain from slipping back into incision.
, Describe the T tube: Correct Answers -Placed in Common Bile
Duct after removal of gallbladder
-Tube drains bile while surgical site is healing
-End looks like a "T" p. 414 Taylor skills
-Make sure tubing not kinked.
-Don't contaminate drain spout -wipe with sterile gauze and re-
seal.
-May be clamped with a rubber band after meals to divert bile
into duodenum to aid in digestion.
Diameter of nasal trumpet should be: Correct Answers
Diameter should be slightly smaller than diameter of nostril
Enemas - how to manage cramping: Correct Answers If cramps
or pain, stop flow, have patient take deep breaths and restart at a
slower rate
Examples of vesicants (3) Correct Answers chemotherapy
some antibiotics
potassium chloride
Febrile Non-Hemolytic Reaction vs.
Acute Hemolytic Reaction Correct Answers *Febrile Non-
Hemolytic Reaction*
-Caused by antibodies to donor leukocytes that remain in the
unit of blood
-90% of transfusion reactions (most common)
-Greater risk if multiple transfusions (develop antibodies) & RH
negative women who have borne RH positive children
-Chills, fever elevation of 1 degree or more that begins 2 or
more hours after transfusion started
