Nursing 3000 Acute Care Final Exam
and All Actual Answers
How to test for pneumonia? - Answer -Chest x-rays
- ABGs
- Sputum culture to identify organisms
What is Viral Pneumonia? - Answer - less severe than bacterial
- low grade fever
- non- productive cough
- WBCs normal to low elevation
- Chest X-ray shows minimal changes
Bacterial Pneumonia - Answer - more severe
- high fever > 101 oF
- productive cough
- WBC's elevated
- Chest x-ray shows infiltration
Classic Symptoms of Pneumonia - Answer - Chills
- Rhonchi
- Wheezes
- Decreased SpO2
What is Effusion and Pleural Effusion? - Answer Effusion: abnormal collection of fluid in
hollow spaces or between tissues of the body
Pleural Effusion: abnormal collection of fluid between the lining of the lungs
DKA Causing Factors - Answer - Sepsis
- Sickness
- Skipping Insuln
- Surgery
Priority Nursing Diagnosis (6) for DKA - Answer - fluid volume deficit
- risk of electrolyte imbalance
, - risk of ineffective cerebral perfusion
- risk for decrease cardiac output
- risk of ineffective renal perfusion
- risk for shock
Cues of Inhalation Injury Above the Glottis - Answer - Presence of facial burns
- Singed nasal hair
- Hoarseness, painful swallowing
- Darkened oral and nasal membranes
- Carbonaceous sputum
History of being burned in enclosed space
- Clothing burns around chest and neck
Two ways to asssess for extent of burn - Answer - Lund-Browder
- Rules of Nine
Disadvantage of Lund-Browder - Answer - weakness in assessing lateral burns
- lack of anatomical landmarking
- inaccurate representation of obese or female patients
Classification of Burns - Answer - Face, Neck, Chest --> respiratory obstruction
- hands, feet, joint, eyes --> impediments in self care
- butt, nose, perineum, ears --> infection
- circumferential burns of the extremities can cause circulatory compromise
Emergent Phase - Answer - period required to resolve immediate problems resulting from
the injury
- usually lasts up to 72 hours
- primary concerns are onset of hypovolemic shock and edema
- phase begins with fluid loss and edema formation and continues until fluid mobilization and
diuresis begins
Parkland (Baxter) Formula - Answer 4 mL * kg * TBSA
- estimates the fluid requirement
and All Actual Answers
How to test for pneumonia? - Answer -Chest x-rays
- ABGs
- Sputum culture to identify organisms
What is Viral Pneumonia? - Answer - less severe than bacterial
- low grade fever
- non- productive cough
- WBCs normal to low elevation
- Chest X-ray shows minimal changes
Bacterial Pneumonia - Answer - more severe
- high fever > 101 oF
- productive cough
- WBC's elevated
- Chest x-ray shows infiltration
Classic Symptoms of Pneumonia - Answer - Chills
- Rhonchi
- Wheezes
- Decreased SpO2
What is Effusion and Pleural Effusion? - Answer Effusion: abnormal collection of fluid in
hollow spaces or between tissues of the body
Pleural Effusion: abnormal collection of fluid between the lining of the lungs
DKA Causing Factors - Answer - Sepsis
- Sickness
- Skipping Insuln
- Surgery
Priority Nursing Diagnosis (6) for DKA - Answer - fluid volume deficit
- risk of electrolyte imbalance
, - risk of ineffective cerebral perfusion
- risk for decrease cardiac output
- risk of ineffective renal perfusion
- risk for shock
Cues of Inhalation Injury Above the Glottis - Answer - Presence of facial burns
- Singed nasal hair
- Hoarseness, painful swallowing
- Darkened oral and nasal membranes
- Carbonaceous sputum
History of being burned in enclosed space
- Clothing burns around chest and neck
Two ways to asssess for extent of burn - Answer - Lund-Browder
- Rules of Nine
Disadvantage of Lund-Browder - Answer - weakness in assessing lateral burns
- lack of anatomical landmarking
- inaccurate representation of obese or female patients
Classification of Burns - Answer - Face, Neck, Chest --> respiratory obstruction
- hands, feet, joint, eyes --> impediments in self care
- butt, nose, perineum, ears --> infection
- circumferential burns of the extremities can cause circulatory compromise
Emergent Phase - Answer - period required to resolve immediate problems resulting from
the injury
- usually lasts up to 72 hours
- primary concerns are onset of hypovolemic shock and edema
- phase begins with fluid loss and edema formation and continues until fluid mobilization and
diuresis begins
Parkland (Baxter) Formula - Answer 4 mL * kg * TBSA
- estimates the fluid requirement
