Nursing 220 final exam
Nurse is assisting g older adult patient with orthostatic hyper tension to ambulate for the
first time after surgery which action should nurse take first?
straight ahead while walking
gait belt on waist
bp while lay, sitting and standing
march in place - answerC blood pressure while sitting and standing
explanation: asses before performing action
a nurse is caring for a patient with C dif. which is most appropriate for preventing
transmission?
A alcohol based sanitizer after glove removal
B place patient on airborne precautions
C perform hand hygiene using soap and water
D reuse disposable gowns if not visibly soiled - answerc perform hand hygiene and
using soap and water
post op patient reports SOB.
wha tis next action
increase iv fluids
assess pulse ox
tell patient to take slow deep breaths
notify provider - answerassess pulse ox
pt had appendectomy 6 hours ago with pain 8/10 the MAR list hydromoprhone 0.5 mg
IV q4h prn pain what should the nurse do first?
A administer hydromorphone
B ask patient pain after reposition
C review last time dose was given
D offer non pharmacological intervention - answerc review last time medication was
given
A patient newly prescribed warfarin asks how to monitor its effectiveness. which
response is appropriate
A we will check aPTT levels weekly
B you will come in for regular INR testing
C you will come in for regular inr testing - answerregular inr testing
patient with diarrhea is receiving iv fluids which assessment? indicates the treatment is
effective
A urine output increases to 30 ml/hr
B skin turgor remains tented
Nurse is assisting g older adult patient with orthostatic hyper tension to ambulate for the
first time after surgery which action should nurse take first?
straight ahead while walking
gait belt on waist
bp while lay, sitting and standing
march in place - answerC blood pressure while sitting and standing
explanation: asses before performing action
a nurse is caring for a patient with C dif. which is most appropriate for preventing
transmission?
A alcohol based sanitizer after glove removal
B place patient on airborne precautions
C perform hand hygiene using soap and water
D reuse disposable gowns if not visibly soiled - answerc perform hand hygiene and
using soap and water
post op patient reports SOB.
wha tis next action
increase iv fluids
assess pulse ox
tell patient to take slow deep breaths
notify provider - answerassess pulse ox
pt had appendectomy 6 hours ago with pain 8/10 the MAR list hydromoprhone 0.5 mg
IV q4h prn pain what should the nurse do first?
A administer hydromorphone
B ask patient pain after reposition
C review last time dose was given
D offer non pharmacological intervention - answerc review last time medication was
given
A patient newly prescribed warfarin asks how to monitor its effectiveness. which
response is appropriate
A we will check aPTT levels weekly
B you will come in for regular INR testing
C you will come in for regular inr testing - answerregular inr testing
patient with diarrhea is receiving iv fluids which assessment? indicates the treatment is
effective
A urine output increases to 30 ml/hr
B skin turgor remains tented
