Nursing 120 Final Review pt 1- West Coast University

20 QUESTIONS OF SELECT ALL
LOTS OF DELEGATION QUESTIONS

Final
1. TPN nutrition – what do you need to connect after?
- D10 (prior to TPN)

2. Lab results :
CBC:
albumin
PTT: 11 – 14 secs
INR: 0.8 – 1.2
hgb
WBC:
Platelets:

pH: 7.35 – 7.45
HCO3:
RR:
HR:
BP:

K: 3.5 – 5.0
Ca:
Na: 135 - 145
Cl:
Cr:
BUN:


3. What is anemia?
-Anemia: deficiency of RBCs or hemoglobin in the blood resulting in pallor

4. Connect renal function and anemia
-When kidneys are damaged, they don’t make enough erythropoietin. As a result, the bone
marrow makes fewer RBCs causing anemia.

-Other causes of anemia in people with damaged kidneys include blood loss from hemodialysis
and low levels of iron.

6. how do you use crutches?
 Standing: hold both crutches on unaffected side and other hand to side rail, then
push in standing position
 Once stable, bring other crutch on the other hand
 For wide base of support, bring crutches 6 inches to front and 6 inches to side.
 Top of crutches should be 1-2 inches below the armpits.

,  Hand grips should be even with the top of the hip line
 Elbows slightly bent
 The aid should rest on hand, not armpits (to avoid vessel damage)

7. what is medical asepsis?
-Clean technique (wash hands)
-Reduces or inhibits number and growth of microorganisms

8. what is surgical asepsis?
 -Eliminate all microorganisms
 -Parenteral Meds(example)
 -Urinary catheter(example)
 -Surgical procedures(example)
 -STERILE dressing change(example)

9. what is airborne precautions SA what do you need to wear
 Used if the organism can cause infection over long distances while suspended in
the air (example sneezing and coughing)
 Apply isolation in negative pressure room
 Teach patient to cover mouth when sneezing or coughing
 Wear isolation gear (n95 mask, gown, gloves) when entering pt room
 Tell pt to wear same gear when exiting the isolation room



10. Patient with fluid volume deficit SA/ S/S / assess capillary refill
 Cap refill
 Daily weight
 Skin turgor
 Dry mucous membranes
 Weak/rapid pulse

-Flat neck veins
-Low BP
-Change in mental status
11. Pneumonia SA nursing intervention /
-Assess respiratory status
-Assess clinical manifestations

 Promote nutrition
 Hydration
 Breathing exercises (something about mechanical breathing)

-Oxygen Therapy

, The nurse is assessing a 79­year­old client diagnosed with pneumonia. Which signs and
symptoms should the nurse expect to assess in the client?

 1. Confusion and lethargy.
 2. High fever and chills.
 3. Frothy sputum and edema.
 4. Bradypnea and jugular vein distention.
 Correct: 1

12. review seizure and assessment collection of data SA
-Seizure History (prodromal signs, behavior, postictal state, history of status epilepticus)
-Seizure Activity (circumstances b4 attack, description of movement, position of eyes,
duration, behavior after attack)

 Strict bed rest (risk for falls)
 Record first thing pt does in seizure
 During seizures
 maintain patent airway
 Protect patients head
 Turn pt to side
 If standing, ease them on floor away from objects
 DO NOT RESTRAIN PT
 Don’t place anything in PT mouth
 Keep suction, O2, and padding close to bed
 Wear helmet
The nurse enters the room as the client is beginning to have a tonic­clonic
seizure.What action should the nurse implement first?
1. Note the first thing the client does in the seizure
2. Assess the size of the client’s pupils.
3. Determine if the client is incontinent of urine or stool.
4. Provide the client with privacy during the seizure.
Correct:1

The nurse walks into the room and the client is having a tonic clonic seizure while sitting in the
chair. Which intervention should the nurse implement first?

a. Prepare to administer intravenous diazepam (valium)

b. Remove the client from the chair safely to the ground

c. Place the client on the left side while protecting the head
d. Note what the client is doing during the seizure activity


13. patient with hernia SA/ what can cause it? (know what it is)