NR 341 Exam #3 Review
Immediate nursing interventions for a patient with a swollen PICC line. - Answer -Stop
the infusion immediately and do not infuse anything else.
-Notify HCP
-Measure the circumference of the affected extremity and compare to baseline.
Dietary considerations for a patient with end-stage renal disease. - Answer Decrease
potassium intake
What is the nurse's priority assessment upon a patient's return from dialysis? - Answer
Obtain the patient's BP (fluid removal can cause hypotension)
A patient in the ER complains of the "worst headache of their life," what do you
suspect? - Answer Hemorrhagic stroke
How do you test cranial nerve III? - Answer PERRLA
Your patient has SIADH and their sodium level is 123. What is your priority intervention?
- Answer Restrict fluid intake
Where is McBurney's point? - Answer 1/3 the distance from superior iliac spine to
umbilicus in the RLQ
What are the steps of taking a patients blood glucose level? - Answer -Make sure that
the test strips aren't expired
-Identify the pt
-Apply gloves
-Clean the site with alcohol
-Poke on the side of the finger pad
-Wipe away the first drop of blood then collect the sample
How do you draw up cloudy and clear insulin into the same syringe? - Answer *Clear
before cloudy*
1. Wipe the top of both viles
2. Put air into cloudy
3. Put air into clear
4. Withdraw clear
5. Withdraw cloudy
Important nursing actions prior to initiating tube feeding via NG tube - Answer -Check
placement via x-ray
-Check residual
-Hook up feeding and re-feed amount removed to check residual
What are the signs and symptoms of organ rejection? - Answer -Fever
-Organ might stop working (I.e., dec. urine output for a pt with kidney transplant)
-Flu-like symptoms (N/V, chills)
, NR 341 Exam #3 Review
A patient suffered a femur fracture, what are they most at-risk for? - Answer Fat
embolism
What are the signs and symptoms of autonomic dysreflexia? - Answer -High BP
-Irritation
-Sweating above level of injury
-Nasal congestion
-Cool below level of injury
What kind of insulin drip will the nurse start for a patient in DKA? - Answer Regular
insulin drip only
Nursing considerations for a patient with Bell's palsy - Answer -Educate that this occurs
suddenly, causes facial drooping, and must run its course and goes away on its own.
-Offer emotional support and reassurance.
What are the signs and symptoms of liver cirrhosis? - Answer -Abd distention (ascites)
-Rigid abd
-Jaundice
-Easily bruised
-Confusion
-Esophageal varices
What are the diabetes sick day rules? - Answer -Continue to monitor blood sugar
-May have to adjust insulin dosage
-Stay hydrated (240-360 mL of water every hour)
-Check urine for ketones
A patient is septic and bleeding from their IV sites and in their stools, what do you
suspect is going on? - Answer DIC
Signs and symptoms of peritonitis in a patient receiving peritoneal dialysis - Answer
Cloudy effluent
Rigid abdomen
How do you assess the neurovascular status of a patient with a cast on? - Answer -
Check the cap refill, temp, and pulses of the affected extremity.
-Ask if the pt is experiencing tingling and numbness.
-Ask if they can wiggle their fingers/toes.
What is included in a primary survey for the care of an emergency patient? - Answer
•Aims to identify life threatening conditions so appropriate interventions can be started
•Airway, breathing, circulation, disability, exposure and environmental control, facilitation
of adjuncts and family, resuscitation adjuncts
Immediate nursing interventions for a patient with a swollen PICC line. - Answer -Stop
the infusion immediately and do not infuse anything else.
-Notify HCP
-Measure the circumference of the affected extremity and compare to baseline.
Dietary considerations for a patient with end-stage renal disease. - Answer Decrease
potassium intake
What is the nurse's priority assessment upon a patient's return from dialysis? - Answer
Obtain the patient's BP (fluid removal can cause hypotension)
A patient in the ER complains of the "worst headache of their life," what do you
suspect? - Answer Hemorrhagic stroke
How do you test cranial nerve III? - Answer PERRLA
Your patient has SIADH and their sodium level is 123. What is your priority intervention?
- Answer Restrict fluid intake
Where is McBurney's point? - Answer 1/3 the distance from superior iliac spine to
umbilicus in the RLQ
What are the steps of taking a patients blood glucose level? - Answer -Make sure that
the test strips aren't expired
-Identify the pt
-Apply gloves
-Clean the site with alcohol
-Poke on the side of the finger pad
-Wipe away the first drop of blood then collect the sample
How do you draw up cloudy and clear insulin into the same syringe? - Answer *Clear
before cloudy*
1. Wipe the top of both viles
2. Put air into cloudy
3. Put air into clear
4. Withdraw clear
5. Withdraw cloudy
Important nursing actions prior to initiating tube feeding via NG tube - Answer -Check
placement via x-ray
-Check residual
-Hook up feeding and re-feed amount removed to check residual
What are the signs and symptoms of organ rejection? - Answer -Fever
-Organ might stop working (I.e., dec. urine output for a pt with kidney transplant)
-Flu-like symptoms (N/V, chills)
, NR 341 Exam #3 Review
A patient suffered a femur fracture, what are they most at-risk for? - Answer Fat
embolism
What are the signs and symptoms of autonomic dysreflexia? - Answer -High BP
-Irritation
-Sweating above level of injury
-Nasal congestion
-Cool below level of injury
What kind of insulin drip will the nurse start for a patient in DKA? - Answer Regular
insulin drip only
Nursing considerations for a patient with Bell's palsy - Answer -Educate that this occurs
suddenly, causes facial drooping, and must run its course and goes away on its own.
-Offer emotional support and reassurance.
What are the signs and symptoms of liver cirrhosis? - Answer -Abd distention (ascites)
-Rigid abd
-Jaundice
-Easily bruised
-Confusion
-Esophageal varices
What are the diabetes sick day rules? - Answer -Continue to monitor blood sugar
-May have to adjust insulin dosage
-Stay hydrated (240-360 mL of water every hour)
-Check urine for ketones
A patient is septic and bleeding from their IV sites and in their stools, what do you
suspect is going on? - Answer DIC
Signs and symptoms of peritonitis in a patient receiving peritoneal dialysis - Answer
Cloudy effluent
Rigid abdomen
How do you assess the neurovascular status of a patient with a cast on? - Answer -
Check the cap refill, temp, and pulses of the affected extremity.
-Ask if the pt is experiencing tingling and numbness.
-Ask if they can wiggle their fingers/toes.
What is included in a primary survey for the care of an emergency patient? - Answer
•Aims to identify life threatening conditions so appropriate interventions can be started
•Airway, breathing, circulation, disability, exposure and environmental control, facilitation
of adjuncts and family, resuscitation adjuncts
