EXAM FORM 2023 UPDATE
Meds for DI, what to look out for/do: - ANSWERS--adjust based on urine output
-daily weights
-inform of weight gain of 2 lb in 24 hr
-notify if headaches or confusion occur
-monitor for infection
-monitor for dizziness/drowsiness
Meningitis care plan: - ANSWERS--isolate as soon as it is suspected
-droplet precautions
-fever reduction methods
-provide quiet environment
-minimize exposure to bright light
-bed at 30 degrees
-seizure precautions
-antipyretics
-emesis basin at bedside
Mild allergic transfusion reaction s/s: - ANSWERS--itching
-urticaria
-flushing
give benadryl
Most immediate risk to the client following a kidney biopsy: - ANSWERS-hemorrhage
Nonpharm interventions for total knee replacement postop client complaining of pain but
refusing pain meds: - ANSWERS-cold or ice therapy
Nursing actions for aspiration pneumonia r/t enteral feedings: - ANSWERS--stop the
feeding
-turn the client to his side
-suction the airway
-admin O2 if indicated
-auscultate breath sounds for increased congestion
-notify provider & get chest xray
Nursing actions for diarrhea r/t enteral feedings: - ANSWERS--slow the rate & contact
provider
-contact dietitian
-provide skin care & protection
,Nursing actions to prevent overfeeding r/t enteral feedings: - ANSWERS--check residual
Q 4-6 hr
-withhold as prescribed then resume
Ongoing monitoring of a client with Cushing's disease includes: - ANSWERS--
monitoring liver enzymes
-monitoring fluid & elecs (hyperkalemia)
-weight
-WBC, neutrophils, platelets, Hgb & Hct
Paracentesis actions: - ANSWERS--informed consent
-labs (BUN, creat, albumin, protein, glucose)
-void or urinary cath
-high fowlers
-review baseline vitals & abd girth
-admin sedation as prescribed
-admin IV bolus fluids or albumin prior to & after
Paracentesis client teaching: - ANSWERS-supine
void prior to procedure
Physical movements slow down significantly, affecting walking more. Which stage of
Parkinson's? - ANSWERS-Stage 3
Planning care for a client receiving enoxaparin for PE: - ANSWERS--bleeding
precautions
-assess for contraindications: recent trauma, active bleeding, peptic ulcer disease, hx of
stroke)
-monitor for side effects (bleeding, thrombocytopenia, etc)
Planning to admin thrombolytic therapy to a client who had a stroke... - ANSWERS-
admin within 4.5 hours of onset of initial symptoms
positive kernig's sign - ANSWERS-test dealing with the extension of the neck
Post hip arthroplasty positioning: - ANSWERS-supine w/head of bed slightly elevated &
affected leg in a neutral position
place pillow or abduction device between the legs when turning to the unaffected side
client should not be turned to affected side
Post hip arthroplasty: - ANSWERS--monitor for s/s of DVT and PE
-antiembolitic stockings or compression devices while in bed
-encourage: plantar flexion, dorsiflexion, & circumduction exercises
-encourage early ambulation
, -client's Hgb & Hct may drop 24-48 hrs post surgery
Post knee arthroplasty: - ANSWERS--no pillows under knee
-to prevent heel ulcers: place small pillow/blanket under ankle area
-ice/cold therapy to help w/swelling
-compression bandage & suction
-CPM may be applied after surgery
Preparing a client for a lumbar puncture: - ANSWERS--remove all jewelry
-void prior
-cannonball position, side lying with knees to chest or sitting stretched over an overbed
table
Preprocedure & Postprocedure following a kidney biopsy nsg actions: - ANSWERS-Pre:
NPO 4-6 hr prior, review coag studies
POST:
-monitor vitals
-assess dressings & urinary output (hematuria)
-review Hgb & Hct
-admin PRN pain meds
-remain supine
Preventing AKI: - ANSWERS--fluid resuscitation
-smoking cessation
-weight loss
-NSAID use monitoring
-control DM & HTN
-take prescribed abx
Priority action following the placement of an NG tube? - ANSWERS-get chest xray to
confirm placement
Priority action for symptomatic sinus bradycardia: - ANSWERS-atropine & isoproterenol
then pacemaker
Priority assessment for hypokalemia: - ANSWERS-pts taking digoxin
ineffective respirations or diminished breath sounds
Priority finding following general anesthesia: - ANSWERS-return of gag reflex
Priority intervention for Diabetic ketoacidosis: - ANSWERS-administer insulin
administer IV fluids