NEWEST 2024/2025 WITH ACTUAL QUESTIONS
AND CORRECT VERIFIED ANSWERS|ALREADY
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A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions - ANSWER-D. Contractions
Do not delegate - ANSWER-What you can EAT E-evaluate A-assess T-teach
Addison's & Cushings - ANSWER-Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia,
hypo/hyperglycemia
Better peripheral perfusion? - ANSWER-EleVate Veins, DAngle Arteries
APGAR - ANSWER-Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
,Airborne precautions - ANSWER-MTV or My chicken hez tb measles, chickenpox
(varicella) Herpes zoster/shingles TB
Airborne precautions protective equip - ANSWER-private room, neg pressure with 6-12
air exchanges/hr mask & respirator N95 for TB
Droplet precautions - ANSWER-spiderman! sepsis, scarlet fever, streptococcal
pharyngitis, parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
Contact precaution - ANSWER-MRS WHISE
protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases
caused by micro-organisms (C diff),
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching
the outside of the bag
PMGG= Private room/ share same illness, mask, gown and gloves
Skin infection - ANSWER-VCHIPS
Varicella zoster
,Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
Air or Pulmonary Embolism - ANSWER-S/S chest pain, dyspnea, tachycardia,
pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of
bed.)
Woman in labor (un-reassuring FHR) - ANSWER-(late decels, decreased variability, fetal
bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC - ANSWER-Pt on Right side (promotes emptying of the
stomach) Head of bed elevated (prevent aspiration)
After lumbar puncture and oil based myelogram - ANSWER-pt is flat SUPINE (prevent
headache and leaking of CSF)
Pt with heat stroke - ANSWER-flat with legs elevated
during Continuous Bladder Irrigation (CBI) - ANSWER-catheter is taped to the thigh. leg
must be kept straight.
After Myringotomy - ANSWER-position on the side of AFFECTED ear, allows drainage.
After Cateract surgery - ANSWER-pt sleep on UNAFFECTED side with a night shield for
1-4 weeks
, after Thyroidectomy - ANSWER-low or semi-fowler's position, support head, neck and
shoulders.
Infant with Spina Bifida - ANSWER-Prone so that sac does not rupture
Buck's Traction (skin) - ANSWER-elevate foot of bed for counter traction
After total hip replacement - ANSWER-don't sleep on side of surgery, don't flex hip more
than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip
abduction by separating thighs with pillows.
Prolapsed cord - ANSWER-Knee to chest or Trendelenburg
oxygen 8 to 10 L
Cleft Lip - ANSWER-position on back or in infant seat to prevent trauma to the suture
line. while feeding hold in upright position.
To prevent dumping syndrome - ANSWER-(post operative ulcer/stomach surgeries) eat
in reclining position. Lie down after meals for 20-30 min. also restrict fluids during
meals, low CHO and fiber diet. small, frequent meals.
AKA (above knee amputation) - ANSWER-elevate for first 24 hours on pillow. position
prone daily to maintain hip extension.
BKA (below knee amputation) - ANSWER-foot of bed elevated for first 24 hours. position
prone to provide hip extension.
detached retina - ANSWER-area of detachment should be in the dependent position
administration of enema - ANSWER-pt should be left side lying (Sim's) with knee flexed.