EXAM/ 120 Q&A/ 2024-2025.
Define Sinus Tachycardia - Answer: Regular Rhythm, rate 100-180 beats/min (higher in infants)
When is the best time of the month to perform a self-breast examination? - Answer: 4th to 7th
day during menstrual cycle or days after cycle has ended.
Define total Patient Care - Answer: Rn is responsible for all aspects of care for one or more pts
during a shift of care. Care is usually consistent, comprehensive, and holistic, care can be
delegated. RN works directly with pt, family and health care team members.
Define Primary nursing - Answer: 1 primary RN assumes responsibility for a caseload of
patients, provides care for the same pts during their stay in health care facility. RN assesses pt,
develops plan of care and delivers appropriate nursing intervention. Communication is lateral
from nurse to nurse and caregiver to caregiver.
Define major surgery - Answer: Involves extensive reconstruction or alteration in body parts,
poses great risks to wellbeing.
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,Describe a stage II pressure ulcer - Answer: Partial thickness loss of dermis presenting a shallow
ulcer red- pink wound bed without slough. May present an intact or open. ruptured serum filled
blister. Shiny dry shallow ulcer without slough or bruising.
Define Presbyscusis - Answer: Hearing loss associated with aging. Usually involves both a loss of
hearing sensitivity and a reduction in the clarity of speech.
Define Ventilation - Answer: movement of air in and out of the lungs. Afterload ejection of
blood from left ventricle
define contact precaution - Answer: Safeguards designed to reduce the risk of transmission of
epidemiologically important microorganisms by direct or indirect contact.
what sound do rhonchi make - Answer: sonorous wheeze-coarse, low pitched: may clear with
cough.
describe head lice - Answer: attach their eggs to hair, eggs look like oval particles of dandruff.
Lice are difficult to see, observe for bites or pustule eruptions in the follicles and area where
skin surfaces meet behind the ears in the ears and in the groin.
describe diffusion - Answer: movement of gases between air spaces and blood stream
what is the final step in a complete assessment? - Answer: documentation
S/S of hypostatic pneumonia - Answer: decreased lung expansion, generalized respiratory
muscle weakness and secretions occur without immobility. (comes from inflammation of the
lung from stasis or pooling of secretions. )
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, s/s of respiratory acidosis - Answer: increased PaCo2 and increased hydrogen ion concentration
below 7.35. This reflects the excess carbonic acid in the blood (hypoventilation produces R.
acidosis)
what is the primary advantage of hydrogel dressing ? - Answer: contains a high percentage of
water for wounds that require moisture. Maintaining a moist wound environment needed for
healing. Hydrogel facilitates debridement by softening dead tissue.
A pt complains of chills, dizziness and feeling hot during a blood transfusion. What are the
nurses most appropriate actions? - Answer: Stop transfusion immediately.
Remove blood component and tubing containing and tubing contacting blood products
replace with new primed tubing with 0.9% sodium chloride
Maintain patent IV line with normal saline
Stay with patient observe signs and symptoms and monitor every 5 min.
Notify health care ream or response team
notify bank
prepare to do cpr and give emergency drugs
save blood container, tube, labels and transfusion record
get blood and 1st urine
document transfusion reaction, description, treatment and outcomes
The nurse is providing preoperative teaching for a patient regarding pain control after surgery.
Which of the following statements is/are true regarding the use of postoperative analgesia? -
Answer: -inform nurse as soon as pain becomes a persistent discomfort.
-takes time for a drug to act
-drugs rarely eliminates all discomfort.
-don't be fearful of dependency
- USE of PCA pump
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