NUR2090 FINAL EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED A++
When does a HCP need to see pt after restraints are applied
within the hour
how often must restraints be ordered
every 24 hours, q 4 hours for violent pts
Med error preventions
tall man letters, no interruptions, medication-dispensing cabinets, bar-code
administration
therapeutic communication
empathy, positive regard, honesty, trust, self-awareness/self-reflection
non-therapeutic communication
rescue feelings, false reassurance, giving advice, changing the subject, being
moralistic, nonprofessional involvement
rescue feelings
nurse is essential to a patient's welfare
airborne precautions
private room, respirator for healthcare worker, mask for pt during transportation
TB, measles, varicella
droplet precautions
private room or with pt with same infection, mask
Flu, N. meningitidis, rubella, pertussis, respiratory viruses
contact precautions
,private room or with pt with same infection, gloves at all times, mask, gown and
protective barriers, pt designated equipment
C. diff, norovirus, skin infections
infiltration
swelling, coolness, discomfort, slowed infusion rate, absence of blood return
infiltration action
discontinue and change site, warm soaks
infiltration prevention
long bone sites, no joints, stabilization devices
phlebitis
pain, warmth, redness, hard/cord-like vein, slowed infusion rate
phlebitis action
discontinue and change site, warm soaks, don't irrigate
phlebitis prevention
change IV sites every 72hrs, large veins and needles, dilute meds, central lines
infection
redness, warmth, purulent drainage, fever, chills, malaise, elevated WBCs
infection action
discontinue and change site, culture cath tip, draw blood, treat with abx
infection prevention
asepsis, hand washing, change tubing/dressing every 96 hrs
fluid overload action
slow IV, notify provider, semi-fowler's position, O2 PRN
air embolism
pain in chest/shoulder/back, dyspnea, low BP, thready pulse, cyanosis, LOC
, air embolism prevention
tape all connectors, luer lock, air eliminating filters, EID, valsalva maneuver when
changing tubing/discontinuing central line
rectal temp contraindications
diarrhea, rectal surgery, neutropenia
tympanic membrane temp
pull pinna back, up and out
rectal temp
1 in for child, 1.5 in for adult
apical pulse uses
rapid rates, irregular rhythms, prior to cardiac drug admin
Lub
closure of mitral and tricuspid valves S1
Dub
closure of aortic and pulmonic valves S2
physiologic response to pain
increase BP/HR/RR
increased catabolic and metabolic state, O2 consumption, BG, FFA, blood lactate
and ketones
rebound tenderness
pain felt upon release of pressure over a part of the abdomen
patient self report of pain
onset, location, duration (constant or intermittent), quality (burning, stabbing),
intensity (0-10), aggravating and alleviating, impact on function, pain care goal,
med/tx concerns
SOLUTIONS VERIFIED A++
When does a HCP need to see pt after restraints are applied
within the hour
how often must restraints be ordered
every 24 hours, q 4 hours for violent pts
Med error preventions
tall man letters, no interruptions, medication-dispensing cabinets, bar-code
administration
therapeutic communication
empathy, positive regard, honesty, trust, self-awareness/self-reflection
non-therapeutic communication
rescue feelings, false reassurance, giving advice, changing the subject, being
moralistic, nonprofessional involvement
rescue feelings
nurse is essential to a patient's welfare
airborne precautions
private room, respirator for healthcare worker, mask for pt during transportation
TB, measles, varicella
droplet precautions
private room or with pt with same infection, mask
Flu, N. meningitidis, rubella, pertussis, respiratory viruses
contact precautions
,private room or with pt with same infection, gloves at all times, mask, gown and
protective barriers, pt designated equipment
C. diff, norovirus, skin infections
infiltration
swelling, coolness, discomfort, slowed infusion rate, absence of blood return
infiltration action
discontinue and change site, warm soaks
infiltration prevention
long bone sites, no joints, stabilization devices
phlebitis
pain, warmth, redness, hard/cord-like vein, slowed infusion rate
phlebitis action
discontinue and change site, warm soaks, don't irrigate
phlebitis prevention
change IV sites every 72hrs, large veins and needles, dilute meds, central lines
infection
redness, warmth, purulent drainage, fever, chills, malaise, elevated WBCs
infection action
discontinue and change site, culture cath tip, draw blood, treat with abx
infection prevention
asepsis, hand washing, change tubing/dressing every 96 hrs
fluid overload action
slow IV, notify provider, semi-fowler's position, O2 PRN
air embolism
pain in chest/shoulder/back, dyspnea, low BP, thready pulse, cyanosis, LOC
, air embolism prevention
tape all connectors, luer lock, air eliminating filters, EID, valsalva maneuver when
changing tubing/discontinuing central line
rectal temp contraindications
diarrhea, rectal surgery, neutropenia
tympanic membrane temp
pull pinna back, up and out
rectal temp
1 in for child, 1.5 in for adult
apical pulse uses
rapid rates, irregular rhythms, prior to cardiac drug admin
Lub
closure of mitral and tricuspid valves S1
Dub
closure of aortic and pulmonic valves S2
physiologic response to pain
increase BP/HR/RR
increased catabolic and metabolic state, O2 consumption, BG, FFA, blood lactate
and ketones
rebound tenderness
pain felt upon release of pressure over a part of the abdomen
patient self report of pain
onset, location, duration (constant or intermittent), quality (burning, stabbing),
intensity (0-10), aggravating and alleviating, impact on function, pain care goal,
med/tx concerns
