NURS 239 Final Exam –updated Questions With Complete
Solutions
When giving Lovenox, what labs do you check? SATA
-platelets
-PTT
Patient on who is paralyzed and on a ventilator, what kind of
medication do you need to give?
sedation
After thoracic sx, dropping of O2 sat, what are you going to do?
SATA
-Turn every 2 hours
-splint when coughing
-suction as necessary
ARDS patient is placed on a mechanical ventilator, low pressure
alarm?
disconnection
Patient is receiving thrombolytic therapy for a PE, how are we
going to best assess their oxygenation status?
ABGs
Patient has a tracheostomy and a nonproductive cough, how are
we going to assess the effectiveness of suctioning?
-listen to lung sounds
-look at O2 sat
,Patient has a chest tube in, what are you going to NOT chart?
-platelet count
High pressure alarm on vent?
suction patient
Patient has a flail chest, what is a sign of this?
paradoxyl chest wall movements
Septic shock with DIC, what indicates the thrombi?
PE
signs of bleeding
altered LOC
patient has a high fever, low BP, high HR, fluid in the lungs,
what is the correct order to give medications in?
give fluids
cultures
administer antibiotic
give tylenol
MODS experiencing failure of the GI system, what assessment
finding?
absent bowel sounds
The most accurate assessment parameters for the nurse to use to
determine adequate tissue perfusion in the patient with MODS
are
a. blood pressure, pulse, and respirations.
,b. breath sounds, blood pressure, and body temperature.
c. pulse pressure, level of consciousness, and pupillary response.
d. level of consciousness, urine output, and skin color and
temperature.
LOC, urine output, skin color and temperature
C.Diff patient, helping them with ADLs, the nurse knows to?
-wash hands with soap and water
-stethescope in the room
-enteric precautions
What lab value will show fluid resuscitation is working in a
septic patient?
CVP
normal value is 2-6
Medication of choice for patient with esophageal varices?
Octreotide (Sandostatin) OR Vasopressin
Medications given to treat portal hypertension
Beta Blockers (-lol) to reduce portal hypertension
Isosorbide to decrease BP
Acute liver failure with ascites, RAAS system is stimulated by
what?
drop in pressure
Excessive bruising, nose bleeds
give FFP
, Patient with a crush injury, now renal failure, what is
happening?
intra renal
Pre renal is caused by all of the following
CHF
dehydration
low blood pressure
Hepatic encephalopathy late sign?
coma
Medication to treat acities
Spinorlacdone (furosemide)
SPA (salt poor albumin - if Na is low)
Patient just had a right sided stroke. What will this patient
present like?
- paralyzed left side: hemiplegia
- left-sided neglect
- spatial-perceptual deficits
- impulsive (safety problems)
- impaired judgement
Patient just had a left sided stroke. What will this patient present
like?
- paralyzed right side: hemiplegia
- aphasia; impaired speech/language
- impaired comprehension r/t math & language
Solutions
When giving Lovenox, what labs do you check? SATA
-platelets
-PTT
Patient on who is paralyzed and on a ventilator, what kind of
medication do you need to give?
sedation
After thoracic sx, dropping of O2 sat, what are you going to do?
SATA
-Turn every 2 hours
-splint when coughing
-suction as necessary
ARDS patient is placed on a mechanical ventilator, low pressure
alarm?
disconnection
Patient is receiving thrombolytic therapy for a PE, how are we
going to best assess their oxygenation status?
ABGs
Patient has a tracheostomy and a nonproductive cough, how are
we going to assess the effectiveness of suctioning?
-listen to lung sounds
-look at O2 sat
,Patient has a chest tube in, what are you going to NOT chart?
-platelet count
High pressure alarm on vent?
suction patient
Patient has a flail chest, what is a sign of this?
paradoxyl chest wall movements
Septic shock with DIC, what indicates the thrombi?
PE
signs of bleeding
altered LOC
patient has a high fever, low BP, high HR, fluid in the lungs,
what is the correct order to give medications in?
give fluids
cultures
administer antibiotic
give tylenol
MODS experiencing failure of the GI system, what assessment
finding?
absent bowel sounds
The most accurate assessment parameters for the nurse to use to
determine adequate tissue perfusion in the patient with MODS
are
a. blood pressure, pulse, and respirations.
,b. breath sounds, blood pressure, and body temperature.
c. pulse pressure, level of consciousness, and pupillary response.
d. level of consciousness, urine output, and skin color and
temperature.
LOC, urine output, skin color and temperature
C.Diff patient, helping them with ADLs, the nurse knows to?
-wash hands with soap and water
-stethescope in the room
-enteric precautions
What lab value will show fluid resuscitation is working in a
septic patient?
CVP
normal value is 2-6
Medication of choice for patient with esophageal varices?
Octreotide (Sandostatin) OR Vasopressin
Medications given to treat portal hypertension
Beta Blockers (-lol) to reduce portal hypertension
Isosorbide to decrease BP
Acute liver failure with ascites, RAAS system is stimulated by
what?
drop in pressure
Excessive bruising, nose bleeds
give FFP
, Patient with a crush injury, now renal failure, what is
happening?
intra renal
Pre renal is caused by all of the following
CHF
dehydration
low blood pressure
Hepatic encephalopathy late sign?
coma
Medication to treat acities
Spinorlacdone (furosemide)
SPA (salt poor albumin - if Na is low)
Patient just had a right sided stroke. What will this patient
present like?
- paralyzed left side: hemiplegia
- left-sided neglect
- spatial-perceptual deficits
- impulsive (safety problems)
- impaired judgement
Patient just had a left sided stroke. What will this patient present
like?
- paralyzed right side: hemiplegia
- aphasia; impaired speech/language
- impaired comprehension r/t math & language
