NUR2090 FINAL Questions with 100%
Correct Answers
When does a HCP need to see pt after restraints are applied Correct Answer:
within the hour
how often must restraints be ordered Correct Answer: every 24 hours, q 4 hours
for violent pts
Med error preventions Correct Answer: tall man letters, no interruptions,
medication-dispensing cabinets, bar-code administration
therapeutic communication Correct Answer: empathy, positive regard, honesty,
trust, self-awareness/self-reflection
non-therapeutic communication Correct Answer: rescue feelings, false
reassurance, giving advice, changing the subject, being moralistic,
nonprofessional involvement
rescue feelings Correct Answer: nurse is essential to a patient's welfare
airborne precautions Correct Answer: private room, respirator for healthcare
worker, mask for pt during transportation
TB, measles, varicella
droplet precautions Correct Answer: private room or with pt with same infection,
mask
Flu, N. meningitidis, rubella, pertussis, respiratory viruses
,contact precautions Correct Answer: 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 Correct Answer: swelling, coolness, discomfort, slowed infusion rate,
absence of blood return
infiltration action Correct Answer: discontinue and change site, warm soaks
infiltration prevention Correct Answer: long bone sites, no joints, stabilization
devices
phlebitis Correct Answer: pain, warmth, redness, hard/cord-like vein, slowed
infusion rate
phlebitis action Correct Answer: discontinue and change site, warm soaks, don't
irrigate
phlebitis prevention Correct Answer: change IV sites every 72hrs, large veins and
needles, dilute meds, central lines
infection Correct Answer: redness, warmth, purulent drainage, fever, chills,
malaise, elevated WBCs
infection action Correct Answer: discontinue and change site, culture cath tip,
draw blood, treat with abx
infection prevention Correct Answer: asepsis, hand washing, change
tubing/dressing every 96 hrs
fluid overload action Correct Answer: slow IV, notify provider, semi-fowler's
position, O2 PRN
, air embolism Correct Answer: pain in chest/shoulder/back, dyspnea, low BP,
thready pulse, cyanosis, LOC
air embolism prevention Correct Answer: tape all connectors, luer lock, air
eliminating filters, EID, valsalva maneuver when changing tubing/discontinuing
central line
rectal temp contraindications Correct Answer: diarrhea, rectal surgery,
neutropenia
tympanic membrane temp Correct Answer: pull pinna back, up and out
rectal temp Correct Answer: 1 in for child, 1.5 in for adult
apical pulse uses Correct Answer: rapid rates, irregular rhythms, prior to cardiac
drug admin
Lub Correct Answer: closure of mitral and tricuspid valves S1
Dub Correct Answer: closure of aortic and pulmonic valves S2
physiologic response to pain Correct Answer: increase BP/HR/RR
increased catabolic and metabolic state, O2 consumption, BG, FFA, blood
lactate and ketones
rebound tenderness Correct Answer: pain felt upon release of pressure over a
part of the abdomen
patient self report of pain Correct Answer: onset, location, duration (constant or
intermittent), quality (burning, stabbing), intensity (0-10), aggravating and
alleviating, impact on function, pain care goal, med/tx concerns
Glasgow coma scale 13-15 Correct Answer: mild brain injury
Correct Answers
When does a HCP need to see pt after restraints are applied Correct Answer:
within the hour
how often must restraints be ordered Correct Answer: every 24 hours, q 4 hours
for violent pts
Med error preventions Correct Answer: tall man letters, no interruptions,
medication-dispensing cabinets, bar-code administration
therapeutic communication Correct Answer: empathy, positive regard, honesty,
trust, self-awareness/self-reflection
non-therapeutic communication Correct Answer: rescue feelings, false
reassurance, giving advice, changing the subject, being moralistic,
nonprofessional involvement
rescue feelings Correct Answer: nurse is essential to a patient's welfare
airborne precautions Correct Answer: private room, respirator for healthcare
worker, mask for pt during transportation
TB, measles, varicella
droplet precautions Correct Answer: private room or with pt with same infection,
mask
Flu, N. meningitidis, rubella, pertussis, respiratory viruses
,contact precautions Correct Answer: 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 Correct Answer: swelling, coolness, discomfort, slowed infusion rate,
absence of blood return
infiltration action Correct Answer: discontinue and change site, warm soaks
infiltration prevention Correct Answer: long bone sites, no joints, stabilization
devices
phlebitis Correct Answer: pain, warmth, redness, hard/cord-like vein, slowed
infusion rate
phlebitis action Correct Answer: discontinue and change site, warm soaks, don't
irrigate
phlebitis prevention Correct Answer: change IV sites every 72hrs, large veins and
needles, dilute meds, central lines
infection Correct Answer: redness, warmth, purulent drainage, fever, chills,
malaise, elevated WBCs
infection action Correct Answer: discontinue and change site, culture cath tip,
draw blood, treat with abx
infection prevention Correct Answer: asepsis, hand washing, change
tubing/dressing every 96 hrs
fluid overload action Correct Answer: slow IV, notify provider, semi-fowler's
position, O2 PRN
, air embolism Correct Answer: pain in chest/shoulder/back, dyspnea, low BP,
thready pulse, cyanosis, LOC
air embolism prevention Correct Answer: tape all connectors, luer lock, air
eliminating filters, EID, valsalva maneuver when changing tubing/discontinuing
central line
rectal temp contraindications Correct Answer: diarrhea, rectal surgery,
neutropenia
tympanic membrane temp Correct Answer: pull pinna back, up and out
rectal temp Correct Answer: 1 in for child, 1.5 in for adult
apical pulse uses Correct Answer: rapid rates, irregular rhythms, prior to cardiac
drug admin
Lub Correct Answer: closure of mitral and tricuspid valves S1
Dub Correct Answer: closure of aortic and pulmonic valves S2
physiologic response to pain Correct Answer: increase BP/HR/RR
increased catabolic and metabolic state, O2 consumption, BG, FFA, blood
lactate and ketones
rebound tenderness Correct Answer: pain felt upon release of pressure over a
part of the abdomen
patient self report of pain Correct Answer: onset, location, duration (constant or
intermittent), quality (burning, stabbing), intensity (0-10), aggravating and
alleviating, impact on function, pain care goal, med/tx concerns
Glasgow coma scale 13-15 Correct Answer: mild brain injury
