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Exit Exam Study Guide
Fundamental Concepts in Nursing (NUR 352)
Arizona State University
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Exit Exam Study Guide
- Labs; evaluate nutritional status? – Serum Albumin
- Carbidopa – Levodopa , teaching to include? – Change positions slowly
- To prevent neural tube defects? – Folate
- Dementia , Nursing Action to reduce risk of injury? – Assist the client to the toilet frequently
- Febrile patient : to reduce fever applies cooling blanket , Adverse reaction finding? – Shivering
- Community health, family home visit , First Nursing Action? – Clarify the source of the referral
- Thyroidectomy , complication that indicates need for further assessment? – Laryngeal Stridor
- Diarrhea , intermittent enteral feedings , nursing action? – Administer feedings at slower rate
- 3-day old newborn, congenital heart defect, intervention to decrease cardiac demand? – Maintain the infant’s temperature at 37 C.
- Fine hair, exophthalmos, intolerance to heat , endocrine disorders associated with finding? – Hyperthyroidism
- Fetal Heart Tones , 12 weeks gestation, Nursing action? – Leopold’s Maneuver 12 w/ Retinoblastoma , Expected Finding? – White eye reflex 13 w/ Coarctation of the Aorta , Expected Finding? – Weak Femoral Pulses 14 care plan, Pt. w/ COPD and Severe Dyspnea ; Nursing Action to promote intake? – Limit Fluid Intake with meals 15, Methylergonovine Contraindication? – Hypertension 16 about Exercise , 28 weeks gestation , Indicates Understanding? – Drink more water after exercise. 17, parents of infant w/ positional Plagiocephaly , Indicates Understanding? – “I should keep the helmet on my baby for 23 hours a day.” 18 Self-Administration; Insulin Glargine, Type 1 DM , Indicates Understanding? – “I will not mix this insulin with other types of insulin.”
- Metoprolol ; monitor and Report to Provider? – Bradycardia
- Teaching parents of a newborn, Genetic Screening, Include in Teaching? – “This test should be performed after your baby is 24 hours old.”
- Misoprostol : for Labor Induction , Include in Teaching? – “You will have intermittent fetal monitoring while you receive the medication.” 22 of Care, Pt. w/ Preeclampsia and to receive Mag Sulfate, Nursing Action? – Measure the client’s urine output every hour.
- ER, Which Pt. to see First? – Hypertension and reports a headache 24 Newly Licensed Nurse , Indicates Need for Intervention? – Crushes a sublingual tablet to administer into a client’s feeding tube
25 Arthritis, 1-day postop Total Hip Arthroplasty. Med that delays wound healing? – Prednisone 26 unit, pt. muttering “The voices are telling me to jump.” Appropriate Response? – “I understand that the voices are frightening you, but I do not hear any voices.” 27. Change of shift. Client w/ Priority Finding? – 2 hours post cast placement with +2 pitting edema and pallor. 28 IV bag, medication leaks onto counter. Medication for biohazard spill protocol? – Doxorubicin Hydrochloride 29-age child, postop received Morphine IV bolus 10 min ago, Priority Finding? – Bradypnea 30: wants to obtain therapist’s notes, Appropriate Response? – “We can provide a copy of your records, but the therapist’s notes are not included.” 31. Electrical cord frayed, First Nursing Action? – Remove the device from the room 32. Migraines past 4 months , First Nursing Action? – Review the child’s electronic pain diary. 33 of clients, Greatest risk for developing Acute Post Streptococcal Glomerulonephritis? – 7- year-old boy who is recovering from Impetigo 34. Pulmonary Embolism, Manifestations? – Dyspnea 35. Change of shift, Client to Assess First? – A client who has a hip fracture and new onset of Tachypnea 36. Chest tube w/ water seal drainage. Tidaling noted , explanation? – The system is working properly. 37 staff Teaching, Risk Factors to becoming Violent? – Previous violent behavior. 38. Indwelling Urinary Catheter – Male, Nursing Action? – Lift the penis so that it is perpendicular to the client’s body. 39. Labs prior to surgery, Which to Report? – Sodium 160 40. 6-year-old; Sickle Cell Anemia management, Importance of which factor? – Adequate hydration 41. Coworker is impaired, Charge Nurse First Action? – Report to the charge nurse 42. 11 weeks gestation, Immunization to recommend? – Influenza 43. Intermittent Enteral Feedings, places client at Aspiration Risk? – History of GERD 44. Child, new onset of Seizures. Undergoing ECG. Teaching? – “Ensure the child’s hair is clean and without conditioner before preprocedure.” 45. 99 lb. patient. 1 protein/kg/day. How many g per day? (Round to nearest whole) – 68g/day. 46. Cardiac Catheterization, tasks to do prior to procedure? – Obtain a CBC with differential 47. 33 weeks gestation following amniocentesis , monitor for which complication? – Contractions 48. Change of Shift. Assess which Patient First? – A client who has leukemia and platelet level of 95,000/mm 49. Modified Radical Mastectomy, Closed Suction Drain. Nursing Action? – Position the client’s affected extremity below heart level. 50. Bipolar disorder, experiencing mania. Interventions to include? – Encourage the client to take frequent rest periods.
- Discharge Teaching. Parents of toddler w/ Cystic Fibrosis. Include in Teaching? – Perform chest percussion and postural drainage twice a day.”
- ER. Labs. First Nursing Action? – Elevate head of bed to 30 degrees.
- Delegating to AP. Which is in the scope of practice? – Performing postmortem care.
- Cefazolin. First Administration. Nursing Action? – Review the client’s allergy history.
- Depressive disorders. Phenelzine. Food to avoid? – Smoked Salmon
- Emergency Response. Client to recommend for early discharge? – A client who is 1-day postop following Vertebroplasty
- Schizophrenia. Auditory Hallucinations, Action to include in plan of care? – Ask the client directly what he is hearing.
- Acute care medical unit. Labs for Rheumatic Fever? – Elevated sedimentation rate and C- reactive protein.
- Seizure disorder. Phenytoin. Which instruction is appropriate? – “Increase your intake of Vitamin D while taking this medication.”
- Leaving because facility prohibits smoking. Nursing Action? – Inform the client of the risks involved if she leaves 87 – C. Diff. Nursing Action? – Change gloves after contact with infectious material. Wear a gown when providing care.
- Home safety. Indicates effective teaching? – “I have grab bars next to my tub.”
- Acute mental health facility. Which patient do you see first? – A client who is taking Clozapine to treat Schizophrenia and reports Sore Throat 90 91 - 4 days postpartum; Assessment Findings? - Fundus displaced to the right. Lochia serosa.
- Preparing to feed client with Dysphagia. Nursing Action? – Sit at or below the client’s eye level during feedings. 93 nurse manager updates protocol for use of belt restrains. Nursing Guidelines to include? – Document the client’s restraint every 4 hours. 94 assessment. Reports allergy to several foods. Which food indicates Latex Allergy? – Banana
- CVA patient. Left sided drooping. Refuses to see family members. Best Intervention to adapt to Body Image Change? – Establish short-term goals that will enable the client to look in the mirror.
- Crackles. Which location to Auscultate? – Left nipple line area. Bottom Right Box
- 6 -year-old, physical examination. Need for Intervention? – Eats at least one snack a day. 98 medical records. Identify which client requires follow up? – Client who received a Mantoux test 48 hours ago and has induration.
- 3 over 30 min. Available is 3 50 mL. mL/hr? – 100 mL/hr 100 teaching. 12 weeks gestation. Which screening at 16 weeks? – Maternal Alpha-fetoprotein
- Bacterial Meningitis. Nursing Action? – Implement seizure precautions.
102 health. Elder abuse screening. Identify which as an indication? – A client who reports being given sedative medications by family members. 103 for nurse during Orientation Phase with new client? – Establish the responsibilities of the nurse and client. 104 client do you refer to speech therapy? – Client who has dysphagia following a stroke. 105. Laissez-faire. Actions to expect from the leader? – Allows the group to discuss whatever they would like regarding medications. 106. Implanted venous access port, use what to assess? – A noncoring needle. 107 of newborn. Circumcision. Include in teaching? – “Apply petroleum jelly to the glans with diaper changes.” 108. Stimulant withdrawal. Expected Finding? – Decreased Appetite 109. PICC teaching. Indicates understanding? – “Informed consent is required prior to PICC placement.” 110. Prenatal teaching. Infection prevention. Indicates Understanding? – “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 111 112 in telemetry unit. Unconscious and monitor shows V. Tach. After confirming no palpable pulse, Nursing Action? – Defibrillate 113 week postpartum. Excessive vaginal bleeding and does not speak same language. Nursing Action to collect data? – Request a female interpreter through the facility. 114 Health. Client recently learned she is pregnant. Concerned about costs. Nursing Action? – Assist the adolescent in applying for Medicaid. 115. Client in labor. Received Epidural. Nursing Action? – Reposition the client side-to-side each hour. 116 teaching to parent of infant with cleft lip palate. Feeding techniques to include? – Burp the infant frequently during feedings. 117 118 ECG image indicates Potassium toxicity? – Prolonged PR interval, Decreased or disappearing P wave, Widening of QRS, Amplified R wave. 119 labor. Notes FHR baseline 100/min for past 15 min. Identify which condition as cause for fetal bradycardia? – Maternal Hypoglycemia 120. Nasogastric tube. Verify tube placement prior to each feeding. Nursing Action? – Test the pH of gastric contents. 121. End-stage Kidney Disease. Contraindication to donate kidney for transplant? – Hypertension. 122 mental health facility. Seclusion and in restraints. Nursing Action? – Plan to monitor the client every 30 min while restrained. (15?) 123. Major Depressive Disorder. First Nursing Action? – Implement seizure precautions for the client. 124
- Pt. taking Clozapine. Which finding is a contraindication? – WBC count 2,900/mm
- Biofeedback for migraines. Information to include? – “Biofeedback requires concentration to control physiological responses.” 151 who attempted suicide states. “I wish I was dead,” Appropriate response? – “You seem like you’re feeling hopeless.”
- Postop CABG – coronary artery bypass graft – Instructions to prevent complications? – Prepare for fluid volume replacement if the CV pressure steadily increases.
- Partner states she is overwhelmed caring for client. When suggesting respite care, which explanation should the nurse provide? – “Respite care allows for time away from caring for your husband.”
- Cystic fibrosis & requires postural drainage. Nursing Action? – Perform the procedure twice a day. 155 client. New prescription for Hydromorphone. Nursing Action? – Count the current number of unit doses available in medication cabinet.
- Acute Glomerulonephritis to choose breakfast. What do you recommend? – Smoked Salmon
- Adverse effects of Sertraline? – Excessive sweating 158 weeks gestation. History of Herpes Simplex Virus 2. Which question is important to ask? – “Do you have an active lesion?” 159 assessment data, which patient to refer to a dietician? – Client who has a nonhealing leg ulcer. 160 asks for information regarding organ donation, which response to make? – “Your desire to be an organ donor must be documented in writing.” 161 to include when discussing Borderline Personality Disorder? – “The client exhibits impulsive behavior.”
- Discharge teaching. Following total Gastrectomy. Medication to instruct? – Vitamin B 12 163 Appendectomy. Receiving Gentamicin. Assessment Finding of Adverse Effect? – Creatinine 2 mg/dL 164 wound would heal by Primary Intention? – Approximated surgical incision 165 hours postop Total Hip Arthroplasty. Action to include in plan of care? – Administer low-dose Heparin
- DVT. Action to take? – Withhold heparin IV infusion. (?) 167 to promote nighttime sleep. Instructions to include? – Eat a light snack before bedtime.
- UTI. Labs that indicate medication is effective? – WBC 9,200/mm
- Distributive justice by performing which task? – Ensuring that a client who is homeless receives preventative medical care. 170 incision patient who doesn’t speak the same language. Communicating with use of interpreter. Action to take? – Speak directly to the patient.
- Peripheral Catheter site, nurse notices redness and warmth around insertion site. Document this finding as which complication? – Phlebitis.
172 with Depressive disorder and new prescription for Amitriptyline; Indicates Understanding? – “I know it will be a couple of weeks before the medication helps me feel better.” 173. 14 weeks gestation about findings to report. Which finding to include? – Urinary frequency. 174. Expressive Aphasia and right sided Hemiparesis following CVA. Which action promotes communication among staff caring for this client? – Having interdisciplinary team meetings for the client on a regular basis. 175. Pneumonia labs. Which to report to? – Nephrologist. 176 labs of client undergoing Hip Arthroplasty in 2 days. Results to report? – Potassium 3 mEq/L 177 radiation and has Stomatitis. Indicates Understanding? – “I should limit my intake of dairy products to prevent nausea.” OR “Soft brittle toothbrush to clean teeth after meals.” 178 – 2 units of RBC, Client with Anemia. Actions to take? – Verify with another nurse that the unit of blood is compatible with client’s blood type. Assess the client’s lung sounds prior to the infusion. Infuse the blood over 4 hours. 179 positive for heroin during pregnancy. Neonatal Abstinence Syndrome. Actions to include in plan of care? – Minimize noise in the newborn’s environment. 180. Labs. Heart Failure. Potassium 5; withhold which medication? – Spironolactone.
Main Version Priority One
- X
- School-age child. 4 hours postop Appendicitis ; Include in plan of care? – Administer analgesics on a scheduled basis for the first 24 hours.
- Change of shift. Who to assess first? – Client who has a hip fracture and a new onset of tachypnea.
- Transdermal nicotine patch. Nursing Action? – Wear gloves to apply the patch to the client’s skin.
- Change of shift. Which client do you assess first? – A client who was just given orange juice for low blood glucose levels.
- Intermittent Enteral Tube feedings. Which places client at risk for aspiration? – History of GERD
- Cushing’s disease. Labs to expect? – Serum glucose level increased.
- Severe Preeclampsia. Receiving Magnesium Sulfate, has toxicity? – Administer Calcium Gluconate IV.
- Teaching about factors that increases client’s risk to become violent? Which risk factor to include?
- Previous violent behavior.
- Sterile dressing change. Action when setting up the sterile field? – Place the cap from the solution sterile side up on a clean surface.
- Older adult client. Teaching methods to promote nighttime sleep include? – Eat a light snack before bedtime.
36 weeks gestation. History of Hep C. client asks if she will be able to breastfeed. Which response is appropriate? – “You may breastfeed unless your nipples are cracked or bleeding.” 37 following transurethral resection of the prostate. Priority assessment finding after reviewing client information? – Level of consciousness. 38 who has Hyperthermia, Nursing Action? – Initiate seizure precaution. 39 for belt restraints. Include which guidelines? – Document client’s condition every 15 min. 40 thickness burns of the thorax and upper torso. After securing airway, nurse’s priority? – Initiate fluid resuscitation. 41 - Cancer patient being transferred to hospice care. Daughter tells nurse. “I’m not sure what to say to my mom if she asks me about dying.” Appropriate responses? – “Let’s talk about your mom’s cancer and how things will progress from here.” “Tell me how you are feeling about your mom dying.” “You sound like you have questions about your mom dying. Let’s talk.” 42 records of four clients. Identify which client finding for follow-up care? – Mantoux test 48 hours ago and has induration. 43 health. Home visit. Task to perform first? – Clarify the source of the referral. 44 who will undergo a procedure, states does not want provider to discuss the result with his partner. Appropriate response? – “You have the right to decide who receives the information.” 45 weight loss about losing 6. Original weight of 90 kg. What is the total % lost? – 7% 46 4 hours postpartum. Cannot urinate. Which intervention to implement? – Pour water from a squeeze bottle over the client’s perineal area. 47 teaching. Cancer patient. Prescribed 25 mcg/hr. transdermal patch. Include in teaching? – Avoid hot tub while wearing the patch. 48 a plan of care for patient who has paraplegia. Area of nonblanchable erythema over his ischium. Interventions to include? – Teach the client to shift his weight every 15 minutes while sitting. 49 who has anxiety disorder in Orientation Phase. Statements to make? – We should establish our roles in the initial session. 50 teaching. Phenelzine. Which is safe to eat? – Whole grain bread. 51 fire in client’s bathroom. Identify correct sequence. – Transport the client to another area. Activate the alarm. Close nearby windows and doors. Use fire extinguisher. 52 anxiety. Nurse should expect? – Heightened perceptual field. 53 – Type 1 DM. Client reports she is not feeling well. Finding that indicates hypoglycemia? – Tremors. Diaphoresis. Inability to concentrate. 54 caring for an infant who has coarctation of the aorta. Expected finding? – Weak femoral pulses 55 prevention to reduce abuse. Strategies to include? – Teach parenting skills to families at risk for abuse. 56 and nurse, group of clients. Which task is appropriate to delegate to AP? – Applying condom catheter to a client w/ Spinal Cord Injury.
57 Ulcer Disease. Indicates Understanding? – “I will avoid food and beverages that contain caffeine.” 58 reports Xerostomia following radiation therapy to the mandible. Nursing Action? – Provide humidification of room air 59 task to delegate to AP? – Perform chest compressions during cardiac resuscitation. 60 to lavender oil use? – History of asthma. 61 Depressive Disorder. Amitriptyline; Adverse effect to monitor for? – Urinary retention. 62 contraceptive contraindication? – Hypertension. 63. SATA – Consent. Information to provide by provider before signing. – Explain the procedure. Expected outcome of the procedure. Potential complications. Possible alternate treatments. 64. Include in teaching? – “You should not have this procedure if you are allergic to iodine.” (?) Should be for CT scan... 65 on labs. Recommend increasing dietary intake of? – Vitamin B12 (Pernicious anemia) 66-cell anemia experiencing vaso-constrictive crisis. Include in plan of care? – Initiate IV fluid replacement (blood too viscous) 67-month-old. Car-seat safety. Image that represents understanding? – B 68 dissatisfied w/ care from provider. Decides to leave against medical advice. After notifying the provider, nursing action? – Explain the risks of leaving. 69 transfusion for chronic anemia. Nursing Action? – Flush the blood administration tubing with 0% NS before transfusion. 70 postpartum home visit. Identify which as manifestation of risk for child abuse? – “I think the baby should be sleeping through the night by now.” 71 with gastroenteritis. Assessment to report to provider? – Sunken fontanels and dry mucous membranes. 72-week postpartum reports excessive vaginal bleeding. Does not speak the same language as the nurse. Nursing action to get information? – Request a female interpreter through the facility. 73 anemia. Lab values to evaluate effectiveness of treatment? – Vitamin B12 level. 74 task to assign to AP? – Postmortem care. 75, difficulty voiding. Indicates ability to void restored? – Two voids of 150 mL over past 2 hours. 76 glomerulonephritis. Expected finding? – Hematuria. 77 effect of sertraline; includes which effect? – Excessive sweating. 78 teaching parents about genetic screening. Include in teaching? – This test should be performed after your baby is 24 hours old. 79 fibrosis and requires postural drainage. Nursing action? – Perform the procedure twice a day. 80 issues in nursing. Examples to include in teaching? – Administration of potassium via IV bolus.
104 sensitivity. Which is appropriate? – Tape stockinet over monitoring device and cords. 105. Client is at risk for? – Dumping syndrome. 106 - Lung cancer, Sealed Radiation Implant. Nursing Action? – Wear a lead apron when providing care. Limit visitors to 30 min. Close the door to the client’s room. 107 newly licensed nurses. Grieving process. Include in teaching? – Client might feel guilt over some aspect of their loss. 108 patient. Concerned 3-year-old will feel left out. Appropriate response? – “Teach your son to change the baby’s diapers.” 109 health history. Identify which as a Cause of Constipation? – New prescription for an iron supplement. 110 newborn who has Patent Ductus Arteriosus. Expected findings? – Bounding pulse. 111, on Magnesium Sulfate. Include in plan of care? – Measure urine output every hour (for toxicity) 112-stage Kidney Disease, client’s adult child asks about donating a kidney. Which condition is a contraindication to donation? – Hypertension. 113; 5kg below ideal weight. Experiences SOB while eating. Nursing Action? – Request non-gas forming foods from dietary department. 114 STI should be reported to State Health Department? – Chlamydia 115; IV Insulin, Potassium level 5. Which intervention is appropriate? – Place a cardiac monitor on the client. 116 teaching. Postop repair of Detached Retina; Indicates Understanding? – “I can resume activities such as sewing.” 117 IV. Action to reduce risk of adverse effects? – Give the dose over 60 min. 118 Kidney Disease. Discharge Teaching. Include in Teaching? - Eat 1kg/day of protein. 119 tasks to AP; statement to make? – “Tell me the standing weight of the client in room 102 before breakfast.” 120 Failure, continuous IV infusion of low dose Dopamine. Highest Priority Finding? – Erythema 5cm (2inch) above IV site. 121 about use of Crutches using 3-point gait, Indicates Understanding? – Positioning both hands on the grips with the elbows slightly flexed. 122-month-old. Well child visit, which Developmental Task should the toddler be able to perform? – Kick a belt forward. 123 Manager meeting. Alternative therapies for Rheumatoid Arthritis, which statement to make? – “We can review some information to help you select a safe alternative practitioner.” 124 stroke, priority finding to report? – The client coughs after swallowing. 125-stage Liver Disease. Undergoing Paracentesis. Action to evaluate effectiveness of the procedure? - Compare the client’s current weight with preprocedural weight.
126 of care for newborn, mother tested positive for heroin. Newborn is experiencing Neonatal Abstinence Syndrome. Nursing Action in plan of care? – Minimize noise in the newborn’s environment. 127 planning, activity to engage in to assist in disaster preparedness? – Participate in community drills and mock events. 128 admission assessment. Narcissistic Personality Disorder. Expected Finding? – Preoccupied with aging. 129 Disorder, experiencing Mania. Intervention to include in plan of care? – Encourage the client to take frequent rest periods. 130 mL 0% NS w/ 20 mEq/L Potassium chloride to correct hypokalemia. Finding that contraindicates? – Severe renal impairment. 131 experiencing dyspnea, hears soft turbulent sound between heartbeats at the midclavicular line in the fifth intercostal space, which is an appropriate documentation? – Murmur at Mitral area. 132 allergy; teaching, indicates understanding? – I will remove bananas from my diet. 133 Type 2. Contraindication from using Metforming? – Renal insufficiency. 134 weeks following Amniocentesis; Monitor for which complication? – Contractions. 135; which client to assess first? – 8-year old client who is 12 hours postop following Tonsillectomy and is experiencing frequent swallowing. 136 exercises; teaching, indicates understanding? – I will determine which muscles to contract by stopping and starting my stream of urine. 137 teaching. Amniocentesis. Indicates understanding? – I should urinate before the test. 138; reports cocaine use 1 hr ago. Expected findings? – Elevated temperature. 139 sounds, Acute Pericarditis. Manifestation expected? – Scratchy, high pitched sound upon auscultation. 140 teaching, Irritable Bowel Syndrome. Recommendations to include? – Consume food high in bran fiber. 141 ulcers on the coccyx and abrasions around wrists. Action when observing elderly abuse? – Privately interview the client about her condition. 142. Right-sided weakness and facial drooping; Priority Action? – Maintain NPO for client. 143 1 DM, 10 weeks gestation. Managing diabetes during pregnancy, statement that indicates understanding? – “I will need to increase my insulin doses later in my pregnancy.” 144 tingling around the mouth and laxative use at least once daily. Assessment findings, action to perform first? – Test the client for Trousseau’s sign. 145, stoma site teaching, requires further teaching? – “I should change the stoma pouch every day.” 146 Sulfate; toxicity finding? – Hyporeflexia. 147 mg/kg/day divided 12 hours. 4; available is 125 mg/ 1 mL. How many mL to administer per dose? – 1 mL per dose.
176 in telemetry unit. Report to provider? – ST segment elevations. 177 to client, need for nurse to intervene with newly licensed nurse? – Uses the TPN tubing to administer next dose of antibiotics. (Do not use the same line as TPN). 178 licensed nurse, teaching about therapeutic techniques, mental health. Which group facilitating techniques to include in the teaching? – Use modeling to help the clients improve their interpersonal skills. 179 client’s respirations. Nursing Action? – Count respirations for 1 minute if the rhythm is irregular. 180 lab staff discussing client’s biopsy. Nursing Action? – Report the information to the charge nurse. 181 contraceptive. Contraindications? – Migraines with aura 182; which client to see first? – Preeclampsia and reports persistent headache. 183. Actions to include in plan of care? – Instruct the client to empty her bladder prior to procedure. 184 labor, FHR 100/min for the past 15 min. Identify which condition could be causing bradycardia? – Maternal hypoglycemia. 185 phase of Bipolar Disorder. Partner states, “I don’t know what to do. Everything has been happening so quickly.” Which response is therapeutic? – “Can you talk about what was happening with your partner at home?” 186 acid. Lab to monitor? – Liver Function Test. 187 teaching. Include in teaching? – “You should push the button before physical activity to allow maximum pain control.” 188 toddler for urine culture. Appropriate action? – Don sterile gloves prior to the procedure. 189, which to report? – Potassium 3 mEq/L 190 patient. States, “I’m hearing voices.” Nurse should respond with? – “What are the voices telling you?”
Lidia
Sequence of visiting home. Home health nursing. – 1 Get referral from hospital. 2? 3? 4 Charting.
Opioid withdrawal symptoms? – Somnolence, fever, tachycardia.
Withdrawal? – N/V, tachycardia, diaphoresis, tremors, grand mal seizures.
Diazepam antidote? – Flumazenil.
Elderly patient, can’t sleep. Nursing action? – Light snack before bed time.
Insomnia. What to report? – Wakes up to go urinate
3 rd day, location of fundus postpartum? – At umbilicus level.
Proper body mechanics? (picture) – Lift with legs, not with back.
Peritoneal dialysis; sign of infection? – Cloudy urine. 10 diet? – Boiled egg.
Colostomy 24 hours ago. Priority findings? – Stoma appears dark purple in color. 12 complains of being overwhelmed with care for husband? – Suggest respite care. 13 – Intracranial Pressure (ICP)? – Lasix (Should be Mannitol), Slightly elevate head, (one more option). 14 is unsure of scope of practice, how can she review? – Nurse Practice Act. 15 contraindications? – NSAIDs, Aspirin, Ibuprofen. 16 of dehydration in babies? – Sunken fontanels anteriorly. 17 - Left-sided Stroke. Expected Findings? – Slower organization and performance of tasks, Memory problems related to language, Fearful or anxious response to stroke, Responds well to nonverbal cues.
Indicates effectiveness? – Decreased edema (by decreasing BP) 19 bones. Expect which medication? – Hydrocodone. 20 to report? – 2 questions. – Chlamydia, Lyme Disease. 21 Lithium level is 0. What to do? – Continue medication.
John’s Wort and Citalopram. What to watch for? – Serotonin Syndrome. 23 ulcer from bed. Shows fat tissue, what stage is it? – Stage III Pressure Ulcer. 24 hears CAN talk about patient in elevator, Nursing Action? – Notify manager.
Post leg surgery. Finding to report? – Weak pulses.
receiving RBCs. Indicates therapy was effective? – Increased Hgb levels. 27, IV insertion? – In kid’s room (?)
asks if she can get antibiotic 2 hours early. Appropriate response? – Tell patient only 30 min early. 29 tunnel care? – Do not use affected hand for 4-6 weeks (?) 30, what do? – Notify authorities. 31 high in Calcium? – Kale. (other choices were raw carrot and egg.) 32; instructing about diet? – Eat less phosphorus.
What to report? – 170 HR 34 in labor. Nursing action? – FHR monitor. 35 test. Positive result is? – 5mm induration. 36 safety? – Take car seat to plane (?) 37 nitroglycerin. Medication safety rule? – Should be in a dark color container. 38, but family insist on CPR. What to do? – Continue with client’s wishes and contact the committee and talk with family. 39 abuse, what to report? – Explain what will happen after reporting abuse. 40 can’t urinate. Nursing Action? – Massage Fundus. 41 tube patient. What to report? – Continuous bubbling.
70 tube with water seal chamber. Notes tidaling in the water seal. What is the explanation? – System is working properly. 71; client experiencing stimulant withdrawal, expected finding? – Fatigue, depression, agitated, anxiety, craving, increased appetite. 72 about risks to become violent. Risk factors to become violent? – Previous violent behavior. 73. Assessing Major Depressive Disorder, Nursing Action? – Encourage client to verbalize feelings, assess hopelessness, assess for harming themselves. 74 class; infection prevention. Indicates understanding? – “I can visit my nephew who has chickenpox 5 days after the sores have crusted.” 75-stage Kidney Disease. Adult child asks about becoming a donor, which condition contraindicates the procedure? – Hypertension. 76 repeatedly refuses meals. AP states, “If you don’t eat, I’ll put restraints on your wrists and feed you.” Which of the following torts? – Assault. 77 labs prior to surgery. Finding to report? – Sodium 160 mEq/dL. 78 nurse teaching about Absence Seizures. Information to include? – “This type of seizure can be mistaken for daydreaming.” 79 Fibrosis. Requires postural drainage, nursing action? – Perform the procedure twice daily. 80 swallowing, occasional choking during meals. Refer to? – Speech-language pathologist. 81, assess for which complication? – Laryngeal Stridor. 82-year old with Sickle Cell Anemia. Managing the disease, emphasize the importance of which factors to prevent Sickle Cell Crisis? – Adequate hydration. 83 health nurse. Client with Amyotrophic Lateral Sclerosis (ALS) and recent weight loss. Priority admission data? – Swallowing ability. 84, circumcision instructions to include? – Apply petroleum jelly to the glans with diaper changes. 85 response following a disaster, multiple admissions, who to recommend for early discharge? – 1 day postop following a vertebroplasty. 86 health, client with Lyme disease. Nursing Action? – Ensure the state health department has been notified. 87 effects of Sertraline. Which to include? – Excessive sweating. 88 labor. FHR baseline 100/min for 15 min. Which is the cause of fetal bradycardia? – Maternal Hypoglycemia. 89 labor, what to report to provider? – Contractions lasting 80 seconds. FHR 170 90, experiencing Auditory Hallucinations. Action to include in plan of care? – Ask the client what he is hearing. 91 lab test results. Prior to Hip Arthroplasty in 2 days. Results to report? – Potassium 3 mEq/L
92 states she is overwhelmed by caring for him. Respite care explanations? – “Respite care allows for time away from caring for your husband.” 93 of shift. Who to assess first? – A client who has a hip fracture and a new onset of tachypnea 94. Malpractice in nursing. Example to include? – Administering potassium via IV bolus. 95 pulmonary embolism, expected manifestation? – Dyspnea. 96 regarding organ donation. Response to make? – “Your desire to become an organ donor must be documented in writing.” 97 teaching. Irritable bowel syndrome. Recommendations to include? – Eat food high in bran fiber. 98 Personality Disorder. Expected finding? – Preoccupied with aging. 99 health nurse. Client recently attempted suicide states, “I wish I was dead.” Which is an appropriate response? – “You seem like you’re feeling hopeless.” 100 wound irrigation and wound dressing change. Indicates break in surgical aseptic technique? - Balancing the bottle on the sterile basin while pouring the liquid. 101 who has hearing loss. Instructions to include in the plan of care? – Avoid using hand motions when speaking to the client. 102, nurse witnesses. MD obtains. 103? – Can’t give to liver dysfunction patients. 104 therapy? – Confusion, headache, and short-term memory loss and dizziness. 105? – Worry about no tears or no urine. 106 baby is 2 months old? – Hepatitis A vaccine. 107 for elderly? – TDAP, flu, shingles. 108 – 30-40 seconds. (increased in hemophilia patients.) 109 adults? – Increased systolic BP due to decreased elasticity of blood vessels. 110 style? – Seek and encourage staff to participate 111-faire? – Avoid change/limits amount of feedback given to staff. 112? – Relies on their own judgment and makes own decision. 113 understanding by? – Nodding. 114 urine specific gravity – 1.005-1. Decreased is renal failure or excessive fluid intake. Increased is dehydration, diarrhea, UTI. 115? – Continue next dose, if increased or thirst; toxicity (confusion = toxicity) 116 phase? – Promote self-assessment, establish termination phase. 117 phase? – Therapeutic, problem solving, past experiences. 118 toxicity? - +2 pitting edema (?) 119. Nursing action? – Raise HOB 10-20 degrees. Limit environmental noise. 120’s rule? – Subtract 3 months and add 7 days. 121? – Respiratory Acidosis.
Exit Exam Study Guide
Course: Fundamental Concepts in Nursing (NUR 352)
University: Arizona State University
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