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2023 NUR280 Comprehensive Review 1 Exam with Answers (561 Solved Questions)

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    Comp #1 Spinal Cord Injury/Surgery/Procedure - Expected finding: o Decreased reflexes o Numbness/tingling o Inability to urinate (from low spinal cord injury) - Not Expected: o Decreased RR. o Headache (increased ICP) o CSF halo (yellow fluid) - Post-Op: o Airway, circulation o Monitor for ICP, Neuro checks, VS closely - Complication: o Autonomic Dysreflexia. S/S:  Numbness & tingling (expected)  Severe hypotension  Cessation of breathing (not expected). Heparin/Enoxaparin (LMWH) - Anticoagulant that can be give IV or SQ o Labs:  aPTT 30-40 (WNL), while on Heparin should be 1.5-2x the normal value [aPTT on heparin 60-90]  Risk for bleeding (aPTT >70)  Warfarin & Heparin until Warfarin reaches therapeutic INR levels [2-3]  H&H (rule of thumb, hematocrit [37-52] will be 3x the amount of hemoglobin [12-18]) example: HgB 8 = Hct 24, or HgB 10 = Hct 30  Platelets 1.5-2.5x the normal (want them high not low)  Normal Platelets Range: 150-400 - Antidote: o Protamine Sulfate - Complication o HIT (Heparin Induced Thrombocytopenia)  Due to being on med for longer than a week  Monitor for s/s of bleeding  Lab: low platelet count (<150) o Interventions:  Stop heparin  Direct thrombin inhibitor  Lepirudin and Argatroban  Treat active and prevent any new thrombosis - SQ Administration

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    o Don’t aspirate or expel the bubbles out of prefilled syringe Colostomy - Descending colostomy located on LLQ (involves the large intestines) - Stoma should be reddish pink, moist and shiny (Saunders pg. 688) o Call MD if stoma looks:  Pale/ Pink (low h&h levels)  Dark purple/ Black (compromised circulation)  Shrink in size/Dry  Small amount of mucous drain in the bag - Expect liquid stool in the immediate postop period but become mores more solid depending on location o Ascending Colon: liquid o Transverse Colon: loose to semi-formed o Descending Colon: close to normal - Empty pouch when 1/3 full - Monitor for dehydration & electrolyte imbalance - Avoid food that causes excess gas or odor o Give yogurt to help decrease smell - Avoid contact of skin with stool - Should start functioning 2-3 days after surgery Ventilator Associated Pneumonia (VAP) - Prevention o HOB elevated >30 degrees o ulcer prophylaxis (H2 blockers) o preventing aspiration o pulmonary hygiene (chest physiotherapy, postural drainage/percussion and turning/re-positioning Q2hours) o remove water from circuits, and suction PRN. o Vigilant, frequent oral care is key!  brushing teeth Q8hours, antimicrobial rinse and lip moisturizer Q2hours o Cough Sepsis: - Bloodstream infection/UTI, bacteria, fungi, vasodilation o considered a type of distributive shock, prevention is key. - Risk Factors: o cancer patients (highest risk) o malnutrition o immunocompromised o open wounds o DM, CKD, Hepatitis, HIV/AIDS - S/S:

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    o DIC (disseminated intravascular coagulation) o low O2 o tachypnea o decreased/absent urine output o change in LOC o hypoxia o death/dysfunction of organs - Interventions: o Resuscitation oxygen therapy o Blood replacement therapy o Drug therapy - Identify early manifestations of infection o treat with antibiotics o strict aseptic technique o IV fluids o inotropic medications. Septic Shock - Caused by an infection o Medical emergency can happen to anyone who is a patient in the hospital. - Capillaries dilate o Fluid exits the vascular system and enters interstitial spaces. - S/S: o Hypotension o Tachycardia o Increased RR o Increased temp o cold and clammy skin. o Changes in LOC (earliest sign) - Treatment: o Fluids  Normal Saline and Lactated Ringers (Bolus) o Broad Spectrum antibiotics o Vasopressors A-Fib - Multiple Rapid impulses - Quivering atria - Irregular heart rhythm - HR 130-150+ - Treatments: o Oxygen o Amiodarone & Digoxin  With rapid ventricular response (RVR) o Calcium Channel Blocker (CCB)

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     Diltiazem o Beta Blocker (BB)  Metoprolol o Monitor electrolytes  Low potassium (increases risk for dig toxicity) o Anticoagulatory therapy  Warfarin  Prevents blood from clotting due to the quivering of the heart o Synchronized Cardioversion  When symptomatic and non-responsive to med Hyperbilirubinemia pg. 382 - Occurs when there is too much bilirubin in the blood. o Bilirubin is made by the breakdown of RBCs.  Indicates issues with the liver - Lab Value o Bilirubin: < 1  increased with impaired liver function. - S/S: o Jaundice o Poor sucking reflex o Enlarged liver o Lethargy o Poor muscle tone o Elevated bilirubin - Treatment: o Phototherapy  Used to reduce serum bilirubin levels  Adv. Rx.  Dehydration  Sensory deprivation  Eye damage  Bronze baby syndrome o Grayish brown skin Vital Signs (Peds) - Newborn/Infant (0-12mo) o BP: 60-80/40-50 o HR: 110-170 [2month old] o RR: 30-60 o Temp: 97.5-99.5 (Rectal) o O2: >95% - Toddler (1-3yrs) o BP: 90-105/ 50-70 o HR: 80-140

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    o RR: 22-37 o Temp: 97.6 to 99.5 (Axillary) - School Age (3-12yrs) o HR 70-100 [should not increase when child is eating] o BP 120/60 - High School (12+ yrs) o HR: 60-100 o BP: 125/65 - Take into consideration if patient is: o Sleeping, an athlete, running/any activity, age, resting ABGs - pH: 7-35-7.45 - HCO3: 22-28 - CO2: 45-35 - Respiratory Acidosis o Symptoms:  Hypoventilation (retains CO2)  Drowsiness/ Confusion  Hypoxia/ low RR o Risk Factors:  Hypoventilation  Respiratory failure  brain trauma  atelectasis  CNS depressants  Cystic Fibrosis - Respiratory Alkalosis: o Risk Factors:  Hyperventilation (getting rid of all CO2)  Kussmaul’s  hysteria, fever, pain, CAN stimulants, acute distress. o Symptoms:  Tachypnea  Dizziness/ lightheadedness  perioral numbness  paresthesia. - Metabolic Acidosis: o Risk Factors:  Insufficient supply of insulin (DM or DKA)  excessive intake of aspirin  high fat diet, renal insufficiency  lactic acidosis  malnutrition

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     severe diarrhea. - Metabolic Alkalosis: o Risk Factors:  AKI, diuretics, excessive vomiting, NG tube suctioning, excessive sodium bicarb intake. o S/S:  Muscle cramps  paresthesia around mouth and on toes  hypotension  tetany (hypocalcemia)  decreased respiratory effort ERCP: (Endoscopic Retrograde Cholangiopancreatography) - Endoscopy procedure to help diagnose any disease or stones in the gallbladder, biliary system, pancreas, or liver. o The test looks "upstream" where digestive fluid coming from the liver, gallbladder, and pancreas to where it enters the intestines. - Pre-Procedure o NPO 6-8hrs prior o Ask for allergies to iodine contrast - Post-Procedure o Monitor VS o Assess return of gag reflex  Before giving anything to eat/drink (risk for aspiration) o Monitor s/s of perforation peritonitis  Pallor  Guarding of abdomen  Tachypnea  Tachycardia  Increased temp & chill  Restlessness  Abdominal distention/pain NG tube Placement of a tube from nose through the stomach to manage GI dysfunction and provide enteral nutrition. - Procedure: o Elevate HOB  High fowler’s position o Assess nares o Check placement before giving anything  pull back residual to check for pH levels (GI levels is 3.5) o Get X-Ray to confirm placement - Reasons to place one: o Upper GI bleed

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     coffee ground emesis o Lower GI bleed  dark red emesis o Decompress the belly  Bowel obstruction  Ileus  Colon surgery  Non-stop throwing up - At risk for aspiration o HOB elevated at least 35 degrees Tuberculosis Test - Risks Factors: o Low socioeconomic status o Homelessness o Long-term care facilities o Prisons - S/S: o Persistent cough o Malaise o Fever o Weight loss o lymphadenopathy - Airborne precautions o N95 mask o Negative-airflow room o Patient should wear surgical mask when transferring places - TX: “RIPE” (Must be taken for 6-12 months): o Isoniazid  monitor for hepatotoxicity and neurotoxicity  tingling of hands and feet  B12 is used to prevent neurotoxicity o Rifampin  will turn urine and other secretions orange  can interfere with birth control  can cause hepatotoxicity o Pyrazinamide  can cause hepatotoxicity o Ethambutol  can cause ocular toxicity  obtain baseline visual acuity tests o Streptomycin sulfate (for patients with drug resistant)  can cause ototoxicity - Inform patient that sputum samples will be needed every 2-4 weeks to monitor therapy effectiveness.

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    - Patients no longer infectious after 3 consecutive sputum cultures. - Mantoux (0.1mL) o 1cc syringe o Should not be done at the same time of measles o >15mm: positive for > 4yrs o >10mm: positive for <4yrs o >5mm: positive for immunocompromised Desmopressin: - Used for DI (Diabetes Insipidus), bleeds, and to decreases urine output. - Works by replacing vasopressin o Vasopressin: (Vasoconstrictor)  a hormone that is normally produced in the body to help balance the amount of water and salt. - Expected o Fluid retention o High B/P o low HR - Helps prevent dehydration: o Decreases thirst o Decreases urine output - Also used to control nighttime bedwetting in children. o Take at night Nitroglycerin: - Produces vasodilation, decreases preload and afterload and reduces myocardial oxygen consumption o Contra: patients with hypotension, increased ICP, or severe anemia o Caution: Severe renal or hepatic disease - Adv. Rx. o Headache o Orthostatic hypotension o Dizziness/weakness o Faintness o Flushing/Pallor o Dry mouth o Reflex tachycardia - If chest pain reduces after one nitro tab, give a 2nd dose - Max dose is 3 over 15 mins. Call 911 after 1 st dose - Routes: o Sublingual o IV o Oral (Tablet) o Patch

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    o Intradermal - Keep in dark container with childproof lid. Digoxin: - Cardiac glycoside - S/S: o Bradycardia o N/V/anorexia o Diplopia/blurred vision/yellow vision o Drowsiness/fatigue/weakness o photophobia - Given to increases cardiac contractility o Monitor BP & HR before giving dose  Assess apical pulse for 1 full minute before giving  Hold dose if HR <60.  Hold dose if potassium levels are too low. - Eat potassium rich foods o Fresh/Dried fruits  Bananas o green leafy veggies o sweet potatoes o avocados - Decrease calcium intake - Avoid licorice o can cause hypokalemia - Therapeutic levels: 0.5-2.0 - Digoxin Toxicity: o (Early)  N/V/D  Anorexia  Lack of appetite  Blurred vison o (Late)  Drowsiness  Dysrhythmias  Palpitations  Bradycardia  Hypotension  SOB. - Contraindications: o Ventricular dysrhythmias  A-Fib o 2nd and 3rd degree heart block  Heart Failure o Renal disease

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    o Hypothyroidism o Hypokalemia - Avoid OTC meds Blood Transfusion/Administration - Transfusion: o Large bore needle needed  18 or 20g (for maximum flow rate) o Cross and Match  need 2 nurses to verify  consent needed o Check bag for  Volume  Exp. Date o Prime tubing with NS prior to infusing  Y-tubing with filter needed o Administer within 30 minutes of receiving from blood bank  stay with patient for the first 15 minutes  s/s of any Adv. Rx. o Apprehension o Rash, hives, itching, swelling o feeling of impending doom o lower back/flank o chest pain o headache o fever/chills/diaphoresis o tachypnea o tachycardia/thready pulse o hypotension o Pallor/cyanosis o Tingling/numbness o Abdominal cramping o Stop infusion  Change tubing  Keep line open with NS  Call MD & blood bank  Gel lab samples  Stay with client o Never throw blood or tubing away from reaction  Send both blood & tubing back to blood bank o Never refrigerate o Monitor VS & lung sounds  Before Transfusion  15 min into transfusion  Q30 min during transfusion

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     1hr after completion o If NOT used within 30 mins send back to the lab o Transfuse over 2- 4 hours o Tubing set should be changed with each new unit of blood administered o Only compatible fluid with blood  Normal Saline (NS) o If history of reaction to blood products  Pre-medicate with acetaminophen or Benadryl 30 min before infusion  Administer immediately if ordered IV push o Begin transfusion slowly  After 15 min if handled okay, increase rate o Tx for Adv. Rx.  Benadryl  educate it might make them drowsy. - Universal Donor: o O- - Recipient: o AB+ - Pt with O+ blood receiving B+= stop immediately do not assess first Nursing Ethics - (Jehovah Witness – cannot get any blood products) - Accountability: o Accepting responsibility for one's own actions. o Nurses are accountable for their nursing care and other actions. o They must accept all of the professional and personal consequences that can occur as the result of their actions. - Autonomy: o Upheld when the nurse accepts the client as a unique person who has the innate right to have their own opinions, perspectives, values and beliefs. o Nurses encourage patients to make their own decision without any judgments or coercion from the nurse. o The patient has the right to reject or accept all treatments. - Beneficence: o Doing good and doing the right thing for the patient. - Fidelity: o Keeping one's promises. o The nurse must be faithful and true to their professional promises and responsibilities by providing high quality, safe care in a competent manner. - Justice: o Fairness o Nurses must be fair when they distribute care, for example, among the patients in the group of patients that they are taking care of.

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    o Care must be fairly, justly, and equitably distributed among a group of patients. - Non-Maleficence: o Doing no harm. o Harm can be intentional or unintentional. - Veracity: o Being completely truthful with patients o nurses must not withhold the whole truth from clients even when it may lead to patient distress. Nursing Legal Issues - Assault: o Verbally threatening someone.  Example: “I’m going to throat punch you” - Battery: o Physically acting upon that threat.  Example: Person physically throat punches another person. - Consent: o Must be explained and signed by doctor, not nurse. o Nurse can only witness. - Defamation: o “Slander” o False information against someone  Example: Saying a nurse lost their license when they did not, or saying a nurse harmed a patient when they did not. - Libel: o Defaming the character of another by means of the written word.  Example: writing in the patient ‘s chart or writing a note to another nurse and calling the patient a name or a rumor. Diuretics - Used for Fluid Volume Overload - Expected Outcome: o Weight loss o increased urine output o clear lungs o decreased edema - Loop Diuretics: (Furosemide/Lasix) o Used for pulmonary edema, HF, HTN, CKD, SIADH o Monitor V/S, sodium and potassium levels, I&Os, weights. o Adverse Effect:  Hypokalemia  Hyponatremia  Orthostatic Hypotension  Deafness (tinnitus/ ototoxicity)

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    o Instruct patient to increase potassium intake o Contraindicated with ear disorders. o Push slow if giving via IV push. o Elderly can develop confusion or lethargy o Seizure precautions due to hypocalcemia  Provide a quiet environment - Potassium Sparing Diuretics: (Spironolactone) o Do not give with ACE Inhibitors. o Monitor V/S, potassium levels, I&Os, weights. o Hold if SBP <110 or HR <60. o Adverse Effects:  Hyperkalemia  Orthostatic Hypotension - Thiazide Diuretics: (Hydrochlorothiazide). o Used for HTN. o Monitor V/S. o Hold if SBP <110 or HR <60. o Adverse Effect:  Orthostatic Hypotension  lithium toxicity if taking with Lithium. - Ace Inhibitors: o Used to decrease BP and HR.  Example: Lisinopril, Captopril, Enalapril. o Do not give with Potassium sparing diuretics (Spironolactone). o Used for pulmonary edema, HF, HTN. o Adverse Effects:  Angioedema  nagging cough  hyperkalemia  orthostatic hypotension o Hold if SBP <110 or HR <60. Hearing aides - Wash with soap and water only o Do not wash with rubbing alcohol/swabs. o Don’t submerge under water - Do not use hairspray if hearing aids are in ears. - When not using, take the batteries out and keep at bedside o Start at a lowest setting - The hearing aid will make an annoying whistling sound when in and out of the ear. Transfers - From bed to chair

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    o Always use gait belt. o Place wheelchair or chair on patient’s strong side when getting out of bed. o Have them pivot with good leg. o Assess them and their weak side first. Mental Health - Anxiety Disorder o How to manage a panic-level anxiety patient:  Do not ask them how they are feeling, take them away from the area to a less stimulating area, use short, direct, clear, expectations with a low and calm voice, and stay with them!  Never put them in seclusion or leave them alone.  Encourage breathing exercises.  Cognitive behavioral treatment usually prescribed.  Music therapy, calm environment. - Suicide o Males, Native Americans o Hx of:  suicide, schizophrenia, major depression  patients who are just starting antidepressants and have high energy  poor support system, personality disorder  family member/friend just died, and they are giving belongings away  substance abuse, loss of job (negative life changes). o Have patient sign a safety contract. - Bipolar in manic phase o Always assess for s/s of suicide thoughts or ideas. o Ask if they have a plan! o Then document and act accordingly. o Secure their belongings and remove silverware out of room (plastic is ok) and any other harmful items. o Initiate one-on-one supervision. o Crisis hotline: “I’m glad you called; I’d like to send help to you”. - Schizophrenia o Uses word salads. o Command Hallucinations:  Impossible to divert them.  Ask them what the voices are telling them.  Acknowledge the patient but let them know that you do not hear the voices (bring back to reality).  Ex: talking to someone not there “don’t make me do this”, ask what the voices are saying  More supervision needed, at risk for suicide/harm to others.  Allow them to open their food and drinks. o S/S:  Unkept hygiene

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     Catatonic posturing/excitement  Waxy flexibility/ mistrust  Compulsive rituals/over-compliant  Inappropriate/flat affect o Safety is priority - Obsessive Compulsive Disorder (OCD) o Rigidity and inflexible standards made of time  performing rituals that interfere with normal routines  Repetitive behaviors to prevent anxiety o Characterized by:  Obsessive  Violence/aggression  Sexual behavior  Indecisiveness  perfectionism  with a focus on orderliness and control  individual might not be able to accomplish a given task. o Identify for potential self-harm and suicide thoughts  Identify for triggers o TX:  SSRIs  anti-anxiety meds  cognitive behavioral therapy o Be empathetic o allow time to perform rituals but set limits on behaviors that may affect physical health. o Don’t interrupt unless it puts them in harm’s way o implement a schedule o establish written contract o ensure basic needs are met. - Major Depression o Affects feelings, thoughts and behaviors o May be mild, moderate or major o S/S of Major:  Hopelessness  Flat affect  No facial expression towards emotions  Guilt and worthless  Agitation and pace  Poor posture/ unkept appearance  Self-destructive thoughts  Lack of energy  Intense and pervasive  Decreased speech  Social withdrawal

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