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

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2023 NUR280 Comprehensive Review 1 Exam with Answers (561 Solved Questions) - Page 1 preview image

Comp #1Spinal Cord Injury/Surgery/Procedure-Expected finding:oDecreased reflexesoNumbness/tinglingoInability to urinate (from low spinal cord injury)-Not Expected:oDecreased RR.oHeadache (increased ICP)oCSF halo (yellow fluid)-Post-Op:oAirway, circulationoMonitor for ICP, Neuro checks, VS closely-Complication:oAutonomic Dysreflexia. S/S:Numbness & tingling (expected)Severe hypotensionCessation of breathing (not expected).Heparin/Enoxaparin (LMWH)-Anticoagulant that can be give IV or SQoLabs: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 ofhemoglobin [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:oProtamine Sulfate-ComplicationoHIT (Heparin Induced Thrombocytopenia)Due to being on med for longer than a weekMonitor for s/s of bleedingLab: low platelet count (<150)oInterventions:Stop heparinDirect thrombin inhibitorLepirudin and ArgatrobanTreat active and prevent any new thrombosis-SQ Administration

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oDon’t aspirate or expel the bubbles out of prefilled syringeColostomy-Descending colostomy located on LLQ (involves the large intestines)-Stoma should be reddish pink, moist and shiny (Saunders pg. 688)oCall 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 dependingon locationoAscending Colon: liquidoTransverse Colon: loose to semi-formedoDescending Colon: close to normal-Empty pouch when 1/3 full-Monitor for dehydration & electrolyte imbalance-Avoid food that causes excess gas or odoroGive yogurt to help decrease smell-Avoid contact of skin with stool-Should start functioning 2-3 days after surgeryVentilator Associated Pneumonia (VAP)-PreventionoHOB elevated >30 degreesoulcer prophylaxis (H2 blockers)opreventing aspirationopulmonary hygiene (chest physiotherapy, postural drainage/percussion andturning/re-positioning Q2hours)oremove water from circuits, and suction PRN.oVigilant, frequent oral care is key!brushing teeth Q8hours, antimicrobial rinse and lip moisturizer Q2hoursoCoughSepsis:-Bloodstream infection/UTI, bacteria, fungi, vasodilationoconsidered a type of distributive shock, prevention is key.-Risk Factors:ocancer patients (highest risk)omalnutritionoimmunocompromisedoopen woundsoDM, CKD, Hepatitis, HIV/AIDS-S/S:

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oDIC (disseminated intravascular coagulation)olow O2otachypneaodecreased/absent urine outputochange in LOCohypoxiaodeath/dysfunction of organs-Interventions:oResuscitation oxygen therapyoBlood replacement therapyoDrug therapy-Identify early manifestations of infectionotreat with antibioticsostrict aseptic techniqueoIV fluidsoinotropic medications.Septic Shock-Caused by an infectionoMedical emergency can happen to anyone who is a patient in the hospital.-Capillaries dilateoFluid exits the vascular system and enters interstitial spaces.-S/S:oHypotensionoTachycardiaoIncreased RRoIncreased tempocold and clammy skin.oChanges in LOC (earliest sign)-Treatment:oFluidsNormal Saline and Lactated Ringers (Bolus)oBroad Spectrum antibioticsoVasopressorsA-Fib-Multiple Rapid impulses-Quivering atria-Irregular heart rhythm-HR 130-150+-Treatments:oOxygenoAmiodarone & DigoxinWith rapid ventricular response (RVR)oCalcium Channel Blocker (CCB)

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DiltiazemoBeta Blocker (BB)MetoprololoMonitor electrolytesLow potassium (increases risk for dig toxicity)oAnticoagulatory therapyWarfarinPrevents blood from clotting due to the quivering of the heartoSynchronized CardioversionWhen symptomatic and non-responsive to medHyperbilirubinemia pg. 382-Occurs when there is too much bilirubin in the blood.oBilirubin is made by the breakdown of RBCs.Indicates issues with the liver-Lab ValueoBilirubin: < 1increased with impaired liver function.-S/S:oJaundiceoPoor sucking reflexoEnlarged liveroLethargyoPoor muscle toneoElevated bilirubin-Treatment:oPhototherapyUsed to reduce serum bilirubin levelsAdv. Rx.DehydrationSensory deprivationEye damageBronze baby syndromeoGrayish brown skinVital Signs (Peds)-Newborn/Infant (0-12mo)oBP: 60-80/40-50oHR: 110-170 [2month old]oRR: 30-60oTemp: 97.5-99.5 (Rectal)oO2: >95%-Toddler (1-3yrs)oBP: 90-105/ 50-70oHR: 80-140

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oRR: 22-37oTemp: 97.6 to 99.5 (Axillary)-School Age (3-12yrs)oHR 70-100 [should not increase when child is eating]oBP 120/60-High School (12+ yrs)oHR: 60-100oBP: 125/65-Take into consideration if patient is:oSleeping, an athlete, running/any activity, age, restingABGs-pH: 7-35-7.45-HCO3: 22-28-CO2: 45-35-Respiratory AcidosisoSymptoms:Hypoventilation (retains CO2)Drowsiness/ ConfusionHypoxia/ low RRoRisk Factors:HypoventilationRespiratory failurebrain traumaatelectasisCNS depressantsCystic Fibrosis-Respiratory Alkalosis:oRisk Factors:Hyperventilation (getting rid of all CO2)Kussmaul’shysteria, fever, pain, CAN stimulants, acute distress.oSymptoms:TachypneaDizziness/ lightheadednessperioral numbnessparesthesia.-Metabolic Acidosis:oRisk 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:oRisk Factors:AKI, diuretics, excessive vomiting, NG tube suctioning, excessive sodiumbicarb intake.oS/S:Muscle crampsparesthesia around mouth and on toeshypotensiontetany (hypocalcemia)decreased respiratory effortERCP: (Endoscopic Retrograde Cholangiopancreatography)-Endoscopy procedure to help diagnose any disease or stones in the gallbladder, biliarysystem, pancreas, or liver.oThe test looks "upstream" where digestive fluid coming from the liver,gallbladder, and pancreas to where it enters the intestines.-Pre-ProcedureoNPO 6-8hrs prioroAsk for allergies to iodine contrast-Post-ProcedureoMonitor VSoAssess return of gag reflexBefore giving anything to eat/drink (risk for aspiration)oMonitor s/s of perforation peritonitisPallorGuarding of abdomenTachypneaTachycardiaIncreased temp & chillRestlessnessAbdominal distention/painNG tubePlacement of a tube from nose through the stomach to manage GI dysfunction and provideenteral nutrition.-Procedure:oElevate HOBHigh fowler’s positionoAssess naresoCheck placement before giving anythingpull back residual to check for pH levels (GI levels is 3.5)oGet X-Ray to confirm placement-Reasons to place one:oUpper GI bleed

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coffee ground emesisoLower GI bleeddark red emesisoDecompress the bellyBowel obstructionIleusColon surgeryNon-stop throwing up-At risk for aspirationoHOB elevated at least 35 degreesTuberculosis Test-Risks Factors:oLow socioeconomic statusoHomelessnessoLong-term care facilitiesoPrisons-S/S:oPersistent coughoMalaiseoFeveroWeight lossolymphadenopathy-Airborne precautionsoN95 maskoNegative-airflow roomoPatient should wear surgical mask when transferring places-TX: “RIPE” (Must be taken for 6-12 months):oIsoniazidmonitor for hepatotoxicity and neurotoxicitytingling of hands and feetB12 is used to prevent neurotoxicityoRifampinwill turn urine and other secretions orangecan interfere with birth controlcan cause hepatotoxicityoPyrazinamidecan cause hepatotoxicityoEthambutolcan cause ocular toxicityobtain baseline visual acuity testsoStreptomycin sulfate (for patients with drug resistant)can cause ototoxicity-Inform patient that sputum samples will be needed every 2-4 weeks to monitor therapyeffectiveness.

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-Patients no longer infectious after 3 consecutive sputum cultures.-Mantoux (0.1mL)o1cc syringeoShould not be done at the same time of measleso>15mm: positive for > 4yrso>10mm: positive for <4yrso>5mm: positive for immunocompromisedDesmopressin:-Used for DI (Diabetes Insipidus), bleeds, and to decreases urine output.-Works by replacing vasopressinoVasopressin: (Vasoconstrictor)a hormone that is normally produced in the body to help balance theamount of water and salt.-ExpectedoFluid retentionoHigh B/Polow HR-Helps prevent dehydration:oDecreases thirstoDecreases urine output-Also used to control nighttime bedwetting in children.oTake at nightNitroglycerin:-Produces vasodilation, decreases preload and afterload and reduces myocardial oxygenconsumptionoContra: patients with hypotension, increased ICP, or severe anemiaoCaution: Severe renal or hepatic disease-Adv. Rx.oHeadacheoOrthostatic hypotensionoDizziness/weaknessoFaintnessoFlushing/PalloroDry mouthoReflex tachycardia-If chest pain reduces after one nitro tab, give a 2nd dose-Max dose is 3 over 15 mins. Call 911 after 1stdose-Routes:oSublingualoIVoOral (Tablet)oPatch

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oIntradermal-Keep in dark container with childproof lid.Digoxin:-Cardiac glycoside-S/S:oBradycardiaoN/V/anorexiaoDiplopia/blurred vision/yellow visionoDrowsiness/fatigue/weaknessophotophobia-Given to increases cardiac contractilityoMonitor 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 foodsoFresh/Dried fruitsBananasogreen leafy veggiesosweet potatoesoavocados-Decrease calcium intake-Avoid licoriceocan cause hypokalemia-Therapeutic levels: 0.5-2.0-Digoxin Toxicity:o(Early)N/V/DAnorexiaLack of appetiteBlurred visono(Late)DrowsinessDysrhythmiasPalpitationsBradycardiaHypotensionSOB.-Contraindications:oVentricular dysrhythmiasA-Fibo2nd and 3rd degree heart blockHeart FailureoRenal disease

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oHypothyroidismoHypokalemia-Avoid OTC medsBlood Transfusion/Administration-Transfusion:oLarge bore needle needed18 or 20g (for maximum flow rate)oCross and Matchneed 2 nurses to verifyconsent neededoCheck bag forVolumeExp. DateoPrime tubing with NS prior to infusingY-tubing with filter neededoAdminister within 30 minutes of receiving from blood bankstay with patient for the first 15 minutess/s of any Adv. Rx.oApprehensionoRash, hives, itching, swellingofeeling of impending doomolower back/flankochest painoheadacheofever/chills/diaphoresisotachypneaotachycardia/thready pulseohypotensionoPallor/cyanosisoTingling/numbnessoAbdominal crampingoStop infusionChange tubingKeep line open with NSCall MD & blood bankGel lab samplesStay with clientoNever throw blood or tubing away from reactionSend both blood & tubing back to blood bankoNever refrigerateoMonitor VS & lung soundsBefore Transfusion15 min into transfusionQ30 min during transfusion

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1hr after completionoIf NOT used within 30 mins send back to the laboTransfuse over 2- 4 hoursoTubing set should be changed with each new unit of blood administeredoOnly compatible fluid with bloodNormal Saline (NS)oIf history of reaction to blood productsPre-medicate with acetaminophen or Benadryl 30 min before infusionAdminister immediately if ordered IV pushoBegin transfusion slowlyAfter 15 min if handled okay, increase rateoTx for Adv. Rx.Benadryleducate it might make them drowsy.-Universal Donor:oO--Recipient:oAB+-Pt with O+ blood receiving B+= stop immediately do not assess firstNursing Ethics-(Jehovah Witness – cannot get any blood products)-Accountability:oAccepting responsibility for one's own actions.oNurses are accountable for their nursing care and other actions.oThey must accept all of the professional and personal consequences that can occuras the result of their actions.-Autonomy:oUpheld when the nurse accepts the client as a unique person who has the innateright to have their own opinions, perspectives, values and beliefs.oNurses encourage patients to make their own decision without any judgments orcoercion from the nurse.oThe patient has the right to reject or accept all treatments.-Beneficence:oDoing good and doing the right thing for the patient.-Fidelity:oKeeping one's promises.oThe nurse must be faithful and true to their professional promises andresponsibilities by providing high quality, safe care in a competent manner.-Justice:oFairnessoNurses must be fair when they distribute care, for example, among the patients inthe group of patients that they are taking care of.

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oCare must be fairly, justly, and equitably distributed among a group of patients.-Non-Maleficence:oDoing no harm.oHarm can be intentional or unintentional.-Veracity:oBeing completely truthful with patientsonurses must not withhold the whole truth from clients even when it may lead topatient distress.Nursing Legal Issues-Assault:oVerbally threatening someone.Example: “I’m going to throat punch you”-Battery:oPhysically acting upon that threat.Example: Person physically throat punches another person.-Consent:oMust be explained and signed by doctor, not nurse.oNurse can only witness.-Defamation:o“Slander”oFalse information against someoneExample: Saying a nurse lost their license when they did not, or saying anurse harmed a patient when they did not.-Libel:oDefaming the character of another by means of the written word.Example: writing in the patient ‘s chart or writing a note to another nurseand calling the patient a name or a rumor.Diuretics-Used for Fluid Volume Overload-Expected Outcome:oWeight lossoincreased urine outputoclear lungsodecreased edema-Loop Diuretics: (Furosemide/Lasix)oUsed for pulmonary edema, HF, HTN, CKD, SIADHoMonitor V/S, sodium and potassium levels, I&Os, weights.oAdverse Effect:HypokalemiaHyponatremiaOrthostatic HypotensionDeafness (tinnitus/ ototoxicity)

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oInstruct patient to increase potassium intakeoContraindicated with ear disorders.oPush slow if giving via IV push.oElderly can develop confusion or lethargyoSeizure precautions due to hypocalcemiaProvide a quiet environment-Potassium Sparing Diuretics: (Spironolactone)oDo not give with ACE Inhibitors.oMonitor V/S, potassium levels, I&Os, weights.oHold if SBP <110 or HR <60.oAdverse Effects:HyperkalemiaOrthostatic Hypotension-Thiazide Diuretics: (Hydrochlorothiazide).oUsed for HTN.oMonitor V/S.oHold if SBP <110 or HR <60.oAdverse Effect:Orthostatic Hypotensionlithium toxicity if taking with Lithium.-Ace Inhibitors:oUsed to decrease BP and HR.Example: Lisinopril, Captopril, Enalapril.oDo not give with Potassium sparing diuretics (Spironolactone).oUsed for pulmonary edema, HF, HTN.oAdverse Effects:Angioedemanagging coughhyperkalemiaorthostatic hypotensionoHold if SBP <110 or HR <60.Hearing aides-Wash with soap and water onlyoDo not wash with rubbing alcohol/swabs.oDon’t submerge under water-Do not use hairspray if hearing aids are in ears.-When not using, take the batteries out and keep at bedsideoStart 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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oAlways use gait belt.oPlace wheelchair or chair on patient’s strong side when getting out of bed.oHave them pivot with good leg.oAssess them and their weak side first.Mental Health-Anxiety DisorderoHow to manage a panic-level anxiety patient:Do not ask them how they are feeling, take them away from the area to aless stimulating area, use short, direct, clear, expectations with a low andcalm 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.-SuicideoMales, Native AmericansoHx 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).oHave patient sign a safety contract.-Bipolar in manic phaseoAlways assess for s/s of suicide thoughts or ideas.oAsk if they have a plan!oThen document and act accordingly.oSecure their belongings and remove silverware out of room (plastic is ok) and anyother harmful items.oInitiate one-on-one supervision.oCrisis hotline: “I’m glad you called; I’d like to send help to you”.-SchizophreniaoUses word salads.oCommand 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 thevoices (bring back to reality).Ex: talking to someone not there “don’t make me do this”, askwhat the voices are sayingMore supervision needed, at risk for suicide/harm to others.Allow them to open their food and drinks.oS/S:Unkept hygiene

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Catatonic posturing/excitementWaxy flexibility/ mistrustCompulsive rituals/over-compliantInappropriate/flat affectoSafety is priority-Obsessive Compulsive Disorder (OCD)oRigidity and inflexible standards made of timeperforming rituals that interfere with normal routinesRepetitive behaviors to prevent anxietyoCharacterized 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.oIdentify for potential self-harm and suicide thoughtsIdentify for triggersoTX:SSRIsanti-anxiety medscognitive behavioral therapyoBe empatheticoallow time to perform rituals but set limits on behaviors that may affect physicalhealth.oDon’t interrupt unless it puts them in harm’s wayoimplement a scheduleoestablish written contractoensure basic needs are met.-Major DepressionoAffects feelings, thoughts and behaviorsoMay be mild, moderate or majoroS/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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