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NUR 436 Final Exam Questions with Correct Answers
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NUR 436 Final Exam Questions with Correct Answers
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NUR 436 Final Exam Questions withCorrect Answers
Victoria Gonzales? - Answer-● 8 month old
● Admitted with respiratory distress syndrome and failure to thrive
● She has BPD and short bowel syndrome due to NEC
● Tracheostomy care
Isabella Capstone - Answer-● 6 month old
● Admitted for bronchiolitis and RSV
● She has a shunt
● On droplet and contact precautions for RSV
● IV bolus stopcock method
● BBG suctioning
Nasopharyngeal suctioning only if indicated
5 rights of delegation - Answer-○ Right task: one that can be delegated for a specific pt
○ Right circumstances: appropriate patient setting, available resources, and considering
relevant factors, including pt stability
○ Right person: right person is delegating the right task to the right person
○ Right directions and communication: clear, concise description of task
○ Right supervision and evaluation: appropriate monitoring, evaluation, intervention, and
feedback
Prioritization Skills acronym & description? - Answer-○ C: critical- potentially life
threatening
■ respiratory distress, chest pain
○ U: urgent: safety needs and pain control
■ low blood sugar, pain medication
○ R: routine responsibilities
■ assessments, vitals, scheduled meds
○ E: patient requests:
■ ice chips, warm blankets, etc
● Five F's of prioritizing - Answer-○ Fatal: failure to do could cause death or
injury( respiratory distress)
○ Fundamental: essential to professional definition of job (assessments)
○ Frequent: must be done many times (vitals)
○ Fixed: must be done within a certain time frame (meds)
Facility: aspects of the job set as standards (charting)
Coder Johnson dx - Answer-Chest pain r/o MI
,Med admin through tube feeds? - Answer-▪ Feedings should be stopped prior to med
administration
▪ tubing should be flushed with water (15-30mL) before and after med is administered
▪ Meds should only be dissolved in water
How much flush do you need when giving meds via a feeding tube in infants or
children? - Answer-the volume of water to flush is 1.5x the amount predetermined to
flush an unused feeding tube
What fluid do you give if a TPN solution is unavailable? - Answer-IV of D10 or 20% in
water is administered if the TPN solution is unavailable
Can you add insulin to a TPN formula? - Answer-yes
How to discontinue TPN and why? - Answer-● discontinuation should be done gradually
to avoid rebound hypoglycemia
Metabolic complications of TPN? - Answer-hyperglycemia
hypoglycemia
hyperkalemia
hypocalcemia
dehydration (related to hyperosmolar diuresis resulting from hyperglycemia)
fluid overload (weight gain greater than 1kg.day and edema)
What line can you give TPN through? - Answer-● can only be administered via a central
line
When is TPN needed? - Answer-● used when a clients GI tract is not functioning or
when a client cannot physically consume sufficient nutrients orally or enterally
● commonly used in clients who need intense nutritional support for an extended period
of time
Once blood bag is spiked, when does it expire? - Answer-● If the blood bag is spiked, it
expires after 4 hours at room temperature or after 24 hours in the refrigerator
When must the blood bag be used within? or what? - Answer-● All blood components
that are not used within 30 minutes must be
stored in a monitored refrigerator
What is the only thing that can be added or transfused with blood? - Answer-NS
What must be checked with another person for Pre-administration Protocol for blood -
Answer-■ Transfusion record number and pt identification number must
match
■ Blood type matches transfusion record and blood bag
, ■ Empty urine drainage collection or have pt void, if reaction occurs, a urine specimen
must be obtained and sent to lab
What must you assess before giving blood? - Answer-○ Obtain a baseline set of vital
signs before getting blood
○ Assess IV patency
What kind of tubing do you use for blood admin? - Answer-y tubing
How long do you have to reman with pt when giving blood? - Answer-15 min
How often do you monitor vitals when giving blood? - Answer-Monitor vital signs at 5,
15, and every 30 minutes until 1 hour after transfusion, then hourly from start of
transfusion, and at end of transfusion
What do you do after blood has infused? - Answer-○ After blood has infused, flush IV
line with 0.9% NS
Blood infusion time? - Answer-1 1⁄2-2 hours, max 4
Peds & adult rate for first 15 min - Answer-■ Peds pt: 1 mL/kg/hr for first 15 minutes
■ Adult pts: 2 mL/min for first 15 minutes
PRBC infusion time? - Answer-max 4 hours
Time frame for FFP? - Answer-○ use as soon as thawed, max 6 hours
What can you delegate when administering blood? - Answer-○ Baseline vitals, 5-minute
vitals, and 15-minute vitals cannot be delegated
○ Hourly vitals can be delegated if transfusion is going well
Benefits of transfusions - Answer-○ A blood transfusion can help correct a condition and
it will help return blood levels to normal
○ A red blood cell transfusion will increase the ability of the blood to carry oxygen to the
heart and other organ
○ A platelet, plasma, or factor concentrate transfusion will help blood clot more easily
and will lower the chances of abnormal bleeding
Common Transfusion Reactions - Answer-○ Fever
○ Chills
○ Hives/itching
○ SOB
What do you do if a pt is having blood transfusion reaction? - Answer-○ STOP
transfusion immediately
○ Remove blood tubing, connect NS tubing to IV site, begin NS infusion
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