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NURSING NUR 2811C|VERSION3SUMMARY. 2020/2021
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Exam of 35 pages for the course NURSING NUR 2811C at Chamberlain College Of Nursing (NURSING NUR 2811C)
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VERSION 3 SCREEN SHOTS:1. SATA. Older male in ER has become increasingly confused in 3 days; nursing action?
- Determine oxygen saturation rate and breath sounds.
- Evaluate polypharmacy for possible drug interactions.
- Obtain urine and sensitivity for possible UTI.
2. Pt. with bipolar disorder reports not taking his Depakote for 6 mo; nurse assessment?
- Affect
3. Female pt. with pyelonephritis is concerned about dialysis; nurse best initial response?
- Explain the relationship between chronic kidney infection, renal failure, and dialysis.
4. Sickle cell c/o pain in fingers; underlying pathophysiology for pain in sickle cell crisis?
- Sickled red blood cells do not flow through small blood vessels leading to vasocclusion
and ischemia.
5. Pt. at clinical reports new onset of pyrosis and dyspepsia; action has highest priority?
- Instruct the client about the side effects of reflux disease.
6. Pt. bathing with inelastic skin turgor, large pendulous breasts, and a soft, flaccid abdomen.
- Teach the client to dry the skin well between skin folds.
7. Which symptom is characteristic of ureteral colic in the client diagnosed with renal calculi?
- Chills, fever, and dysuria.
8. Suspected GuillianBarre syndrome; which comment is significant to diagnosis?
- “About two weeks ago, I missed a day at work because I had a bad cold.
9. Pt. with burns to posterior neck; which intervention to prevent contractures at injury site?
- Actively turn head from side to side 90 degrees hourly.
10. Pt. having anxiety reaction when crossing over a bay bridge; action to implement?
- Teach client to listen to music or audio books while driving.
11. Assessing normal development of 9monthold; information to obtain?
- Can the child sit alone?
12. Parkinson’s meds; symptom management requires a balance among neurotransmitters?
- Acetylcholine and dopamine.
13. Pt. with SARS returned from China in isolation; which intervention in plan of care?
- Require use of gown, gloves, and N-95 mask.
14. DKA pt. on sliding scale regular insulin; intervention important to implement?
- Confer with the healthcare provider about a continuous IV insulin infusion
,15. Teacher thinks she is pregnant (neg test at night) but is on tetracycline for acne; instructions?
- Use first voiding of the day for accurate results of pregnancy test.
16. Child with rheumatoid arthritis has a viral infection and fever/ taking aspirin for arthritis.
- Stop taking aspirin and give different NSAID.
17. Pt. admitted with possible head injury and spinal cord injury; priority assessment?
- Respiratory status
18. Caring for pt. with acute MI; observation warrants immediate intervention?
- The telemetry displays ventricular bigenminy.
19. 2 day posttotal laryngectomy transferred to private room is anxious; intervention?
- Answer the client’s call signal in person quickly after he calls.
20. Child with HF receiving Lasix with potassium of 3.0 mEq/L; important assessment?
- Cardiac rhythm and heart rate.
21. Child coming to ER with hx of flulike symptoms for past week; equipment to assemble?
- Mechanical Ventilator.
22. What script anticipate for pt. with increased ICP secondary to head injury?
- Mannitol (Osmitrol).
23. Pt. is cigarette smoker and alcohol drinker is post-cholecystectomy but tremulous, agitated,
febrile, and disoriented; this is likely the finding of what?
- Impending delirium tremors.
24. Pt. paranoia and homicidal ideation in ER saying daughter lives in TV; thought disorder?
- Easily changes the subject.
25. Infant on Captopril for HF; which finding indicates med effectiveness?
- Blood pressure decreased from 125/85 on admission to 106/60 today.
26. Pt. fell at home and is on labetalol and ranitidine; intervention to include in plan of care?
- Frequent monitoring of blood pressure.
27. Pt. with mitral stenosis at 28weeks gestation; what investigate first?
- Persistent cough.
28. Home care of child with cystic fibrosis; parental action shows understanding?
- Gives pancreatic enzymes before every meal and snack.
29. Child admitted with possible nephrotic syndrome; parent statement goes with diagnosis?
- “I couldn’t get my son’s socks and shoes in this morning.”
,30. Pt. scheduled for laminectomy with back pain r/t intervertebral disk; preop teaching about
numbness and tingling in lower extremities occurs due to?
- Manipulation of nerves and muscles during surgery.
1) A nurse is planning care for a child who has scabies and he keeps itching…
ANS: Keep nails trimmed short and have him wear mittens
2) An acute care hospital has a disaster something about an outage and a generator. The UAP
asks the charge nurse what she can do to help…
ANS: Tell clients to stay in their rooms
3) Discharge teaching to a patient with heart failure what parameter is most important for weight
monitoring…
ANS: Weigh themselves at the same time everyday
4) Patient with metabolic syndrome is going to start exercising what is most important to tell
him…
ANS: Monitor BP as exercise increases
6) Patient c/o pain distal to insertion site, what action should the nurse implement?
ANS: Remove
7) A seriously ill patient that has a DNR is transferred to a medical facility in another state that
does not honor that what should the nurse implement?
ANS: Honor clients wishes
8) Question regarding taking a sample for sputum out of a water chamber from a patient with a
chest tube insertion for a person on a trach, where do you take the sample from?
ANS: Rubberized port at bottom of the catheter chamber
9) A patient is in the acute phase of burn to prevent auto contamination when changing dressings
how should you do it?
ANS: Change each dressing separately
10) The nurse enters a client’s room with his morning meds. Patient states he will take them
later. What action should the nurse take?
ANS: make a deal him on a time to return and give the meds
11) A client has returned from China and has SARS. What will you do before coming into
contact with him?
ANS: Gown, gloves, n95 mask
, 12) A client admitted with chest tightness respiratory acidosis an increase in which lab would
show this?
ANS: PaCO2
13) Male client bladder always feels full
14) Question on palpate lymph nodes on a child which is of concern?
ANS: large, warm, non-tender
15) A Patient who is diabetic has DKA and is receiving insulin using a sliding scale, his blood
sugar has been 520-540. What action should the nurse take?
ANS: call physician and to get order for IV insulin
16) An adult has 110 BPM what intervention should the nurse implement first?
17) A nurse makes a home visit for parents of a child with cystic fibrosis, how would the nurse
know that they are following treatments at home?
ANS: give pancreatic enzymes with each snack
18) Peptic ulcer disease
19) A nurse observes a mother in a hallway punishing her 3 year old child for wetting his pants,
what action should the nurse take?
ANS: provide toilet training pants and calming the mother
20) Laminectomy for a herniated intercerbral disc, when conducting preoperative teaching what
should the nurse implement?
21) When conducting an assessment on a 6 month old infant...
ANS: Keep child on your lap
22) Patient comes in vomiting…
ANS: Maintain NPO status
23) A mother who is breastfeeding 2 days post-op has inverted nipples…
ANS: use a breast shield
24) Smoking 2 packs a day has COPD??
25) A male client has anxiety when driving over the bay bridge which would you suggest to help
address this fear?
ANS: Listen to music
26) Using the parkland formula for a patient with burns 4ml x Patients weight in kg which is
76kg x whatever % of burns, which is 40%. SO it is 4ml x 76kg x 40% =
ANS: 12,160
27) Question about MONO (kissing disease)
ANS: Ellen BARRE (something like that I don’t remember how to spell it!)
28) A patient with bilateral hearing aids it is ringing…
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