NUR 185 test 1 Hondros With complete
solution Newest
Nurse admits patient to med surg unit. Resp rate of 38. Patient using chest muscles to
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breathe, pulse ox of 87 on room air, pink frothy sputum. What intervention would you
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implement first? - O2 at 2 Liters/Min
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Caring for pt. who is intubated and receiving mechanical ventilation. What action by the
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nurse would decrease the patient's incidence of developing ventilator associated
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pneumonia? - Put head of bed at 30-45 degrees.
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The nurse is administering acetylcysteine (muca-mist) as nebulizer treatment to patient.
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Which should the nurse have available for adverse effect on the patient? - Suction
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equipment
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Patient coming in with SOB and resp. rate of 32. ABG results PH 7.3 (acid), Co2-50
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Bicarb-28, PO2-70
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Resp. Acidosis, what orders do you anticipate carrying out? - Apply O2 and give med-
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neb treatment.
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You have 4 patients in a long term care facility. Which would you check first? - COPD
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patient with resp rate of 30, O2 of 87 and on 3 Liters of O2 complaining of dyspnea.
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Caring for newly intubated patient getting mechanical ventilation. Pt.'s wife was not at
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hosp. when this occurred. Wife appears angry and states "What have you all done to
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him?" What would be your response as a nurse? - Explain to the patient why the patient
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had to be intubated, continue to update patient's wife on condition and plan of care, I'm
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sorry that you walked in on him like that, I understand this must have been very
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frightening.
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Patient has SOB, edema in legs and face and has the following labs: BUN-95 (high),
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Creatinine of 9.2, Potassium of 6.0 (high). What are you going to do - Give Kexolate,
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prepare the patient a central line for dialysis. Cardiac monitoring.
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Working with a UAP, what task can be delegated? - Instill non-prescription eye drops in
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patient's eyes.
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Nurse is caring for patient who had total knee replacement yesterday. Patient up in chair
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stating he feels good. Pain is 3/10. Resp. 16, pulse is 75, bp is 110/78. Pulse ox 88
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reading is after incentive spirometer. What actions would you take at this time? - Move
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pulse ox to another finger on the other hand and recheck.
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