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FUNDS FINAL EXAM
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FUNDS FINAL EXAM FUNDS FINAL EXAM FUNDS FINAL EXAM
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FUNDS FINAL EXAMWhat are the 3 things to do when an incorrect medication has been administered in terms of
urgency? - ANS 1. Reassess the patient for adverse reactions. 2. Notify the provider. 3. Document
A patient complains of nausea while on an oral medication. What should the nurse assess? - ANS
Assess the patient and look for the pill in the emesis. Risk for vomiting and expelling the medication.
Notes: Pt complains of nausea - oral medication. Assess the pt and look for the pill in the emesis.
What should the nurse do if the patient is complaining of pain, tingling, and itching at the IM site? -
ANS Assess the patient for other reactions. Notes: Pt complains of pain, tingling, and itching at the IM
site. Assess for adverse reactions.
What is a time out period? - ANS Confirm pt ID, surgical procedure, and surgical site. Notes: Before
surgical procedure confirmation of correct Patient ID, correct surgical procedure, and correct surgical
site.
If a patient is taking an anti-coagulant before surgery what should be done? Why? - ANS Postpone
surgery due to bleeding risk Notes: Patient should also be NPO
What should the nurse do if the patients vitals are HR:120bpm and BP: 80/50mmHg
postoperatively? - ANS Notify the provider for cause of concern. Notes: Post op - vitals are 120bpm,
bp is 80/50. Notify provider for cause of concern.
What complications should be looked for in a post-operative patient? - ANS Impaired wound healing.
Check the patient's clotting factor, nutrition, and other health concerns. Notes: Obese people would
be more at risk for post-op impaired wound healing. Monitor albumin levels.
What kind of patient would be more at risk for impaired wound healing? - ANS An obese patient,
with poor nutrition, who smokes.
Notes: Monitor labs, nutrition, and wound care.
What are the signs of infection? (SATA) - ANS Increased pain, incisional pain, serosanguineous
drainage, fever, and chills. Pus, redness, and swelling.
What findings are present with purulent drainage? - ANS Pus, thick yellow/green odorous drainage.
,Notes: thick, often has a musty or foul odor, and varies in color (such as dark yellow or green),
depending on the causative organism. Made up of white blood cells, liquefied dead tissue debris,
and both dead and live bacteria.
What findings are consistent with serous drainage? - ANS Generally watery, is composed primarily of
the clear, serous portion of the blood and serous membranes.
What findings are consistent with serosanguineous drainage? - ANS Pale to Pink drainage. Mixture of
serum and red blood cells. It is light pink to blood tinged.
What findings are consistent with sanguineous drainage? - ANS Consists of large numbers of red
blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding,
whereas darker drainage indicates older bleeding.
What should the nurse monitor for a post-op patient after surgery on the GI? - ANS Patient should
pass gas (indicative of return of peristalsis). Monitor patient for a bowel movement.
Notes: Auscultate the abdominal sounds. If patient is unable to pass gas have the patient walk down
the hallway.
Which HCP is responsible for receiving consent from the patient prior to surgery? - ANS The doctor
receives informed consent.
Notes: The nurse verifies that consent has been obtained.
What should the nurse do for a terminally ill cancer patient? - ANS Provide effective pain
management
Notes: Palliative care is a dignified death
What should be done to improve the sleep pattern of a patient with insomnia? - ANS Do not disturb
the pts sleep pattern, remove electronics, and turn off lights, shower/bath may help, retain bedtime
routine, sleep diary created by partner to monitor sleep patterns.
What is a risk associated with sleepwalking? - ANS Risk of falls and safety
What is the best way to prevent infections? - ANS Hand hygiene
, What are standard precautions? - ANS Hand hygiene and gloves
Notes: Wear clean nonsterile gloves when touching blood, body fluids, excretions or secretions,
contaminated items, mucous membranes, and nonintact skin. Change gloves between tasks on the
same patient as necessary and remove gloves promptly after use.
If the patient has a bug in the stool, what precautions should be taken by the nurse? - ANS Contact
precautions
Notes: Wear PPE whenever you enter the room for all interactions that may involve contact with the
patient and potentially contaminated areas in the patient's environment. Change gloves after having
contact with infective material. Remove PPE before leaving the patient environment, and wash
hands with an antimicrobial or waterless antiseptic agent. Limit movement of the patient out of the
room.
Avoid sharing patient-care equipment.
What are airborne precautions? - ANS patients who have infections that spread through the air such
as tuberculosis, varicella (chicken pox), and rubeola (measles).
Notes: Patient is sneezing. Place patient in a private room that has monitored negative air pressure
in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air
outside, or monitored filtration if air is recirculated. Keep door closed and patient in room. Wear a
respirator when entering room of patient with known or suspected tuberculosis. If patient has
known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be
worn unless the person entering room is immune to these diseases.
What are droplet precautions? - ANS Patients with an infection that is spread by large-particle
droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young
children.
Notes: Patient is coughing and sneezing. Wear PPE upon entry into the room for all interactions that
may involve contact with the patient and potentially contaminated areas in the patient's
environment.
Transport patients out of the room only when necessary and place a surgical mask on the patient if
possible.
Keep visitors 3 ft from the infected person.
Except for hand hygiene, what other method is used to prevent infection? - ANS Identifying which
patients are at high risk
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