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NUR 2900 Exam #1 Revised questions with Correct answers
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NUR 2900 Exam #1 Revised questions with Correctanswers
Guidelines of prioritizing correct answer✔✔ - Systemic manifestation
before local manifestations
- Acute manifestations before chronic manifestations
- What must be addressed now vs. later
- Unexpected vs. expected
Three Tier System of Prioritizing correct answer✔✔ 1. ABCC I/I:
Airway, Breathing, Cardiac, Circulation, prevention of Injury/Infection
2. Patients with specific focus on pain/mobility/nutrition/etc.
3. Self-esteem issues including health education
How often should temperature be taken post-op? correct answer✔✔
Every 4 hours for the first 24 hours
How often should vitals be taken post-op? correct answer✔✔
HR/BP/RR - every 15 minutes for the 1st hour and every 30 mins for the
next 2 hours
Temp - Every 4 hours for the first 24 hours
How long should you wait for a post-op patient's first void? correct
answer✔✔ Patient is expected to void within 8 hours after surgery
,What should be done with a post-op patient's first void? correct
answer✔✔ - Patient should pee into a hat so nurse can measure the
amount of urine for the purpose of knowing the bladder is emptying (>
30 mL/hour = 240 mL after 8 hrs)
- Used to measure amount, appearance, and consistency
Nursing Interventions to Promote Cardiac Output correct answer✔✔ -
Early ambulation
- Leg exercises and frequent position changes are initiated to stimulate
circulation (use of anti-embolism stockings and early ambulation)
+ Patients should avoid positions that compromise venous return
(raising the bed's knee gatch, placing a pillow under knees, sitting for
long periods and dangling the legs with pressure at the back of the
knees)
- Assessing patency of IV lines and ensuring correct fluids are given at
prescribed rate
- Intake and output 🡪 including emesis and output from wound drainage
systems are recorded separately and totaled to determine fluid balance
- Electrolyte levels and hemoglobin and hematocrit levels are monitored
Benefits of Early Ambulation correct answer✔✔ - Increases metabolism
and pulmonary aeration
- Promoting normal bowel function and voiding
- Prevention of DVT (circulatory problems), hypostatic pneumonia,
atelectasis, and GI discomfort
- Will assist with return of GI function
- Improve circulation
,- Prevent venous stasis
- Helps prevent complications
- Exercise of extremities (extension and flexion of knee and hip joints)
- Proper body mechanics
Who are at risk for wound dehiscence? correct answer✔✔ - Obese
patients
- Pts who get abdominal surgery
- Diabetes bc of problems healing
- Pts getting their sutures removed
What happens when a pt is experiencing wound dehiscence? correct
answer✔✔ - Position the patient is a low fowlers position (don't want to
be sitting up or lying flat) and instruct to lie quietly
- Sterile saline and abdominal pad goes over wound
- Contact physician and/or surgeon
What is the assessment priority for a PICC? correct answer✔✔ Verify
placement with an x-ray
Patient teaching for PICC correct answer✔✔ - Keeping PICC covered
- Ensure dressing patency, caps are secured, and clamps are closed
- How to take care of dressings (clean hands, sterility, changing caps)
- How to take care of the PICC (saline flushes, assessing site)
, Complications of a PICC correct answer✔✔ - Infection (local at site and
systemic inside the body)
- Vein with PICC is sore and irritated
- Bleeding
- Break or leak in PICC
- Leakage of drugs under the skin
- Tip of PICCC moves out of place
When should you seek medical attention for a PICC? correct answer✔✔
- Signs of infection (systemic or local)
- Sudden shortness of breath or sudden onset of chest pain (could be a
sign that a blood clot has traveled to the lungs)
- Not able to flush the PICC or difficulty in flushing
- Not able to draw blood from the PICC
- PICC breaks, falls out, or comes out part of the way
- Bleeding from the PICC line
- If caps are lost
Primary vs Secondary cancer prevention correct answer✔✔ Primary:
Concerned with reducing cancer risk in healthy people; Lifestyle/Diet
changes/Avoid carcinogens
Secondary: Involves detection and screening (mammogram/testicular
exam)
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