2B EXAM PRACTICE QUESTIONS

Question 1

You are allocated Mr John who has been admitted with an exacerbation of chronic obstructive pulmonary disease (COPD) - 2. List three priority nursing assessments for Mr John during the acute phase and provide the rationale for each.

Answer 1

RAPID AX - to assess breathing and airway as well as environment/safety
COLDSPA - determine severity of pain, assess hx and pattern
Posterior chest Ax - hear for any abnormalities or adventious sounds, look at WOB and rise and fall of chest

Question 2

You are allocated Mr John who has been admitted with an exacerbation of chronic obstructive pulmonary disease (COPD)

3. Based on the assessments identified above, list three priority nursing interventions for Mr John during the acute phase and provide the rationale for each.
   RAPID AX
   COLDSPA
   POSTERIOR CHEST AX

Answer 2

Rapid Ax - aim to decrease WOB by administering 02 as required if Spo2<93%.

COLDSPA - administer analgesia prescribed, e.g. bronchodilators

POSTERIOR CHEST AX - sit upright to maximise air entry for gas exchange

Question 3

You are allocated Mr John who has been admitted with an exacerbation of chronic obstructive pulmonary disease (COPD)

4. Three days later, Mr John’s condition has improved. State two assessments the nurse would perform and what would they expect to find that indicates that these interventions have been effective?

Answer 3

Rapid Ax/Vital signs/EWS - 02,

Question 4

Ms Turia who identifies as Maori is admitted with a myocardial infarction.
5. State four important points that the cardiac rehabilitation nurse would provide education on prior to discharge

Answer 4

medication education

EWS

ANGINA ACTION PLAN - use GTN spray, wait 5 mins, use it again, wait 5 mins if it doesn’t relieve treat as heart attack and call an ambulance. chew aspirin if directed by paramedic.

Daily weighs

Decrease workload like exercise.

Question 5

You are allocated Mrs Joseph has just returned to the ward following a hemicolectomy.

7. List four priority post-operative nursing assessments for Mrs Joseph and provide the rationale for these assessments.

Answer 5

COLDSPA - assess pain, pattern and explore appropriate pain relief
Listen for bowel sounds - for ileus, function of bowel
FBC - monitor fluid input and output to assess if any fluid overload or retention
Vital signs - assess if need for 02 as prescribed, sedation score and if person is responsive and alert
RAPID AX - determine braden scale, nutrition risk, and airway/breathing

Question 6

Mrs Jones develops pain & swelling in her left leg. An ultrasound scan confirms a deep vein thrombosis (DVT).

8. Outline the aetiology and pathophysiological process that has most likely occurred in the formation of her DVT.

Answer 6

Aetiology - Virchows Triad

Process - decreased blood flow, trauma to blood vessels stimulates clotting, platelets and fibrin form clot, decreased blood flow leads to < oxygenation and > hematocrit, rbc trapped in fibrin meshwork, clot may occlude blood vessel or embolus may travel to other parts of body.

Question 7

You are allocated Mr Fraser who was admitted with an exacerbation of heart failure.
10. Mr Fraser’s heart failure includes, administering Frusemide, oxygen therapy, and a daily weigh.

What assessments would the nurse perform and what would they expect to find that indicates that these interventions have been effective?

Answer 7

Frusemide - fluid output, oedema <3secs

02 - Sp02,

Question 8

You are allocated Mr Fatialofa who was admitted with a spinal fracture at the level of the first thoracic vertebrae (T1). The nurse notices a kink in Mr Fatialofa’s indwelling catheter.
9. Briefly explain the life-threatening complication that could occur from this and list the clinical manifestations (signs and symptoms) of this complication that is unique to spinal patients. (4 marks)

Answer 8

Autonomic dysreflexia a SPINAL reflexive SNS response that causes symptoms like HTN, headaches, anxiety, bradycardia, diaphoresis and blurred vision.