Final exam

Question 1

Hypervolemia Expected findings

Answer 1

Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
Neuromusculoskeletal: Confusion, Muscle weakness, altered level of consciousness, visual changes,(seizures if hyponatremia
Respiratory: Dyspnea, Orthopnea, crackles, Pitting edema, Distended neck veins, weight gain, skin pallor, and cool to touch

Question 2

Vaccines for toddlers 1-3 year olds

Answer 2

Hep A and B, Tetanus, Pertussis, Measles, Mumps,Rubella, Varicella, Pollio, influenza, Haemop influenza Type b, Pnemoccal Pnemonia

Question 3

RN’s Delegation to APs

Answer 3

Activities of daily living-Bathing, grooming, dressing, ambulating feeding
Routing tasks - Bed making, Specimen collection I/O, vital signs (for stable clients)

Question 4

RN’s delegating to PNs

Answer 4

Monitor findings, Reinforce client teaching, perform tracheostomy care, suction, check ng tube patency, Adm enteral feedings, Inserting a urinary catheter

Question 5

Five rights of Delegation

Answer 5

Right task
right circumstances
Right person
Right direction and communication
Right supervision and evaluation

Question 6

Interventions for obtaining blood pressure

Answer 6

Ensure appropriate cuff size
Ensure the patient is in the correct position(No crossed legs, dangling feet, arm above level of heart)
Ensure the stethoscope works properly.
Ensure the cuff is not wrapped too tight

Question 7

What substances increase pain transmission

Answer 7

Substance p ,Prostaglandins,Bradykinin,Histamine

Question 8

Substances that decrease pain transmission and produce analgesia

Answer 8

Serotonin and endorphins

Question 9

ECG Changes for electrolyte imbalances (hypokalemia)

Answer 9

Premature ventricular contractions, Bradycardia, Blocks, Flattening-Flattened or inverted T waves, Incresed u waves, and ST depression,

Question 10

ECG Changes for electrolyte imbalances (hyperkalemia)

Answer 10

ECG will show Peaked T waves, Widened PR, and QRS,Dysrhtmias, and asystole are possible

Question 11

ECG Changes for electrolyte imbalances(Hypercalcemia)

Answer 11

Common= shortened Qt intervals, Lengthed Qrs duration, Bradycardia, increased amplitude, Diminished t waves, St increased, Av block, Ventricular tachycardia, Fibrillation

Question 12

ECG Changes for electrolyte imbalances(Hypocalcemia)

Answer 12

lengthed qt intervals,Shortened QRS duration
Rare-Av block sinus bradycardia,ventricular fibrillation

Question 13

ECG Changes for electrolyte imbalances(Magnesium )

Answer 13

AV Block

Question 14

Nutrients that promote wound healing

Answer 14

protein
Vitamin a (NO VITAMIN D OR 12)
zinc
vitamen c
iron

Question 15

Dehiscence Wound care

Answer 15

keep it clean
Keep it moist
Manage Exudate
cover w/ moist sterile gauze

Question 16

Herpes Zoster client education

Answer 16

Caused by reactivation of Varicella-zoster virus
Contagious to others until crusted overs
recurrence is triggered by physical or psychological stressors such as trauma, fever, fatigue
SEVERAL DAYS OF DISCOMFORT BEFORE VESCILES APPEAR, PAIN OCCURS FOR A WHILE AFRET LESSONS HAVE GONE

Question 17

NASAL CANULA CLIENT EDUACATION

Answer 17

Tubing w/ two small for insertion into nares,Educate on the reason for o2 therapy,Explain what you are going to do before dong it

Question 18

Discharge teaching