NR 341 Exam #3 Review
Immediate nursing interventions for a patient with a swollen PICC line. – Answer -Stop
the infusion immediately and do not infuse anything else.
-Notify HCP
-Measure the circumference of the affected extremity and compare to baseline.
Dietary considerations for a patient with end-stage renal disease. – Answer Decrease
potassium intake
What is the nurse’s priority assessment upon a patient’s return from dialysis? – Answer
Obtain the patient’s BP (fluid removal can cause hypotension)
A patient in the ER complains of the “worst headache of their life,” what do you
suspect? – Answer Hemorrhagic stroke
How do you test cranial nerve III? – Answer PERRLA
Your patient has SIADH and their sodium level is 123. What is your priority intervention?
- Answer Restrict fluid intake
Where is McBurney’s point? – Answer 1/3 the distance from superior iliac spine to
umbilicus in the RLQ
What are the steps of taking a patients blood glucose level? – Answer -Make sure that
the test strips aren’t expired
-Identify the pt
-Apply gloves
-Clean the site with alcohol
-Poke on the side of the finger pad
-Wipe away the first drop of blood then collect the sample
How do you draw up cloudy and clear insulin into the same syringe? – Answer Clear before cloudy
- Wipe the top of both viles
- Put air into cloudy
- Put air into clear
- Withdraw clear
- Withdraw cloudy
Important nursing actions prior to initiating tube feeding via NG tube – Answer -Check
placement via x-ray
-Check residual
-Hook up feeding and re-feed amount removed to check residual
What are the signs and symptoms of organ rejection? – Answer -Fever
-Organ might stop working (I.e., dec. urine output for a pt with kidney transplant)
-Flu-like symptoms (N/V, chills)
NR 341 Exam #3 Review
A patient suffered a femur fracture, what are they most at-risk for? – Answer Fat
embolism
What are the signs and symptoms of autonomic dysreflexia? – Answer -High BP
-Irritation
-Sweating above level of injury
-Nasal congestion
-Cool below level of injury
What kind of insulin drip will the nurse start for a patient in DKA? – Answer Regular
insulin drip only
Nursing considerations for a patient with Bell’s palsy – Answer -Educate that this occurs
suddenly, causes facial drooping, and must run its course and goes away on its own.
-Offer emotional support and reassurance.
What are the signs and symptoms of liver cirrhosis? – Answer -Abd distention (ascites)
-Rigid abd
-Jaundice
-Easily bruised
-Confusion
-Esophageal varices
What are the diabetes sick day rules? – Answer -Continue to monitor blood sugar
-May have to adjust insulin dosage
-Stay hydrated (240-360 mL of water every hour)
-Check urine for ketones
A patient is septic and bleeding from their IV sites and in their stools, what do you
suspect is going on? – Answer DIC
Signs and symptoms of peritonitis in a patient receiving peritoneal dialysis – Answer
Cloudy effluent
Rigid abdomen
How do you assess the neurovascular status of a patient with a cast on? – Answer –
Check the cap refill, temp, and pulses of the affected extremity.
-Ask if the pt is experiencing tingling and numbness.
-Ask if they can wiggle their fingers/toes.
What is included in a primary survey for the care of an emergency patient? – Answer
•Aims to identify life threatening conditions so appropriate interventions can be started
•Airway, breathing, circulation, disability, exposure and environmental control, facilitation
of adjuncts and family, resuscitation adjuncts