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NUR 185 TEST 1 HONDROS EXAM
UPDATED ACTUAL EXAM WITH CORRECT
SOLUTIONS.
Nurse admits patient to med surg unit. Resp rate of 38. Patient using chest muscles to breathe, pulse ox of 87 on room air, pink frothy sputum. What intervention would you implement first? - correct answer- O2 at 2 Liters/Min
Caring for pt. who is intubated and receiving mechanical ventilation. What action by the nurse would decrease the patient's incidence of developing ventilator associated pneumonia? - correct answer- Put head of bed at 30-45 degrees.
The nurse is administering acetylcysteine (muca-mist) as nebulizer treatment to patient. Which should the nurse have available for adverse effect on the patient? - correct answer- Suction equipment
Patient coming in with SOB and resp. rate of 32. ABG results PH 7.3 (acid), Co2-50 Bicarb-28, PO2-70 Resp. Acidosis, what orders do you anticipate carrying out? - correct answer- Apply O2 and give med-neb treatment. 1 / 2
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You have 4 patients in a long term care facility. Which would you check first? - correct answer- COPD patient with resp rate of 30, O2 of 87 and on 3 Liters of O2 complaining of dyspnea.
Caring for newly intubated patient getting mechanical ventilation. Pt.'s wife was not at hosp. when this occurred. Wife appears angry and states "What have you all done to him?" What would be your response as a nurse? - correct answer- Explain to the patient why the patient had to be intubated, continue to update patient's wife on condition and plan of care, I'm sorry that you walked in on him like that, I understand this must have been very frightening.
Patient has SOB, edema in legs and face and has the following
labs: BUN-95 (high), Creatinine of 9.2, Potassium of 6.0 (high).
What are you going to do - correct answer- Give Kexolate, prepare the patient a central line for dialysis. Cardiac monitoring.
Working with a UAP, what task can be delegated? - correct answer- Instill non-prescription eye drops in patient's eyes.
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