Comp 2 review

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Galen College of Nursing *

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282/283

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Computer Science

Date

Dec 6, 2023

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docx

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Uploaded by kcboysof3

Comp 2 1. Some stuff TB 22 gauge wrong Further teaching: using a 22 g for a tb test 36. A nurse is preparing to administer a Mantoux test to a client. Which of the following actions by the nurse indicates the correct technique? A . Inserting the needle at a 90-degree angle. (5-15 degree angle) B. Injecting the medication in the subcutaneous tissue. (intradermal layer) C. Drawing up 0.1 mL of purified protein derivative (PPD) tuberculin. D. Using a 20-gauge needle. (Correct needle is 26-27 gauge) 2. Sickle cell, avoid high alt? What discharge teaching would you provide for these patients on preventing sickle cell crisis? Avoid travel to high altitudes The nurse is providing discharge instructions to the parents of a child who was admitted with sickle cell crisis. Which of the following instructions should the nurse include in the teaching? A. "Monitor your child's temperature daily." B. "Restrictplayactivityto1hourperday. C. Avoidareaswithhighaltitude." D. "Apply cool compresses when your child expresses pain." The nurse working on a pediatric unit has received the change-of-shift report and is reviewing client data and prescriptions. Which of the following clients should the nurse plan to see first? A. The school-aged child who has diabetes mellitus (type 1 ) and requires blood glucose monitoring. B. The infant who has a diagnosis of pertussis and has a dry hacking cough. C. The adolescent who was admitted with sickle cell crisis and reports visual disturbances. D. The toddler who has bilateral arm casts and needs to be fed their breakfast. Additional Question: What should the nurse do first when doing a blood transfusion? A. ensure patient has 20g iv in place B. check the product for bubbles or dull color C. prime the line with NS in Y-tubing D. verify the blood type with another nurse

3. NG 1,2,3,5 46. The nurse is caring for an older adult client who had surgery for an intestinal obstruction and has a nasogastric (NG) tube to low wall suction. Which interventions from the box below should the nurse include in the plan of care? 1. Discontinue suction when assessing for peristalsis. 2. Encourage the use of an incentive spirometer every 2 hours while awake. 3. Maintain sequential compression devices to bilateral lower extremities. 4. Irrigate the NG tube with sterile normal saline (NS) as prescribed. 5. Turn and reposition the client every 2 hours. 6. Place a sign at the head of the bed (HOB) that says, Do not manipulate the NG tube." Ans: 1, 3, 4, 5 4. Math 325 Math question for burns 4ml/TBSA/KG 5. 89% burn patient priority 10. The nurse is caring for a male client who has a full thickness burn to 35% of the lower body. It is a priority for the nurse to notify the primary health care provider (PHCP) if the client has a A. pulse oximeter reading of 89%. B. hematocrit (Hct) level of 60%. C .temperature of 100.2° F. D. urinary output of 100 mL for the past 2 hours. 24. The nurse working in the ED is assisting to triage clients following an explosion at a local factory. Which of the following clients should the nurse identify as a priority for treatment? A. A client who reports having diabetes mellitus (type 1) and is feeling shaky with clammy skin. B. A client who has a closed tibia fracture to the left leg and minimal swelling to the ankle C. A client who has a large head wound with exposed gray matter and respirations of 6 (black tag =patient dead) 6. Stage 3 ulcer with daughter 7. Linear rash patient disseminated zoster (shingles)

D. A client who has second-degree burns to the chest and arm with respirations greater than 30. Question asked which pt should be put in a treatment room first, said the pt had a rash, indicative of shingles (airborne precaution)-would require follow-up. 8. Acute pancreatitis pain priority A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder. If pain intensifies with inspiration report to provider as this could indicate a pleural effusion or other respiratory complications. 9. 6 year 130 eating 9. A nurse working on a pediatric cardiac unit is reviewing the telemetry monitors for assigned clients. Which of the following clients should the nurse initially plan to assess? A. A 15-year-old adolescent who is sleeping and has a heart rate (HR) of `55 beats/ 'minute. B. A 5-year-old child who is watching television and has a HR of 78 beats/minute. C. A 2-year-old toddler who is walking in the hallway and has a HR of 160 beats/minute. D. A 1-month-old infant who is crying and has a HR of 180 beats/minute. 42. A nurse working in a pediatric cardiac unit is reviewing the current vital signs of assigned clients. Which of the following children should the nurse assess first? A. 16-year-old adolescent who is sleeping and has a pulse rate of 55. B. 6-year-old child who is sitting at a table eating a snack and has a pulse rate

of 130. C. 2-year-old toddler who is walking around in the playroom and has a pulse rate of 150. D. 2-month-old infant who is crying and has a pulse rate of 170. 10. Rupture membranes- bloody Expected findings with amniotic fluid are clear, the color of water, and free of odor 15. The nurse working in the labor and delivery unit is caring for a client in labor whose membranes just spontaneously ruptured. Which of the following findings is a priority for the nurse to report to the primary health care provider? A. A maternal temperature of 99.5 Immediately report any abnormal findings to provider. (bloody fluid report to pcp) Abnormal findings should be reported, which include bloody fluid from vagina (question for rupture of membranes) B. Four contractions in a 10-minute period (5 or more contractions in 10 minutes) C. Appearance of bloody fluid from the vagina D. Contractions lasting 60 seconds (contraction duration 2 minutes or longer) 28. The nurse received a change-of-shift report on assigned clients. The nurse should first see the client who B. had a cervical cerclage placed 10 hrs ago and is at 12 wks gestation C. had a vaginal delivery 24 hrs ago and is having dark red lochia expeckd 23 dang D. had a tubal ligation and is scheduled to be discharged today 11. Eggs diet question 28. The nurse has provided dietary teaching to a client who has a history of atherosclerosis and a recent laboratory test indicating an

increased cholesterol level. Which of the following statements by the client indicates a need for follow-up? A. I flavor my fish with lemon juice." B. T cook my food with canola oil." C. I take an omega-3 supplement daily." D. 'I eat two poached eggs for breakfast every morning." 12. HDL Lower and LDL higher A. had a cesarean delivery 4 hrs ago and is reporting an open area in the incision For patients with CHD, teaching points include: (no poached eggs... egg yolk contains cholesterol) 18. The nurse is screening adult clients at a health fair. It is a priority for the nurse to recommend follow-up with a primary health care provider (PHCP) for the client who is B. 55 years old, has a blood pressure of 124/76 mm Hg, stopped smoking 2 months ago, and is taking prescribed lisinopril daily. C. 50 years old, has a family history of ovarian cancer, and has not had the human papillomavirus (HPV) vaccine. D. 45 years old, has a history of exercise-induced asthma, and has vesicular breath sounds in the peripheral lung fields. 13. Postmortem care PREPARING THE BODY FOR VIEWING (select all)

A. 65 years old, has a decreased high-density lipoprotein (HDL) level, an increased low-density lipoprotein (LDL) level, and currently follows a low-cholesterol diet. most hospitals require the physician to pronounce and sign the death certificate (exam said coroner pronounces dead that is wrong) 14. IBS- loperamide maybe changed to psyllium IBS- loperamide maybe changed to psyllium Loperamide for IBS question its because lubiprostone is given for IBS 37 . The nurse is preparing to administer prescribed medications to the following clients. It is most important for the nurse to follow up with the primary health care provider (PHCP) for the client who has B. diabetes mellitus, is scheduled to have a computed tomography (CT) scan with IV contrast and has been prescribed to withhold metformin. C. has a prosthetic mitral valve, an international normalized ratio (INR) of 3.0, and is currently A. constipation-predominant irritable bowel syndrome (IBS-C) and has been prescribed loperamide. taking a prescribed dose of warfarin. D. a methicillin-resistant Staphylococcus aureus (MRSA) wound infection, an allergy to sulfonamides, and has been prescribed vancomycin. 15. Kidney rejection 1 temp Talked about kidney rejection “pt temperature elevated was the answer” The nurse is caring for a client who had a kidney transplant 1 week ago. It is a priority for the nurse to notify the health care provider (HCP) if the client

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