NURC 1104 Exam 1 Questions with
Answers
Nursing diagnosis for pressure injuries - Answer-Risk for impaired skin integrity
Risk for impaired tissue perfusion
Impaired tissue integrity related to:
orthostatic hypotension - Answer-temporary low BP and dizziness when suddenly rising
from a sitting or reclining position
Systolic drops by 20 points, diastolic by 10
Common size of adult urinary catheter - Answer-14-16Fr
Ways to prevent CAUTI - Answer-assure draining properly,
bag below level of bladder,
monitor urine for S&S of infection,
ensure catheter is not left in out of "convenience"
Use smallest size possible
Keep system closed
steps to collect urine foley specimen - Answer-Clamping foley for 10 mins, collect
aseptically
Specimen from bag must be <30 min old
Minimum urine output - Answer-30 mL/hr
First thing to consider when <30mL/hr urine output - Answer-urinary retention
location of V1 EKG lead - Answer-R Sternal margin 4th intercostal space
location of V4 EKG lead - Answer-L 5th intercostal @ mid-clavicular line
Items required for restraints - Answer-Require order
Order good for 24 hrs
Must check every 15mins
Convert inches to cm - Answer-1 inch = 2.54cm
Convert kg to lbs - Answer-1kg = 2.2lbs
, factors contributing to risk of fall - Answer-Unsteady gait
Meds
Orthostatic Hypotension
Sensory loss
Interventions for aspiration risk - Answer-Speech therapist consult for swallow study
NPO until done
Dysphasia diet
signs of dysphagia - Answer-cough during eating;
change in voice tone or quality after swallowing; abnormal movements of the mouth,
tongue, or lips;
slow, weak, imprecise, or uncoordinated speech
drooling
pocketing of food
Normal pulse - Answer-60-100
Normal BP - Answer-120/80
Normal oral temperature - Answer-97.6F - 99.6F
Normal temporal temperature - Answer-99.6
Normal Tympanic Temperature - Answer-98.6
Normal rectal temp - Answer-99.6
Normal respiratory rate - Answer-12-20 breaths per minute
Normal blood glucose range - Answer-70-100 mg/dL
Assessment steps for accucheck - Answer-Assess skin, perfusion of area to select
puncture site, bleeding precautions, last time patient ate, patient understanding of
procedure
What increases peristalsis? - Answer-exercise
stress
disease
medications
The type of stool that will be expelled into the ostomy bag by a client who has
undergone surgery for an ileostomy will be: - Answer-liquid
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