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NUR 120 Final Exam Questions and Answers Latest Update
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NUR 120 Final Exam Questions and Answers Latest Update
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NUR 120 Final Exam Questions andAnswers Latest Update
PICC Line Care/Management - Answer-Central Venous Access Device
Inserted into a peripheral vein (basilic, median cubital, brachial, or cephalic)
Usually a specially trained nurse inserts
Xray is used to verify placement
DO NOT TAKE BP OR BLOOD DRAWS FROM AFFECTED EXTREMITY
PICC Line Uses - Answer-IV antibiotics
Parenteral Therapy
Chemo
Medications
Blood Components
PICC Line Maintenance - Answer-Check hospital policy for specific guidelines
Change dressing 24 hrs after insertion, when soiled/loose, every 7 days
Use Sterile Technique
Wear mask (nurse and pt.)
Parenteral Nutrition - Answer-method of providing nutrients to the body by an IV route
Nutrients are complex containing proteins, carbohydrates, fats, electrolytes, vitamins,
trace minerals, and sterile water in one container
Goals of PN - Answer-Improve nutritional status
Establish a positive nitrogen balance
Maintain muscle mass
Promote weight maintenance or gain
Enhance healing process
Indications for PN - Answer-Inability to ingest adequate oral food or fluids within a 7 to
10 day timeframe
Insufficient oral or enteral intake
Impaired ability to ingest or absorb food orally or enterally
Patient unwilling or unable to ingest adequate nutrients orally or internally
Prolonged preop and postop nutritional needs
Administration of PN - Answer-Peripherally Inserted Central Catheters (PICC) -
Intermediate term (several days to months) IV therapy in hospital, long-term care, or
home setting
Bolus feedings - divided into 3 to 4 feedings daily
Gravity feedings - raising or lowering the syringe above the abdominal wall regulates
the speed of delivery (as patient tolerates)
Admin over 30 minutes or longer with flow rate regulated with a clamp
,Nursing Interventions for PN - Answer-HOB 30 to 45 degrees
Change tubes and feeding containers every 24 hours
Check gastric residual volume before every feeding or every 4 hours and return the
aspirate to the stomach
Complications of PN - Answer-Pneumothorax
Air embolism
Clotted catheter line
Catheter displacement and contamination
Sepsis
Hyperglycemia
Fluid overload
Rebound hypoglycemia
Tracheostomy - Answer-a surgical procedure in which an opening is made into the
trachea; used to bypass an upper airway obstruction
Tracheal stenosis may develop after the tube is removed
Patient's need to try and cough secretions up on their own prior to suctioning - it can
cause rebound effect if too much suctioning is used
If patient pulls trach out - pick it up and immediately put it back in
Obturator helps to open the trach
Early Complications of Tracheostomy - Answer-Tube dislodgement
Accidental decannulation
Bleeding
Pneumothorax
Air embolism
Aspiration
SQ or mediastinal emphysema
Recurrent laryngeal nerve damage
Posterior tracheal wall penetration
Long Term Complications of Tracheostomy - Answer-Airway obstruction from
accumulation of secretions or protrusion of the cuff over the opening of the tube
Infection
Rupture of the innominate artery
Dysphagia
Tracheoesophageal fistula
Tracheal dilation
Tracheal ischemia
Necrosis
Nursing Interventions for Tracheostomy - Answer-Enhance gas exchange
Promote effective airway clearance
Prevent trauma and infection
,Promote optimal level of mobility
Promote optimal communication and coping ability
Assess lung sounds every 2 to 4 hours
Blood Transfusions - Answer-Run blood slowly for first 15 minutes
Stay with client 15-30 minutes
Recheck vital signs 15 minutes after transfusion started
Take vital signs every hour UNTIL COMPLETED, then hourly for 3 hours
Ask client to report any signs and symptoms of reaction: itching, fever, low back pain,
flank pain over the kidneys, shortness of breath
Consent form is needed and is obtained by the doctor
Use nothing above a 22g needle
Transfusion: Allergic Reaction - Answer-hives, itching, anaphylaxis (STOP blood restart
0.9%)
Transfusion: Febrile Reaction - Answer-fever, chills, headache, malaise (STOP blood,
restart 0.9%)
Transfusion: Bacterial Reaction - Answer-fever, hypertension, dry/flushed skin,
abdominal pain (STOP blood, obtain culture, give antibiotics, IV fluids, vasopressors,
steroids)
Transfusion: Hemolytic Reaction - Answer-Immediate onset, facial flushing, fever, chills,
headache, low back pain, shock.( STOP the blood, restart 0.9% NaCI, notify PC, have
benadryl, and oxygen ready)
Transfusion: Circulatory Overload - Answer-Dyspnea, Dry Cough, Pulmonary Edema,
Crackles (monitor clients at high risk, slow or discontinue blood)
Reasons to Return Blood to Bank - Answer-Incorrect blood type
Incorrect Pt name
Incorrect Barcode
Possible Contamination
Damage to the Bag
Not used within 30 minutes of acquiring from bank
Blood Groups and Compatibility - Answer-Type O - Gives- O, A, B, AB Receives - O
(Universal donor)
Type A - Gives - A, AB Receives - O, A
Type B - Gives - B, AB Receives - O, B
Type AB - Gives - AB Receives - O, A, B, AB
Remember Jehovah's witnesses cannot get plasma or blood - give liquid iron and push
saline
, Packed Red Cells - Answer-used to treat anemia, CRF, Cancer, GI bleeding, Trauma,
Surgical bleeding and CV failure. Give over 2 hours(Squeeze bag to mix cells every 20-
30 minutes)
Platelets - Answer-Treatment or prevention of bleeding associated with deficiencies in
the number or quality of patient's platelets (Give as quickly as possible)
Plasma - Answer-Used for emergencies, restore coagulation factors and blood volume,
contains protein for blood volume expander (burns) - Admin with a straight line set
Calcium - Answer-8.5 - 10.5
Potassium - Answer-3.5 - 5.5
Magnesium - Answer-1.5 - 2.5
Sodium - Answer-135 - 145
Phosphate - Answer-2.7 - 4.5
BUN - Answer-10 - 20
Creatinine - Answer-0.7 - 1.4
Hemoglobin - Answer-Males 13 - 18
Female 12 - 16
Hematocrit - Answer-Males 42% - 52%
Females 35% - 47%
Partial Thromboplastin Time (PTT) - Answer-60 - 70
Activated Partial Thromboplastin Time (aPTT) - Answer-20 - 39
Promthrombin Time - Answer-9.5 - 12
Platelets - Answer-150,000-450,000 cu/mm
WBC - Answer-4500-11,000 cells/mm3
Chemotherapy Care - Answer-N/V, hematopoietic, kidney damage, fatigue
Laundry: pt must wash clothes separate, after washing pt clothes
Chemo Administration: Dosage, Extravasation, Hypersensitivity reactions
Chemo Toxicity - Answer-Gastrointestinal
Hematopoietic
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