2023 NUR280 Comprehensive Review 1 Exam with Answers (561 Solved Questions)

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Comp #1
Spinal Cord Injury/Surgery/Procedure
- Expected finding:
o Decreased reflexes
o Numbness/tingling
o Inability to urinate (from low spinal cord injury)
- Not Expected:
o Decreased RR.
o Headache (increased ICP)
o CSF halo (yellow fluid)
- Post-Op:
o Airway, circulation
o Monitor for ICP, Neuro checks, VS closely
- Complication:
o Autonomic Dysreflexia. S/S:
 Numbness & tingling (expected)
 Severe hypotension
 Cessation of breathing (not expected).
Heparin/Enoxaparin (LMWH)
- Anticoagulant that can be give IV or SQ
o Labs:
 aPTT 30-40 (WNL), while on Heparin should be 1.5-2x the normal value
[aPTT on heparin 60-90]
 Risk for bleeding (aPTT >70)
 Warfarin & Heparin until Warfarin reaches therapeutic INR levels [2-3]
 H&H (rule of thumb, hematocrit [37-52] will be 3x the amount of
hemoglobin [12-18]) example: HgB 8 = Hct 24, or HgB 10 = Hct 30
 Platelets 1.5-2.5x the normal (want them high not low)
 Normal Platelets Range: 150-400
- Antidote:
o Protamine Sulfate
- Complication
o HIT (Heparin Induced Thrombocytopenia)
 Due to being on med for longer than a week
 Monitor for s/s of bleeding
 Lab: low platelet count (<150)
o Interventions:
 Stop heparin
 Direct thrombin inhibitor
 Lepirudin and Argatroban
 Treat active and prevent any new thrombosis
- SQ Administration

o Don’t aspirate or expel the bubbles out of prefilled syringe
Colostomy
- Descending colostomy located on LLQ (involves the large intestines)
- Stoma should be reddish pink, moist and shiny (Saunders pg. 688)
o Call MD if stoma looks:
 Pale/ Pink (low h&h levels)
 Dark purple/ Black (compromised circulation)
 Shrink in size/Dry
 Small amount of mucous drain in the bag
- Expect liquid stool in the immediate postop period but become mores more solid depending
on location
o Ascending Colon: liquid
o Transverse Colon: loose to semi-formed
o Descending Colon: close to normal
- Empty pouch when 1/3 full
- Monitor for dehydration & electrolyte imbalance
- Avoid food that causes excess gas or odor
o Give yogurt to help decrease smell
- Avoid contact of skin with stool
- Should start functioning 2-3 days after surgery
Ventilator Associated Pneumonia (VAP)
- Prevention
o HOB elevated >30 degrees
o ulcer prophylaxis (H2 blockers)
o preventing aspiration
o pulmonary hygiene (chest physiotherapy, postural drainage/percussion and
turning/re-positioning Q2hours)
o remove water from circuits, and suction PRN.
o Vigilant, frequent oral care is key!
 brushing teeth Q8hours, antimicrobial rinse and lip moisturizer Q2hours
o Cough
Sepsis:
- Bloodstream infection/UTI, bacteria, fungi, vasodilation
o considered a type of distributive shock, prevention is key.
- Risk Factors:
o cancer patients (highest risk)
o malnutrition
o immunocompromised
o open wounds
o DM, CKD, Hepatitis, HIV/AIDS
- S/S:

o DIC (disseminated intravascular coagulation)
o low O2
o tachypnea
o decreased/absent urine output
o change in LOC
o hypoxia
o death/dysfunction of organs
- Interventions:
o Resuscitation oxygen therapy
o Blood replacement therapy
o Drug therapy
- Identify early manifestations of infection
o treat with antibiotics
o strict aseptic technique
o IV fluids
o inotropic medications.
Septic Shock
- Caused by an infection
o Medical emergency can happen to anyone who is a patient in the hospital.
- Capillaries dilate
o Fluid exits the vascular system and enters interstitial spaces.
- S/S:
o Hypotension
o Tachycardia
o Increased RR
o Increased temp
o cold and clammy skin.
o Changes in LOC (earliest sign)
- Treatment:
o Fluids
 Normal Saline and Lactated Ringers (Bolus)
o Broad Spectrum antibiotics
o Vasopressors
A-Fib
- Multiple Rapid impulses
- Quivering atria
- Irregular heart rhythm
- HR 130-150+
- Treatments:
o Oxygen
o Amiodarone & Digoxin
 With rapid ventricular response (RVR)
o Calcium Channel Blocker (CCB)

 Diltiazem
o Beta Blocker (BB)
 Metoprolol
o Monitor electrolytes
 Low potassium (increases risk for dig toxicity)
o Anticoagulatory therapy
 Warfarin
 Prevents blood from clotting due to the quivering of the heart
o Synchronized Cardioversion
 When symptomatic and non-responsive to med
Hyperbilirubinemia pg. 382
- Occurs when there is too much bilirubin in the blood.
o Bilirubin is made by the breakdown of RBCs.
 Indicates issues with the liver
- Lab Value
o Bilirubin: < 1
 increased with impaired liver function.
- S/S:
o Jaundice
o Poor sucking reflex
o Enlarged liver
o Lethargy
o Poor muscle tone
o Elevated bilirubin
- Treatment:
o Phototherapy
 Used to reduce serum bilirubin levels
 Adv. Rx.
 Dehydration
 Sensory deprivation
 Eye damage
 Bronze baby syndrome
o Grayish brown skin
Vital Signs (Peds)
- Newborn/Infant (0-12mo)
o BP: 60-80/40-50
o HR: 110-170 [2month old]
o RR: 30-60
o Temp: 97.5-99.5 (Rectal)
o O2: >95%
- Toddler (1-3yrs)
o BP: 90-105/ 50-70
o HR: 80-140

o RR: 22-37
o Temp: 97.6 to 99.5 (Axillary)
- School Age (3-12yrs)
o HR 70-100 [should not increase when child is eating]
o BP 120/60
- High School (12+ yrs)
o HR: 60-100
o BP: 125/65
- Take into consideration if patient is:
o Sleeping, an athlete, running/any activity, age, resting
ABGs
- pH: 7-35-7.45
- HCO3: 22-28
- CO2: 45-35
- Respiratory Acidosis
o Symptoms:
 Hypoventilation (retains CO2)
 Drowsiness/ Confusion
 Hypoxia/ low RR
o Risk Factors:
 Hypoventilation
 Respiratory failure
 brain trauma
 atelectasis
 CNS depressants
 Cystic Fibrosis
- Respiratory Alkalosis:
o Risk Factors:
 Hyperventilation (getting rid of all CO2)
 Kussmaul’s
 hysteria, fever, pain, CAN stimulants, acute distress.
o Symptoms:
 Tachypnea
 Dizziness/ lightheadedness
 perioral numbness
 paresthesia.
- Metabolic Acidosis:
o Risk Factors:
 Insufficient supply of insulin (DM or DKA)
 excessive intake of aspirin
 high fat diet, renal insufficiency
 lactic acidosis
 malnutrition

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 severe diarrhea.
- Metabolic Alkalosis:
o Risk Factors:
 AKI, diuretics, excessive vomiting, NG tube suctioning, excessive sodium
bicarb intake.
o S/S:
 Muscle cramps
 paresthesia around mouth and on toes
 hypotension
 tetany (hypocalcemia)
 decreased respiratory effort
ERCP: (Endoscopic Retrograde Cholangiopancreatography)
- Endoscopy procedure to help diagnose any disease or stones in the gallbladder, biliary
system, pancreas, or liver.
o The test looks "upstream" where digestive fluid coming from the liver,
gallbladder, and pancreas to where it enters the intestines.
- Pre-Procedure
o NPO 6-8hrs prior
o Ask for allergies to iodine contrast
- Post-Procedure
o Monitor VS
o Assess return of gag reflex
 Before giving anything to eat/drink (risk for aspiration)
o Monitor s/s of perforation peritonitis
 Pallor
 Guarding of abdomen
 Tachypnea
 Tachycardia
 Increased temp & chill
 Restlessness
 Abdominal distention/pain
NG tube
Placement of a tube from nose through the stomach to manage GI dysfunction and provide
enteral nutrition.
- Procedure:
o Elevate HOB
 High fowler’s position
o Assess nares
o Check placement before giving anything
 pull back residual to check for pH levels (GI levels is 3.5)
o Get X-Ray to confirm placement
- Reasons to place one:
o Upper GI bleed

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 coffee ground emesis
o Lower GI bleed
 dark red emesis
o Decompress the belly
 Bowel obstruction
 Ileus
 Colon surgery
 Non-stop throwing up
- At risk for aspiration
o HOB elevated at least 35 degrees
Tuberculosis Test
- Risks Factors:
o Low socioeconomic status
o Homelessness
o Long-term care facilities
o Prisons
- S/S:
o Persistent cough
o Malaise
o Fever
o Weight loss
o lymphadenopathy
- Airborne precautions
o N95 mask
o Negative-airflow room
o Patient should wear surgical mask when transferring places
- TX: “RIPE” (Must be taken for 6-12 months):
o Isoniazid
 monitor for hepatotoxicity and neurotoxicity
 tingling of hands and feet
 B12 is used to prevent neurotoxicity
o Rifampin
 will turn urine and other secretions orange
 can interfere with birth control
 can cause hepatotoxicity
o Pyrazinamide
 can cause hepatotoxicity
o Ethambutol
 can cause ocular toxicity
 obtain baseline visual acuity tests
o Streptomycin sulfate (for patients with drug resistant)
 can cause ototoxicity
- Inform patient that sputum samples will be needed every 2-4 weeks to monitor therapy
effectiveness.

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- Patients no longer infectious after 3 consecutive sputum cultures.
- Mantoux (0.1mL)
o 1cc syringe
o Should not be done at the same time of measles
o >15mm: positive for > 4yrs
o >10mm: positive for <4yrs
o >5mm: positive for immunocompromised
Desmopressin:
- Used for DI (Diabetes Insipidus), bleeds, and to decreases urine output.
- Works by replacing vasopressin
o Vasopressin: (Vasoconstrictor)
 a hormone that is normally produced in the body to help balance the
amount of water and salt.
- Expected
o Fluid retention
o High B/P
o low HR
- Helps prevent dehydration:
o Decreases thirst
o Decreases urine output
- Also used to control nighttime bedwetting in children.
o Take at night
Nitroglycerin:
- Produces vasodilation, decreases preload and afterload and reduces myocardial oxygen
consumption
o Contra: patients with hypotension, increased ICP, or severe anemia
o Caution: Severe renal or hepatic disease
- Adv. Rx.
o Headache
o Orthostatic hypotension
o Dizziness/weakness
o Faintness
o Flushing/Pallor
o Dry mouth
o Reflex tachycardia
- If chest pain reduces after one nitro tab, give a 2nd dose
- Max dose is 3 over 15 mins. Call 911 after 1st dose
- Routes:
o Sublingual
o IV
o Oral (Tablet)
o Patch

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o Intradermal
- Keep in dark container with childproof lid.
Digoxin:
- Cardiac glycoside
- S/S:
o Bradycardia
o N/V/anorexia
o Diplopia/blurred vision/yellow vision
o Drowsiness/fatigue/weakness
o photophobia
- Given to increases cardiac contractility
o Monitor BP & HR before giving dose
 Assess apical pulse for 1 full minute before giving
 Hold dose if HR <60.
 Hold dose if potassium levels are too low.
- Eat potassium rich foods
o Fresh/Dried fruits
 Bananas
o green leafy veggies
o sweet potatoes
o avocados
- Decrease calcium intake
- Avoid licorice
o can cause hypokalemia
- Therapeutic levels: 0.5-2.0
- Digoxin Toxicity:
o (Early)
 N/V/D
 Anorexia
 Lack of appetite
 Blurred vison
o (Late)
 Drowsiness
 Dysrhythmias
 Palpitations
 Bradycardia
 Hypotension
 SOB.
- Contraindications:
o Ventricular dysrhythmias
 A-Fib
o 2nd and 3rd degree heart block
 Heart Failure
o Renal disease

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o Hypothyroidism
o Hypokalemia
- Avoid OTC meds
Blood Transfusion/Administration
- Transfusion:
o Large bore needle needed
 18 or 20g (for maximum flow rate)
o Cross and Match
 need 2 nurses to verify
 consent needed
o Check bag for
 Volume
 Exp. Date
o Prime tubing with NS prior to infusing
 Y-tubing with filter needed
o Administer within 30 minutes of receiving from blood bank
 stay with patient for the first 15 minutes
 s/s of any Adv. Rx.
o Apprehension
o Rash, hives, itching, swelling
o feeling of impending doom
o lower back/flank
o chest pain
o headache
o fever/chills/diaphoresis
o tachypnea
o tachycardia/thready pulse
o hypotension
o Pallor/cyanosis
o Tingling/numbness
o Abdominal cramping
o Stop infusion
 Change tubing
 Keep line open with NS
 Call MD & blood bank
 Gel lab samples
 Stay with client
o Never throw blood or tubing away from reaction
 Send both blood & tubing back to blood bank
o Never refrigerate
o Monitor VS & lung sounds
 Before Transfusion
 15 min into transfusion
 Q30 min during transfusion

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 1hr after completion
o If NOT used within 30 mins send back to the lab
o Transfuse over 2- 4 hours
o Tubing set should be changed with each new unit of blood administered
o Only compatible fluid with blood
 Normal Saline (NS)
o If history of reaction to blood products
 Pre-medicate with acetaminophen or Benadryl 30 min before infusion
 Administer immediately if ordered IV push
o Begin transfusion slowly
 After 15 min if handled okay, increase rate
o Tx for Adv. Rx.
 Benadryl
 educate it might make them drowsy.
- Universal Donor:
o O-
- Recipient:
o AB+
- Pt with O+ blood receiving B+= stop immediately do not assess first
Nursing Ethics
- (Jehovah Witness – cannot get any blood products)
- Accountability:
o Accepting responsibility for one's own actions.
o Nurses are accountable for their nursing care and other actions.
o They must accept all of the professional and personal consequences that can occur
as the result of their actions.
- Autonomy:
o Upheld when the nurse accepts the client as a unique person who has the innate
right to have their own opinions, perspectives, values and beliefs.
o Nurses encourage patients to make their own decision without any judgments or
coercion from the nurse.
o The patient has the right to reject or accept all treatments.
- Beneficence:
o Doing good and doing the right thing for the patient.
- Fidelity:
o Keeping one's promises.
o The nurse must be faithful and true to their professional promises and
responsibilities by providing high quality, safe care in a competent manner.
- Justice:
o Fairness
o Nurses must be fair when they distribute care, for example, among the patients in
the group of patients that they are taking care of.

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o Care must be fairly, justly, and equitably distributed among a group of patients.
- Non-Maleficence:
o Doing no harm.
o Harm can be intentional or unintentional.
- Veracity:
o Being completely truthful with patients
o nurses must not withhold the whole truth from clients even when it may lead to
patient distress.
Nursing Legal Issues
- Assault:
o Verbally threatening someone.
 Example: “I’m going to throat punch you”
- Battery:
o Physically acting upon that threat.
 Example: Person physically throat punches another person.
- Consent:
o Must be explained and signed by doctor, not nurse.
o Nurse can only witness.
- Defamation:
o “Slander”
o False information against someone
 Example: Saying a nurse lost their license when they did not, or saying a
nurse harmed a patient when they did not.
- Libel:
o Defaming the character of another by means of the written word.
 Example: writing in the patient ‘s chart or writing a note to another nurse
and calling the patient a name or a rumor.
Diuretics
- Used for Fluid Volume Overload
- Expected Outcome:
o Weight loss
o increased urine output
o clear lungs
o decreased edema
- Loop Diuretics: (Furosemide/Lasix)
o Used for pulmonary edema, HF, HTN, CKD, SIADH
o Monitor V/S, sodium and potassium levels, I&Os, weights.
o Adverse Effect:
 Hypokalemia
 Hyponatremia
 Orthostatic Hypotension
 Deafness (tinnitus/ ototoxicity)

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o Instruct patient to increase potassium intake
o Contraindicated with ear disorders.
o Push slow if giving via IV push.
o Elderly can develop confusion or lethargy
o Seizure precautions due to hypocalcemia
 Provide a quiet environment
- Potassium Sparing Diuretics: (Spironolactone)
o Do not give with ACE Inhibitors.
o Monitor V/S, potassium levels, I&Os, weights.
o Hold if SBP <110 or HR <60.
o Adverse Effects:
 Hyperkalemia
 Orthostatic Hypotension
- Thiazide Diuretics: (Hydrochlorothiazide).
o Used for HTN.
o Monitor V/S.
o Hold if SBP <110 or HR <60.
o Adverse Effect:
 Orthostatic Hypotension
 lithium toxicity if taking with Lithium.
- Ace Inhibitors:
o Used to decrease BP and HR.
 Example: Lisinopril, Captopril, Enalapril.
o Do not give with Potassium sparing diuretics (Spironolactone).
o Used for pulmonary edema, HF, HTN.
o Adverse Effects:
 Angioedema
 nagging cough
 hyperkalemia
 orthostatic hypotension
o Hold if SBP <110 or HR <60.
Hearing aides
- Wash with soap and water only
o Do not wash with rubbing alcohol/swabs.
o Don’t submerge under water
- Do not use hairspray if hearing aids are in ears.
- When not using, take the batteries out and keep at bedside
o Start at a lowest setting
- The hearing aid will make an annoying whistling sound when in and out of the ear.
Transfers
- From bed to chair

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o Always use gait belt.
o Place wheelchair or chair on patient’s strong side when getting out of bed.
o Have them pivot with good leg.
o Assess them and their weak side first.
Mental Health
- Anxiety Disorder
o How to manage a panic-level anxiety patient:
 Do not ask them how they are feeling, take them away from the area to a
less stimulating area, use short, direct, clear, expectations with a low and
calm voice, and stay with them!
 Never put them in seclusion or leave them alone.
 Encourage breathing exercises.
 Cognitive behavioral treatment usually prescribed.
 Music therapy, calm environment.
- Suicide
o Males, Native Americans
o Hx of:
 suicide, schizophrenia, major depression
 patients who are just starting antidepressants and have high energy
 poor support system, personality disorder
 family member/friend just died, and they are giving belongings away
 substance abuse, loss of job (negative life changes).
o Have patient sign a safety contract.
- Bipolar in manic phase
o Always assess for s/s of suicide thoughts or ideas.
o Ask if they have a plan!
o Then document and act accordingly.
o Secure their belongings and remove silverware out of room (plastic is ok) and any
other harmful items.
o Initiate one-on-one supervision.
o Crisis hotline: “I’m glad you called; I’d like to send help to you”.
- Schizophrenia
o Uses word salads.
o Command Hallucinations:
 Impossible to divert them.
 Ask them what the voices are telling them.
 Acknowledge the patient but let them know that you do not hear the
voices (bring back to reality).
 Ex: talking to someone not there “don’t make me do this”, ask
what the voices are saying
 More supervision needed, at risk for suicide/harm to others.
 Allow them to open their food and drinks.
o S/S:
 Unkept hygiene

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 Catatonic posturing/excitement
 Waxy flexibility/ mistrust
 Compulsive rituals/over-compliant
 Inappropriate/flat affect
o Safety is priority
- Obsessive Compulsive Disorder (OCD)
o Rigidity and inflexible standards made of time
 performing rituals that interfere with normal routines
 Repetitive behaviors to prevent anxiety
o Characterized by:
 Obsessive
 Violence/aggression
 Sexual behavior
 Indecisiveness
 perfectionism
 with a focus on orderliness and control
 individual might not be able to accomplish a given task.
o Identify for potential self-harm and suicide thoughts
 Identify for triggers
o TX:
 SSRIs
 anti-anxiety meds
 cognitive behavioral therapy
o Be empathetic
o allow time to perform rituals but set limits on behaviors that may affect physical
health.
o Don’t interrupt unless it puts them in harm’s way
o implement a schedule
o establish written contract
o ensure basic needs are met.
- Major Depression
o Affects feelings, thoughts and behaviors
o May be mild, moderate or major
o S/S of Major:
 Hopelessness
 Flat affect
 No facial expression towards emotions
 Guilt and worthless
 Agitation and pace
 Poor posture/ unkept appearance
 Self-destructive thoughts
 Lack of energy
 Intense and pervasive
 Decreased speech
 Social withdrawal

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2023 NUR280 Comprehensive Review 1 Exam with Answers (561 Solved Questions)

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