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N120 FINAL REVIEW

WEEK 1 & 2 REVIEW 15) Delegate UAP/CNA to


1) Nurse finds new spot on wound  Measure fluids
dressing  Label containers
 Assess VS  Transport pt
2) Pt worries about iodine turning skin  Pt TQ2
brown  Oral care
 Inform pt that it’s normal 16) Delegate LVN to
3) Intervention for pt with ↓ SaO2,  Give PO meds
crackles in lungs, & temp of 99.8  Suctioning
 Encourage IS use 17) Child has G-tube, adequate
4) Consent form not signed understanding by mom
 Ask pt first  HOB at 30-40 degrees
5) DM pt about to exercise 18) NG suction pt c/o nausea, ABD pain
 Use medic alert bracelet  Check suction machine
6) Conditions for PCA use by pt 19) Circulating nurse breaks sterile field by
 When pain occurs  Scratching leg
7) Blood glucose assessment frequency  Dropping equipment
for hypoglycemic pt after giving orange 20) Priority intervention for pt c/o ABD
juice pain 8/10
 Q15min  Ask about pain
8) Pt on metformin concerned w/ 21) C-diff precautions
stomach upset  Contact precaution/isolation
 Inform pt that it’s normal 22) Pt is vomiting
9) Adequate learning of hip surgery by pt  Place pt in lateral position
 Call surgeon in case of 23) DM med routes
drainage  Oral
10) Priority DM pt  IV
 Hypoglycemic pt  IM
11) Pt has ileostomy and expresses disdain 24) Evisceration management
 Ask pt about their concerns  Use sterile technique
12) Pt newly diagnosed w/ DM 25) Intervention for pt c/o HA post-surgery
 Assess pt’s knowledge of DM w/ general anesthesia
13) In-home interventions for DM  Lay pt flat
 Diet 26) Abnormal urine labs
 Exercise  ↑ WBC
 Meds  ↑ protein
14) Priority intervention for constipated pt  ↑ RBC
 Assess for complications  Bacterial presence
N120 FINAL REVIEW
27) Administering ABX for surgery 39) Intervention for cherry red stoma
 Administer before initial  Assess in 30 minutes
incision  Document
28) High risk for DM2 40) Intervention for pt newly diagnosed
 Overweight child who doesn’t with IBD
participate in recess  Allow pt to voice concerns
29) Post-surgery pt is shivering w/ temp of 41) Intervention for pt about to undergo
96.8 post-op ambulation
 Give a blanket  Administer analgesics
30) Pt w/ DM alert given carbs 42) Intervention for post-op pt
 Assess blood glucose after 15  Assess VS Q15min
min 43) Pt displays adequate understanding of
31) Diet for pt w/ acute GI disorder GERD
 NPO  Pt will eat 3 balanced meals
 IV fluids Qday and a snack AHS
32) Diet for GERD pt 44) Pt displays adequate understanding of
 Avoid caffeine, chocolate, oily insulin
food  Pt will inject insulin anywhere
33) Education for preventing post-surgery in ABD
complications 45) Pt is hyperglycemic & feeling hot, nurse
 TCDB should NOT
 ROM exercises  Give carbs
 Pneumatic compression 46) Insulin administration to same site
devices  ↓ absorption
34) DM pt loses sensation in foot  Scarring
 Check for injury in foot 47) DM management priority
35) Footwear for DM pt  Monitor diet
 Fitted shoes and socks 48) Before giving DM pt bath
36) Priority assessment for pt w/ regional  Check water temp
anesthesia 49) DM diet
 Return of sensation to lower  Complex carbs
extremities  Low glycemic index
37) Priority assessment for pt scheduled for 50) Intervention when nurse notices
contrast pre-GI surgery problem with surgery site
 Allergies to shellfish or iodine  Contact surgeon
38) Intervention for evisceration 51) Pt about to ambulate w/ therapist
 Cover w/ sterile gauze  Administer pain meds
 Pt knees bent 52) Risk factor for malignant hyperthermia
 Pt in semi-fowler  Genetics
N120 FINAL REVIEW
53) Improve skin integrity in DM pt 8) Decrease incidence of catheter
 Keep glucose w/in normal infection
range  Don sterile gloves
54) Insulin drip indication 9) Home catheterization management
 DKA  Wash hands w/ antibacterial
55) Assess before insulin drip soap first
 K+ levels 10) Education for pt taking narcotics
56) Crohn’s vs. UC  ↑ fluids for constipation
 Crohn’s affects entire GI tract 11) Inform pt about pyridium
 UC affects only colon  Urine will be orange
57) Diagnostics for Crohn’s & UC 12) Intervention for confused pt w/
 Endoscopy tachypnea
 Double barrel colostomy  Assess SaO2
58) Crohn’s & UC common sign 13) Pt has temp of 100.3, nurse should be
 Diarrhea concerned about
59) Significance of stress in peri-op  Infection
 Affects post-op recovery 14) UTI prevention
 ↓ reduce stress to ↓  Drink 1-2L of water Qday
 Void if possible Q4h
WEEK 3 & 4 REVIEW  Wipe front to back
1) Fracture pt RN delegation 15) Sign of UTI traveling from bladder to
 Long arm ROM test kidneys
2) Valves in cast  Flank pain
 Adjacent to affected site 16) Labs to order w/ loop diuretic
3) Intervention if pt has cramps  K+ levels
 Check electrolyte labs 17) Nurse to interfere w/ UAP if
4) Ankle fracture first intervention  UAP is DC’ing a cath
 RICE  UAP brings HOB to 15 deg
5) Intervention for football player w/ 18) Buck’s traction works if
sprain  Pt shows no/minimal pain
 Elevate extremity 19) Pt has stage 3 ulcer, nurse would
6) Pt requires more education for hip anticipate this to check for systemic
surgery response
 Pt can sleep any way the want  WBC lab order
7) Pt requires long-term healing, what 20) Transverse fracture to right femur
question to ask pt results in
 Is pt willing to go to long-term  Acute pain r/t muscle
rehab 21) Risk factor that places geriatric at
greatest risk for falls
 ↓ bilateral hearing
N120 FINAL REVIEW
22) Intervention for 32 y.o. adult w/ ORIF 35) Care plan for Buck’s traction pt
w/ severe pain & ↑ HR  Assess key pressure points Q2-
 Notify MD 4h
23) Abnormal post-surgery finding 36) Pressure ulcer w/ subcutaneous
 Cap refill >3 to big toe damage
24) Discharge teaching for pt w/ fracture  Stage 3
 Use blow dryer on cool to 37) Pt at greatest risk for UTI
relieve itch  DM pt
25) Pt w/ below knee amputation c/o pain, 38) Educate UTI pt on ABX to
nurse should  ↑ fluid intake
 Administer pain meds 39) Fracture pt diet
26) Abnormal finding for fracture  Vitamins A, D, E
 Pain unrelieved by  Protein
opioids/analgesics  Fats
 Affected leg swelling 40) Skin traction indication
 Numbness  Alignment
27) Can a pt at risk for falls have scatter 41) Alignment prevents
rugs in home  Avascular necrosis
 No  Pain
28) Pt at risk for falls 42) Greatest concern for fracture
 Pt w/ hx of falls  Compartment syndrome
29) Intervention for external fixation pt 43) Compartment syndrome S/S
 Check and clean pin insertion  ↑ swelling & pressure at site
sites daily 44) Greatest concern for long bone/pelvic
30) ORIF pt is SOB fracture
 Check troponin  Fat embolism
31) Pt w/ stage 1 ulcer, nurse should 45) Preventing hospital-acquired UTI
question  Avoid unnecessary
 Debriding would w/ wet to dry catheterizations
32) Pt at greatest risk for osteomyelitis 46) Fat embolism s/s
 Leukemia pt  Restlessness (early sign)
33) Further education required for post-  Petechiae
arthroplasty pt 47) Greatest concern for bladder infection
 Pt rises from armless chair  Flank pain
34) Pt w/ SOB and says “I feel like I’m going 48) Diagnostics for UTI
to die”  Urinalysis
 Elevate HOB and administer  24 hr urine collection
O2  Urine culture & sensitivity test
N120 FINAL REVIEW
49) Abnormal UTI lab findings 10) Pt becomes SOB while walking down
 ↑ proteins hall
 ↑ RBC  Administer O2
 ↑ WBC 11) Method to obtain specimen from pt w/
50) Significance of steroids weak cough
 Suppresses immune system  Suction
51) Labs to monitor w/ steroids 12) ST segment elevation affects
 WBC  Ventricular repolarization
13) MI S/S
WEEK 5 & 6 REVIEW  Weakness in arms
1) P-wave significance  Diaphoresis
 Electrical impulse starting at  Severe apprehension
SA node 14) Atrovent action
 Arterial muscle depolarization  ↓ fluid production in glands
 Duration of ≤0.11 sec that line respiratory tract
2) HOB elevation significance 15) ABG for PNA pt
 Prevent aspiration  ↓ pH
3) Ipratropium drug class  ↑ CO2
 Anticholinergic 16) ↑ fluids and effective coughing
4) Intervention for ipratropium  Promotes airway clearance
 Observe for dry mouth due to 17) Adequate understanding for PNA pt
↓ fluid production  Pt continues to perform deep
 Give candy to ↑ salivation breathing & coughing
5) Pt w/ MI, assess these levels exercises
 Troponin 18) Abnormal finding after administering
6) Pt w/ atherosclerosis, which levels are sulfa
elevated  Urticaria (allergy to med)
 Lipids 19) Pt is restless and confused, priority
7) Coarse crackles at base of lungs intevervention
indicates  Assess VS
 PNA 20) Pt admitted for SOB w/ coronary artery
8) Pt is SOB, priority assessment is exacerbation; crackles upon
 Airway auscultation to anterior indicates
9) Populations at risk for developing PNA  L-side HF
 AIDS/HIV 21) Number of acid-fast tests for TB
 On mechanical ventilation  3 negative tests
 Dysphagia 22) TB complication
 CNS trauma/depression  Ghon lesions
 Immunosuppressed 23) TB pt difficult to treat
 AIDS/HIV pt
N120 FINAL REVIEW
24) HIV pt w/ TB, associated bacteria 38) Heart disease modifiable facts
 P. jiroveci  Smoking
25) DOT for transients  Diet
 Bring in w/ food at homeless  Exercise
shelter  Job
26) Assessing medication compliance 39) Highest priority pt
 “Have you been taking your  Geriatric w/ comorbidities
meds?” 40) Enoxaparin indication
27) Interfere w/ student nurse taking care  Clot development prophylaxis
of TB pt when for pt at risk
 Student nurse puts on surgical 41) Narcan indication
mask  Morphine use leads to
28) Mask to use for TB pt respiratory depression
 N95/HEPA mask 42) Inhalation effect on alveoli
29) Nitro route  Creatives positive pressure in
 Sublingual alveoli
30) Priority respiratory pt 43) Significance of collateral circulation
 Pt w/ ↓ pH & ↑ CO2  Blood can bypass clots
31) Greatest concern for A-fib 44) Cardioversion indication
 Clots  A-fib
 Embolism  SVT
32) Abnormal A-fib lab 45) Coumadin indication
 Digoxin is 2.8  Clots due to a-fib
33) Pt w/ digoxin level of 3.8, priority 46) Digoxin action
intervention  ↑ cardiac output
 Administer Digi-bind 47) Significance of QRS complex
34) Pt on atenolol displays unchanged BP,  Ventricular depolarization
priority intervention 48) Pt on Lisinopril concerned about cough
 Ask if pt is taking meds  Inform pt that it’s normal
35) Pt c/o dizziness when standing 49) Cardioversion shock timing
indicates  Downslope of R-wave
 Orthostatic HoTN 50) PTCA site of entrance
36) Atherosclerosis meds  Femoral artery
 Statins 51) PTCA intervention
37) Early hypoxia S/S  Inform pt to stay in position
 Tachy for 6-12 hrs
 Tachypnea 52) PTCA complication
 Restlessness  Swelling
 No urination
N120 FINAL REVIEW
53) Lack of urine post-op
 Indicates hemorrhage
54) Angina pectoris tx
 Rest
 Relaxation
 Nitro
55) Time it takes for MI to reach full-
thickness ischemia
 1-1.5 hrs
56) Length of time heart can last after full-
thickness ischemia
 20 minutes
57) MI tx
 Morphine
 O2
 Nitro
 Aspirin
58) Common start of cardiac problems
 Arteriosclerosis

WEEK 7 & 8
1) Hemianopsia education
 Tell pt to look 360 deg
2) L-side CVA signs
 Language deficit
 Loss of meaning in objects
3) R-side CVA signs
 False sense of confidence
 False sense of mobility
4) CVA diagnostics
 CT scan
5) CVA med
 Activase
6) Activase contraindication
 Hemorrhagic stroke
7) CNS depression puts pt at risk for
 PNA due to aspiration

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