NUR 4227 Final Exam Review - Part One

The nurse is caring for four post-surgical patients on a medical-surgical unit. Which task is most appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

• Measuring intake and output for a patient with acute kidney injury.

• Administering a PRN albuterol inhaler for a patient with asthma exacerbation.

• Educating a patient on the use of a patient-controlled analgesia (PCA) pump.

• Assessing for bleeding in a patient receiving anticoagulant therapy.

Answer explanation

UAPs can measure intake and output as it is within their scope of practice. Administering medications, patient education, and assessment are responsibilities of the RN.

N.T., a 79-year-old woman, arrives at the emergency room with expressive aphasia, left facial droop, left-sided hemiparesis, and mild dysphagia. Her husband states that when she awoke that morning at 0600, she stayed in bed, complaining of a mild headache over the right temple. He went and got coffee, then thinking it was unusual for her to have those complaints, went back to check on her. He found she was having some trouble saying words and had developed a left-sided facial droop. When he helped her up from the bedside, he noticed weakness in her left hand and leg and brought her to the emergency department. Her past medical history includes paroxysmal atrial fibrillation (PAF), hypertension (HTN), and hyperlipidemia. A recent cardiac stress test had normal findings, and her blood pressure (BP) has been well controlled. N.T. is currently taking flecainide (Tambocor), hormone replacement therapy, amlodipine (Norvasc), aspirin, simvastatin (Zocor), and lisinopril (Zestril).

Question: Based on these clinical findings, which acute event would the nurse be most concerned about?

N. T. is evaluated for an acute neurological event. Which of the following interventions can the nurse delegate to the nursing assistive personnel (NAP)? Select all that apply.

• Obtaining N.T.'s weight

• Assisting N.T. with repositioning every 2 hours

• Initiating oxygen therapy by nasal cannula

• Performing N.T.'s neurologic checks every hour

• Obtaining a manual BP per protocol

The provider has cleared the previous patient for tPa therapy and provided the following instructions:

Concentration: Reconstitute with 50 mL of sterile water to make a total of 50 mg/50 mL (1 mg/mL).

Order: The hospital protocol is to infuse 0.9 mg/kg over 60 minutes with 10% of the dose given as a bolus over 1 minute. The remaining 90% is infused over 60 minutes. N.T. weighs 143 pounds.

Question: What is the bolus dose (in mg) to administer in the first minute? Round to the nearest tenth.

Answer explanation

Answer/Rationale

Usual Dosage Range and Route: 

• 0.9 mg/kg to a maximum of 90 mg

• First 10% of calculated dose as intravenous bolus dose

• Remaining 90% of calculated dose given in infusion over 1 hour

  • 143 pounds/2.2 = 65 kg

  • 0.9 mg/kg X 65 kg = 58.5 mg (total dose)

  • 58.5 mg X .10 (bolus) = 5.9 mg given over 1 minute as bolus

  • 58.5 - 5.85 = 52.7 mg given over 60 minutes for infusion

A nurse is caring for a patient receiving tissue plasminogen activator (tPA) for the treatment of an acute ischemic stroke. During the infusion, the nurse observes the following findings:

• Blood pressure: 180/92 mmHg

• New-onset right-sided hemiparesis

• Complaints of a severe headache

• Heart rate: 92 bpm

Question: Which of the following actions should the nurse take first?

• Stop the tPA infusion immediately.

• Administer labetalol IV to lower the blood pressure.

• Notify the provider of the patient’s condition.

• Prepare the patient for a stat CT scan.

Answer explanation

Rationale:

The nurse's first action should be to stop the tPA infusion immediately, as the symptoms (new hemiparesis, severe headache, and uncontrolled blood pressure) indicate the possibility of an intracranial hemorrhage, a known complication of tPA. Lowering the blood pressure is important but not the immediate priority. The provider must be notified, and a CT scan is critical to confirm the diagnosis, but stopping the infusion is the first and most urgent action to minimize potential harm.

A nurse is caring for a patient who is 12 hours post-craniotomy for the removal of a brain tumor. Which of the following interventions should the nurse prioritize? Select all that apply

• Maintain HOB 10-15 degrees.

• Encourage frequent coughing and deep breathing exercises.

• Monitor for clear drainage from the surgical site or nose.

• Administer Decadron (dexamethasone) as prescribed.

• Assess for new onset of severe headache or vomiting.

Answer explanation

Rationale:

Correct:

• C: Clear drainage may indicate cerebrospinal fluid (CSF) leakage, requiring prompt attention.

• D: Dexamethasone is often used to manage cerebral edema and decrease ICP post-craniotomy.

• E: Severe headache or vomiting could indicate increasing ICP or other complications.

Incorrect:

• A: HOB should be elevated to at least 30 degrees to reduce intracranial pressure (ICP).

• B: Excessive coughing can increase ICP and should be avoided unless absolutely necessary.

The nurse is caring for a patient 24 hours post-craniotomy. Which of the following findings requires the nurse to contact the provider immediately?

• Scant serosanguinous drainage from the surgical dressing.

• Blood pressure: 152/86 mmHg.

• Pupillary asymmetry with sluggish reaction to light.

• Mild headache rated 3/10 on a numeric pain scale.

Answer explanation

Rationale:

Pupillary asymmetry and sluggish reaction to light may indicate increased ICP or brain herniation, which are medical emergencies. Mild serosanguinous drainage is an expected finding post-craniotomy, and a mild headache is common. A slightly elevated blood pressure should be monitored but is not immediately concerning unless there are other signs of increased ICP.

A nurse is caring for a patient admitted with a suspected spinal cord injury after a motor vehicle accident. Which action should the nurse prioritize upon the patient’s arrival to the emergency department?

• Immobilize the cervical spine using a collar and backboard.

• Obtain a detailed history of the accident from the patient.

• Monitor vital signs for signs of neurogenic shock.

• Administer intravenous methylprednisolone as prescribed.

Answer explanation

Rationale: The first priority in a suspected spinal cord injury is to stabilize the spine to prevent further damage. Other actions, such as administering medications, monitoring vital signs, and obtaining history, are important but secondary to immobilization.

A patient with a T6 spinal cord injury reports a pounding headache and blurred vision. The nurse notes a blood pressure of 210/110 mmHg and a heart rate of 50 bpm. What is the nurse’s first action?

• Lower the head of the bed to improve circulation.

• Administer antihypertensive medication as prescribed.

• Call the provider immediately to report the symptoms.

• Check for a distended bladder or bowel impaction.

Answer explanation

The patient is experiencing autonomic dysreflexia, a medical emergency commonly triggered by noxious stimuli below the injury level, such as bladder distension or bowel impaction. The nurse’s first action is to identify and resolve the trigger.

The nurse is caring for four patients with neurological injuries. Which patient should the nurse assess first?

• A patient with a spinal cord injury at T6 who reports a pounding headache and blurred vision.

• A patient with a concussion who is confused but responsive and has a Glasgow Coma Scale (GCS) of 14.

• A patient post-craniotomy with a small amount of serous drainage noted on the surgical dressing.

• A patient with a history of a transient ischemic attack (TIA) who is experiencing slight left-sided weakness.

Answer explanation

Rationale: The patient with a spinal cord injury reporting a headache and blurred vision is likely experiencing autonomic dysreflexia, a life-threatening condition requiring immediate intervention to resolve the triggering cause. The other patients’ conditions, while concerning, are not as acute.