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COMPREHENSIVE EXAMINATION

Master of Science in Nursing


Major in Medical-Surgical Nursing
1. You are caring for a 90 year old man with end-stage heart
failure in a hospital chronic unit. There are peripheral edema
and cachexia with dyspnea at rest and with activity
intolerance.
a. What daily assessments should you do? Elaborate briefly.
Assess edematous areas every shift for skin break down. Assess
patient daily for nocturia and monitor input and output every shift to
monitor fluid balance. If possible weigh patient daily to monitor fluid
retention and weight reduction. Assess for nausea, vomiting and
anorexia. Assess also for orthopnea, cough, palpitations, dizziness
and syncope to determine level of activity that can be performed.
Assess for paroxysmal nocturnal dyspnea. If present we should also
assess the number of pillows the patient is using during sleep.
Assess behavioral changes such as restlessness, confusion, and
decreased attention span or memory. Assess the skin for
diaphoresis, cyanosis and pallor in the skin. We should also assess
the Respiratory Rate and breath sounds. Assess the heart rate,
presence of S3 and S4 and distended neck veins. Lastly we should
also assess the abdomen for distention, hepatosplenomegaly,
ascites, RUQ pain, and discomfort.
b. What are your strategies to relieve anxiety of significant
others?
One way of decreasing the significant others of the patient is by
allowing them to ask questions for it relieve some anxiety by having
accurate information. We should always inform and explain to the
relatives of the patient the things that we are doing (why it is
necessary and how will it help the patient) which includes the daily
nursing assessment, interventions and care we render to the patient
so that their anxiety will be lessen and may be able to participate in
the plan of care for the patient.
c. How will you initiate conversation to prepare the patient
and his family of the impending death? Discuss.
d. Give ways to relieve discomfort of the patient.
Have patient rest in bed or chair when tired to reduce
work. Provide emotional and physical rest to reduce
consumption and to relieve dyspnea and fatigue. Have
sleep with two or more pillows to relieve dyspnea. Elevate

cardiac
oxygen
patient
head of

bed to Fowlers position to improve ventilation by decreasing


venous return to the heart and increasing thoracic expansion.
Support patients arms with pillows to move arms off and away
from chest to facilitate breathing. Use footboard to give patient a
surface to press feet against to improve circulation through muscle
contraction. Administer oxygen via nasal cannula to improve
oxygen saturation and relieve dyspnea and fatigue.
2. A newly diagnosed 47 year old woman of asthma came to the
emergency room due to exacerbation of her symptom of
difficulty of breathing. She is a smoker.
a. What health educating tips should be covered?
Discuss about the negative and harmful effects of smoking to
health. Explain effect of dehydration on sputum production and
consequent effect on bronchospasm. Discuss about the different
triggers of asthma. Assist in identifying factors that precipitate
attacks to develop plans to prevent them. Teach patient to seek
medical attention if taking medicine does not relieve attack or if
dyspnea occurs at night. Teach patient technique of breathing in
through nose and out through pursed lips, two to three times to
prevent bronchiolar collapse and maintain open airways.
b. What nursing care plan would you do for her?
Nursing Diagnosis: Ineffective breathing pattern related to
increased airway resistance caused by bronchospasm, mucosal
edema and mucus production as manifested by dyspnea, wheezing,
rapid respiratory rate, and use of accessory muscles.
Outcome Criteria: Have absence of wheezing, dyspnea and
chest tightness, return of appropriate breath sounds indicating
better airflow, respiratory rate of 12 20/ min;
Nursing Interventions: Provide comfortable position (bed rest
in high Fowlers position or recliner chair) to maximize chest
expansion and promote prolonged expiratory phase to reduce
trapped air. Administer bronchodilators as ordered to treat
bronchospasm. Administer O2 as ordered to increase oxygen
saturation, Auscultate breath sounds to monitor effectiveness of
treatment and patient status. Assess BP, HR, respiratory rate and
level of consciousness to determine change in status. Premedicate
with bronchodilators before doing deep breathing and coughing
exercises or chest physiotherapy to open airways for more efficient
movement of sputum toward mouth. Teach patient to breathe
deeply through the nose and exhale two to three times as long as
inspiration through pursed lips to remove trapped air and increase
PaO2. Assess and document breathing pattern including respiratory

rate, depth, relationship of inspiration to exhalation, use of


accessory muscles, presence of chest discomfort to provide ongoing
parameters to measure effects of treatment.
c. What non pharmacologic intervention would you initiate?
Provide comfortable position (bed rest in high Fowlers position or
recliner chair). Teach patient to breathe deeply through the nose
and exhale two to three times as long as inspiration through pursed
lips.
3. A 72 year old man who has COPD from being a coal miner has
pneumonia on his right lower and middle lobes. To help
mobilize and drain his secretions, a CPT was prescribed. This
patient only wants to sit in bed because it helps him breathe
better.
a. Discuss the most important nursing considerations and
interventions in a patient having CPT?
Perform procedure 1 hour before meals or 1 3 hours after
meals. Administer bronchodilators as ordered 15 minutes before
the procedure. Help patient assume correct position for postural
drainage based on finding from x ray, auscultation, palpation and
percussion of chest. Position should be maintained for 5 15
minutes to mobilize secretions via gravity. Observe patient during
treatment to assess tolerance. Particularly observe breathing and
color changes, especially duskiness in face. Have patient take
several deep abdominal breaths. Percuss appropriate area for 1 2
min. Vibrate the same area while the patient exhales 4 5 breaths.
Assist patient to cough while assuming same position. Splinting with
towel or hands may be necessary to aid in effective coughing.
b. What health teaching can you give to the patient?
Enumerate and discuss briefly.
Encourage patient to continue on full course of antibiotic therapy
to prevent relapse of pneumonia and development of resistant
strains of the organism. Instruct patient on importance of rest and
limited activity to maintain progress toward recovery and prevent
relapse. Encourage patient to obtain adequate rest, nutrition and
fresh air to assist healing process. Teach patient to continue
coughing and deep breathing exercises to remove secretions and
improve ventilation. Teach patient importance of follow up care
and need to seek medical attention for symptoms related to
respiratory infections to prevent relapse. Teach patient to cover
nose and mouth during sneeze or cough and to use tissues when

coughing and expectorating sputum


contribute to the spread of infection.

to

reduce

factors

that

c. Give your nursing care plan for this patient.


Nursing Diagnosis: Ineffective breathing pattern related to
pneumonia, anxiety, and pain as manifested by rapid respirations,
dyspnea, tachypnea, nasal flaring, altered chest excursion, inability
to lie down.
Outcome Criteria: Have respiratory rate of 12 20
breaths/min; express feeling of comfort.
Nursing Interventions: Assess degree of pain and anxiety to
provide guidelines for intervention. Take vital signs and auscultate
lungs q2 4 hr. to provide ongoing data on patients response to
therapy.
Administer oxygen as indicated to maintain optimal
oxygen level and increase patients comfort. Decrease anxiety
(relaxation techniques, diversion) and provide a quiet, restful
environment to encourage rest and to prevent a relapse. Position
patient in semi Fowlers or other comfortable position for
breathing to maximize lung expansion. Prepare patient for CPT.

4. An 85 year old woman is admitted at a medical surgical


ward and complaining of a sudden onset of very sharp and
severe pain in her flank. A CT scan of the kidneys showed renal
stones in both ureters.
a. Discuss assessment methods for pain.
Investigate pain which may be indicative of infection: location,
duration, intensity;
b. Give some non pharmacological pain relief and discuss
rationale.
Hydration has remained the mainstay of any treatment program
aimed at preventing kidney stones. Stones form by the
crystallization of one or more substances which exist in high
concentrations in the urine. Increased fluid intake will decrease the
chance of stone formation by maintaining a high urinary output and
by decreasing the likelihood that these substances will crystallize by
diluting them. There are no strict recommendations with regards to
the number of glasses of fluid to drink, however, the goal should be
to achieve a urine output of greater than two liters per day. Stones
that are less than 5 millimeters in size have a high chance (90%) of
passing through the urinary tract spontaneously with hydration
therapy alone. Larger stones (>6 millimeters) have a much lower

chance of passing
intervention.

on

their

own,

and

often

need

surgical

Dietary modifications can reduce the chance of stone formation


for certain stone types. Therefore, each patient should seek the
advice of their urologist before changing their diet. In general, a diet
low in animal protein, sodium, and oxalate can reduce the chance of
calcium oxalate stone formation. Foods rich in oxalate include:
chocolate, tea, spinach, asparagus, and nuts. A diet rich in fiber is
also advised. Patients should not restrict dairy products, but should
avoid overindulgence - i.e. no more than 3 glasses of milk a day.
c. When and how will you stop pain medications and elaborate
briefly
Pain relievers can help control the pain of passing the stones
(renal colic). For severe pain, you may need to take narcotic pain
killers or nonsteroidal anti-inflammatory drugs (NSAIDS) such as
ibuprofen.
5. A 25 year old male patient is scheduled for below knee
amputation of the right lower extremities due to osteosarcoma
stage II.
a. Discuss the pre op preparation for this patient.
1. Provide care preoperatively by initiating exercise to
strengthen muscles of extremities in preparation for crutch
walking.
2. Encourage coughing and deep breathing exercises.
3. Monitor vital signs and stump dressing for signs of
hemorrhage.
4. Elevate stump for 12 to 24 hours to decrease edema.
5. Maintain elastic bandage to shrink and shape stump in
preparation for prosthesis.
6. When wound is healed, wash stump daily, avoiding the use of
oils which may cause maceration.
7. Apply pressure to the end of the stump with progressively
firmer surfaces to toughen stump.
8. Encourage the client to move the stump.
9. Place the client with a lower extremity amputation in a prone
position twice daily to stretch the flexor muscles and prevent
hip flexion contractures.
10. Teach the client about phantom limb sensation.
11. Support the client through fitting, application, and
utilization of prosthesis.
12. Encourage family to participate in care.
13. Allow the client to express emotional reactions.

b. If he will be given spinal anesthesia, what are the probable


complications and how will you monitor for these
complications?
Spinal anesthesia medicine is injected into the fluid that
surrounds the spinal cord (cerebrospinal fluid). The most common
complication of spinal anesthesia is a headache caused by leaking
of this fluid. It is more common in younger people. A spinal
headache may be treated quickly with a blood patch to prevent
further complications. A blood patch involves injecting a small
amount of the person's own blood into the area where the leak is
most likely occurring to seal the hole and to increase pressure in the
spinal canal and relieve the pull on the membranes surrounding the
canal.
c. Is there a need for using the Aldrete Scoring for this
patient? Why?
I think Aldrete Scoring is a must in every surgical procedure to
determine if the patient is ready for that surgical procedure. Another
one is with Aldrete scoring we can determine if there are obvious
complications that the patient experiences. Lastly I do believe that
most of the hospitals requires aldrete scoring before and after
surgery, upon admission and discharge.
6. How do you respond to an apneic patient with desaturation?
7. Enumerate the equipments that you have seen at the ER and
tell something about them.
8. How will you participate in a Code Red situation?
Try to manage the patients as quickly and safely as possible and try to
work with other members of the health care team so that when the Code
Red is finished all tasks are fulfilled and the ward is now ready to cater to
other patients.
9. What are the roles of nurse in Anesthesia Care Unit?
The PACU nurse is responsible for taking a patient's vital signs
following surgery, including blood pressure, respirations, lung sounds and
pulse. This means having proper training and knowledge for all related
equipment, including blood pressure monitor, cardiac monitoring, pulse
oximeter and other oxygen devices. For example, for a patient who
requires cardiac monitoring, the PACU nurse must know how to connect
the patient to a cardiac monitor (typically a 12-lead) and how to interpret
the results. The vital signs are typically recorded every 5 to 15 minutes
until the patient's vital signs are stable and at pre-admission levels. When
this occurs, the patient is either moved to a room to be admitted to the
hospital or discharged home.
A large part of the PACU nurse's responsibilities lies in pain
management for the post-operative patient. This means having

knowledge of pain medications and their effects, as well as knowing how


to properly administer them. Sometimes, the post-operative patient
requires a PCA (patient controlled analgesia) pump and IV fluids or
infusions. The PACU nurse must know how to set up the PCA pump, as
well as instruct the patient in how to use it.
Taking care of post-operative patients isn't the only responsibility of the
PACU nurse. Maintaining a safe environment, not just in the PACU, but
hospital-wide is also important. This means knowing the correct safety
procedures, including proper handling of hazardous material or waste. The
PACU nurse must also be aware of proper fire safety procedures.
Additionally, the PACU nurse is also responsible for knowing the location
and proper use of personal protective equipment, including latex gloves,
masks and goggles.
The PACU nurse's most important responsibility is to maintain proper
certification. This includes keeping up with certifications in advanced
cardiac life support (ACLS), CPR (cardiopulmonary resuscitation), and if
applicable, pediatric advanced life support (PALS). Additionally, nurses are
also required to take CEUs (continuing education units), which help in
maintaining their nursing certification.
10.

How can you promote infection control?


Email Attachments

Include infection control tips (e.g. hand washing steps, common


cold / flu symptoms) and upcoming events (e.g. flu shot clinics). We
can include complete hand washing steps with pictures, tips on how to
keep your family from getting sick, and ways to keep your immune
system strong.
Lunch and Learn
Host a presentation to educate the community on a variety of
infection control topics. Doctors or nurses can come in to talk about
the flu and the best ways to protect against it (this can be teamed up
with a flu shot clinic). Food handlers can talk to employees about safe
storage / handling of foods to guard against illness.
Infection Protection Health Fair
Invite organizations to provide handout materials to the issues
related to the theme. Health professionals to invite could include food
safety educators, Registered Nurses, Registered Dietitians, Certified
Asthma Educators, Respirologists, Veterinarians, and internal Health
and Safety representatives from your workplace. Organizations could
include your local Public Health department, internal food service

providers,
centres.

cleaning

product

suppliers

and

community/recreation

Get Caught Practicing Infection Protection


Practicing a healthy lifestyle including eating balanced meals,
being active on a regular basis and managing stress are important
ways that we can boost our immune system. This can help to reduce
the susceptibility to many infectious diseases. Also important are using
proper hand washing and sneezing techniques, and getting an annual
flu shot.
Beat the Bite
Raccoons, skunks, bats, dogs, cats, and mice: furry friends or
infected foe? Educate the people in the community about keeping their
homes, families, and pets safe from potentially infected small animals
that are commonly found in our urban and rural areas. Host an
education seminar and invite a local Veterinarian or the Humane
Society to deliver a presentation that outlines how to "animal proof"
your home or cottage before winter, how to safely and humanely deal
with nesting sites, how to recognize the signs of an animal that is
infected with a disease, and steps to take if you have been bitten or
scratched by a wild animal.