1. FALL 2010
Nurs -3164-M02 (Wed) and M01 (Mon)
Exam 2 Blue Print
October 19th, 2010
Exam begins at 8:30 a.m. – Be in the large computer lab by 8:15a.m. Place all books, keys, ID’s etc in
the printer room or your locker. You may only have a pencil at your computer cubicle. We will
provide scratch paper. Failure to have your area cleared, or you are on a program other than par
score at 8:20 a.m. will result in a 5 point test score deduction.
Class will be held after the exam at time announced by faculty
*The following is intended to be a guideline for study and not intended to be 100% inclusive of all
questions / topics.
The following is a “guided study” for Exam 2. It is intended to “guide and not necessarily to give
reference to each question.
• Knowledge level questions – answers are almost verbatim from resource
• Comprehension – student must know a piece of information about the topic in order to answer
the question
• Application – Usually involves what action the nurse is taking
• Analysis – analyzing data such as in development of a nursing diagnosis.
You will have approximate 1 – 1 ½ minutes per question. It is important that you decide on your best
answer PRIOR to moving forward; you may not go back to previous questions.
Nursing Process:
Topics for review:
Overview of purpose of nursing process
Knowledge of the steps of the nursing process
Assessment – components of assessment aspect
Development of clusters – and identifying the nursing problem / diagnoses
Components of the PES format
The “rules” of each aspect of the PES format
Differentiating between risk versus actual diagnosis

2. Steps of the Nursing Process
Activities that take place within each step of the Nursing Process
Prioritizations of Nursing Diagnosis
Use of goals / outcome criteria
Formation of nursing diagnosis
Example of a NP question:
The nurse has assessed the patient and identified the cluster of : dry mucus membranes, skin turgor
greater than three seconds, patient stating he hasn’t been able to “hold anything down for two days”.
Which nursing diagnosis best fits this cluster?
A. Nutritional imbalance less than body requirements r/t decreased food intake
B. Fatigue related to lack of energy
C. Fluid volume deficit related to lack of sufficient fluid intake
D. Risk for fluid volume deficit related to stomach virus
Ans: C – These “signs and symptoms” most strongly suggest that the patient is having a problem
with dehydration which is described in nursing diagnosis “language” as fluid volume deficit
Skin Integrity and Wound Care
Focus is on assessment and nursing interventions. Guided topics for review include but are not
necessarily limited to:
• Types of wound irrigation as well as purpose of irrigations
• Pressure sore staging and nursing interventions related to each stage
• Dehiscence and evisceration – assessment of / related nursing interventions
• Documentation on wounds
• Nursing interventions for maintaining skin integrity
• Packing wounds with moist / wet to dry dressings
• Use of abdominal binders – nursing implications
• Types of wound drainage / inherent implications
• Patients most at risk for developing pressure ulcers
• Significance of blanching / non blanching skin
• Care of skin that demonstrates potential for breakdown
Vital Signs / Oxygenation
Signs and Symptoms of decreased oxygen levels

3. Nursing interventions related to decreased oxygen levels
Nursing interventions related to abnormal vital signs
Implications of low pulse oximetry levels
Concept of orthostatic hypotension / related nursing care
Relationship of blood pressure taking and mastectomy patient
Factors that may increase or decrease vital signs (temp, pulse, BP
Methods to check oxygenation levels
Signs of early hypoxia
Nursing interventions related to decreased oxygenation
Understanding of terms such as: dyspnea, eupnea, fremitis, orthopnea
Relationship between pain and vital signs
Delegation of vital sign tasks to unlicensed health team members (ie nursing assistants)
Sample question:
A client comes to the E.D. complaining of difficulty breathing due to asthma attack. Which assessment
will the nurse do initially?
A. Family History
B. Pulse oximetry
C. Oral temperature
D. Blood pressure
Ans. B – Pulse oximetry will give an immediate picture of the patient’s oxygenation levels. The others
will all be done, however the stems asks “Initially”. Airway and breathing are priority areas of
assessment.
Sample question:
A patient had an appendectomy the previous day. On the third postoperative day, his temperature is
101 degrees orally. What action will be appropriate for the nurse to take upon this finding?
A. Have the nursing assistant retake the temperature
B. Report it to the physician
C. Administer ordered Tylenol for fever above 100.8 degrees orally
D. Assess the patient’s wound for signs and symptoms of infection
Ans: D. All are appropriate interventions; however initially, the nurse further investigates an abnormal
vital sign to identify possible causes that may need additional attention
Medication Administration:
Topics to review include but are not limited to:
Implications related to Pharmacokinetic factors
Concepts related to anaphylactic shock:
Patient’s at risk for medication toxicity
Legal implications related to medication / narcotic use

4. Safety measures for the administration of oral medications
Appropriate procedures for administering medications through N/G tube
Review of sites for IM / Subcutaneous/ID injections
Sample Questions:
The nurse has administered an antibiotic to a patient per IV. Which assessment observation will indicate
to the nurse that the patient is probably having an allergic reaction? Choose all that apply?
A. Complaining of stinging at the IV site.
B. Complaining of nausea
C. Breaking out in a rash
D. Complaining of itching
ANS. CD – Itching and rash are more indicative of allergic reaction that options A or B. Nausea may be a
side effect of the medication, but not usually an allergic reaction. Stinging at IV site may relate more to
the ingredients of the medication and usually does not indicate allergic response.
Which of the following patients will be most likely to experience greater side effects or adverse effects
to medications?
A. A malnourished 85 year old patient
B. A 45 year old patient with diabetes
C. A 76 year old patient with COPD
D. A 30 year old patient with arthritis
Ans. A The malnourished 85 year old is deficient in protein. Protein molecules provide receptor sites for
medication particles. The medication that is “bound” to the protein does not cause the intended
outcome. Only unbound particles travel to the site of action and create the intended effect. Because
the woman is malnourished, she will have MORE than desired medication particles delivered to the site
of action, hence increased opportunity for greater side or adverse effects.
A patient has chronic renal failure. Which aspect of the pharmacokinetic process will the nurse be
concerned about?
A. Absorption
B. Distribution
C. Metabolism
D. Excretion
Ans. D - Most medications are excreted through the kidneys. Disease of the kidneys may prevent
medications from being excreted efficiently and patient may experience additional side effects.

5. Dosage Calculation – 3 questions – Multiple choice similar to those used on the dosage calculation
exams
Note: Not all identified topics have been covered in class; therefore, students are expected to engage in
independent study of those areas.
Please review this blueprint over the week-end and be prepared for discussion of it on Monday and
Wednesday (Oct. 11 and 13).
Suggestion: Also review the material in your ATI books (to be distributed next week).