fundamentals of nursing quizlet exam 2

Check to see that the patient is wearing his identification band Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Inability to maintain oxygenation/ ventilation These include: Question 12If a patients blood pressure is 150/96, his pulse pressure is:A96B246C150D54Question 12 Explanation: The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. to have the correct drug route and dose dispensed must be derided to allow for healing Use the formation of water from hydrogen and oxygen to explain the following terms: chemical reaction, reactant, product. - don't twist Which of the following statement is incorrect about a patient with dysphagia? position-supine A normal adult body temperature, as measured on an oral thermometer, ranges between 97 and 100F (36.1 and 37.8C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. O transport Right: Click the card to flip Flashcards Learn Test Match Created by Use __________ mL of ________________ to deliver medications that have been crushed, dissolved, or powder removed from capsules- in Nasogastric tube. Question 37A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. Lim begins to cry as the nurse discusses hair loss. Continuity of patient care promotes efficient, cost-effective nursing care What is Friction in Nursing Body Mechanics? 15. Your hair is really pretty The nurse administers the wrong medication to a patient and the patient vomits. Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. Less than 30 ml/hour In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs. Impaired physical mobility Genupectoral Proper positioning of client Keep it simple Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. She should notify the physician if the urine output is: prevent needle contamination Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Less than 2 mL total volume Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. In this case, the supervisor is the resource person to approach. Gently press downward with thumb or forefinger against bony orbit. Mobility: Question 27Which of the following vascular system changes results from aging?ADecreased blood flowBIncreased peripheral resistance of the blood vesselsCIncreased work load of the left ventricleDAll of the above Question 27 Explanation: Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. A patient is kept off food and fluids for 10 hours before surgery. 6. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. 8. use only for small volumes, toxic effects, idiosyncratic reactions, allergic reactions, tolerance and dependence, and interactions, wound dressing type- ulcer can be visualized, wound dressing that maintains moist environment, promotes healing and protects would by absorption, wound dressing: sheet or tube, keeps wound moist to aid in healing. If loading fails, click here to try again Questions Not Attempted Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. -"It will take only a minute to swallow the medication before you go to the bathroom." (1) Assessment (2) Nursing Diagnosis (3) Planning (4) Implementation (5) Evaluation *** All of the above require critical thinking! - bag must be full If a patients blood pressure is 150/96, his pulse pressure is: 23. Nursing responsibilities for Mrs. Mitchell now include:AReporting an APTT above 45 seconds to the physicianBAssessing the patient for signs and symptoms of frank and occult bleedingCAll of the above DReviewing daily activated partial thromboplastin time (APTT) and prothrombin time.Question 3 Explanation: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. Everyone! A normal adult body temperature, as measured on an oral thermometer, ranges between 97 and 100F (36.1 and 37.8C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. - Vibration Changes in vital signs may be cause by factors other than blood loss. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. What is the name of the compound with the formula BaCl2_22? Nursing responsibilities for Mrs. Mitchell now include:AReporting an APTT above 45 seconds to the physicianBAll of the above CAssessing the patient for signs and symptoms of frank and occult bleedingDReviewing daily activated partial thromboplastin time (APTT) and prothrombin time.Question 38 Explanation: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. Some type II diabetes The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. Question 42The nurse observes that Mr. Adams begins to have increased difficulty breathing. 3. Explain the procedure to the client- allow them as much control and involvement as possible. The most common deficiency seen in alcoholics is: Hint Question 40The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?APedalBApicalCRadialDFemoral Question 40 Explanation: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. Discourage the patient from walking in the hall for a few more days -To prevent serious medication errors. Complete blood count Teach patient and family about drug reactions and schedule Two patient identifiers Start A 38-year old patients vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. All of these positions are appropriate for a rectal examination. You Selected Performing activities of daily living, Body Alignment Laboratory data Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. What are they? 43. A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Examples of patients suffering from impaired awareness include all of the following except: 44. Exercise Assess for orthostatic hypotension, Active - patient can move joints on own Increased peripheral resistance of the blood vessels Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. How to minimize discomfort with injections? The family of an accident victim who has been declared brain-dead seems amenable to organ donation. Pumps only use buffered short-acting or rapid-acting insulin (not long- or intermediate-acting insulin). Decreased blood pressure and heart rate and shallow respirations Question 7The most common injury among elderly persons is:AHip fracture BAtheroscleotic changes in the blood vesselsCIncreased incidence of gallbladder diseaseDUrinary Tract InfectionQuestion 7 Explanation: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. B. (can be as low as 12) D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). elixir Which of the following nursing interventions would be appropriate? 50. DIneffective airway clearance related to dry, hacking cough.Question 37 Explanation: Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Exam Mode Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). During a Romberg test, the nurse asks the patient to assume which position? Applying a hot water bottle orheating pad to a patient without a physicians order does not include the three required components. Inability to concentrate Dont worry.. offers some relief but doesnt recognize the patients feelings. The nurses most important legal responsibility after a patients death in a hospital is: Notifying the coroner or medical examiner, Ensuring that the attending physician issues the death certification. Obtaining a consent of an autopsy Person, nursing, environment, medicine - Buccal: by the cheek Ex: Dopamine at a low dose will improve renal perfusion. Which of the following is an example of nursing malpractice? The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. red or pink granulation tissue The patient should always feed himself Rhythm Correct Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. 9. ..I didnt get to the bad news yet would be inappropriate at any time. Don't require refrigeration instill prescribed number of drops Which of the following patients is at greatest risk for developing pressure ulcers? Desired effect Which findings should be reported? - Hypotension, tachycardia (may indicate tension pneumothorax). apply prescribed number of inches over paper measuring guide The family of an accident victim who has been declared brain-dead seems amenable to organ donation. An Asian patient is likely to hide his pain. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. Metered dose Which of the following nursing interventions has the greatest potential for improving this situation? report all injuries immediately 23. - Exposure to second hand smoke Monitor determined by the physician as well as the frequency A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. Increased work load of the left ventricle All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation. - Harder time fighting off infection, Lifestyle Factors that Affect Oxygenation, Nutrition/Hydration Muscle weakness - Seizures ARateBAll of the above CSymmetryDRhythmQuestion 26 Explanation: The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. hold position for 5 minutes Return In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. You can program different amounts of insulin for different times of the day and night. APerson, nursing, environment, medicineBPerson, environment, health, nursing CPerson, health, nursing, support systemsDPerson, health, psychology, nursingQuestion 44 Explanation: The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs. Non-rebreather Mask According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs. Friction. Eupnea is normal respiration quiet, rhythmic, and without effort. slough or eschar present in parts of the wound bed The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Waiting to consult a physical therapist is unnecessary. Impaired mobility Parasympathetic nervous system stimulation counts - Wheezing C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. D. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Withdraw all pain medications To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Usually used in aging and rehab plunger, Select the _______________ syringe size possible for accuracy; size range 0.5 mL to 60 mL, Pre-attached needle Decreased blood flow For a rectal examination, the patient can be directed to assume which of the following positions? She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Environmental factors - Pollutants (ask where person lives, know your region an it's risk factors), Nursing history: Signs that may indicate poor oxygenation - Chest percussion Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? - Approximation based on the adult dose. A125 ml in 4 hours B64 ml in 2 hoursC90 ml in 3 hoursDLess than 30 ml/hourQuestion 19 Explanation: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. Anaphalaxsis A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. Choose the letter of the correct answer. Ineffective breathing patterns Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice. - Airway patency (stridor), Diagnostic Test that may indicate poor oxygenation, ECG - what is heart doing? Dont worry.. offers some relief but doesnt recognize the patients feelings. Which of the following statement is incorrect about a patient with dysphagia? Good luck! In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Made of water or glycerin, provided autolytic debridement, wound dressing: high absorption agent, for heavily graining wounds. Diagnose & Plan, NANDA-I list Eupnca 37. The infant falls off the scale, suffering a skull fracture. access to download your test bank fundamentals of nursing practice test questions final exam web answered 0 of 0 questions 1 when it comes to client education . The best response would be: A patient who cannot care for himself at home can I get a witness, caplet With that being said, critical thinking is the backbone of the nursing world. 3. 33. 2-5 mL max in adults, for intramuscular injection oxygen therapy, Reported to provider at time of test Motor vehicle accident, Common developmental safety hazards for ADULT, Issues related to lifestyle habits Risk for impaired skin integrity, Nursing process: Planning for a patient that is immobile, Goals and outcomes Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Writing the order for this test The patient inserts the suppository 10 cm (4 inches) into the vaginal canal. A sign of decreased bowel motility minimizes pain and irritation ID nursing dx, collaborative problems, and wellness dx 3. often includes undermining and or tunneling 38. disposable, prefilled, sterile, cartridge units, glass container with a constricted, pre-scored neck In the lateral position, the patient lies on his side. How do your prioritize if patient misses two doses of meds due to a long procedure? Place a humidifier in the patients room. Put air into the cloudy vial first ** people in liver failure are at rate of liver failure b/c metabolism of meds is very poor, After metabolism, excretion occurs through Your hair is really pretty offers no consolation or alternatives to the patient. Please wait while the activity loads. Maintain the patient on strict bed rest at all times use diversion Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. cleanse area Question 20The nurses most important legal responsibility after a patients death in a hospital is:ANotifying the coroner or medical examinerBObtaining a consent of an autopsyCLabeling the corpse appropriatelyDEnsuring that the attending physician issues the death certification Question 20 Explanation: The nurse is legally responsible for labeling the corpse when death occurs in the hospital. The nurse documents this breathing as:ATachypneaBEupncaCOrthopneaDHyperventilation Question 41 Explanation: Orthopnea is difficulty of breathing except in the upright position. anterieor aspects of thighs rotate sites. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. Malpractice Which of the following patients is at greatest risk for developing pressure ulcers? BIneffective individual coping to COPD.CIneffective airway clearance related to dry, hacking cough.D Ineffective airway clearance related to thick, tenacious secretions.Question 22 Explanation: Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Waiting to consult a physical therapist is unnecessary. Nurse's role This is for parapalegics - Age-related changes: thickening of ventricular walls, reduction of cilia (the ability to capture things that can cause an infection) The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors Question 4A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. CThe nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.DThe nurse administers penicillin to a patient with a documented history of allergy to the drug. - Exhale, then have patient suck in and hold it. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. 64 ml in 2 hours Allergic Reactions nonviable tissue, usually accompanied by purulent drainage The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. You have completed The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:AHypothermiaBInfectionCAnxietyDDehydration Question 15 Explanation: A slightly elevated temperature in the immediate preoperative or post operative period may result from the lack of fluids before surgery rather than from infection. express blood from site Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the neurons, eventually results in atrophy of all the muscles; including those necessary for respiration. Question 35A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. - Occurs in liver (major site of drug metabolism) people having trouble with this are older adults or people with liver diseases. Stress test Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss Cigarette smoking - Dialogue on how to quit In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. remove protective covering The four main concepts common to nursing that appear in each of the current conceptual models are: The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs. Listen to their concerns and answer their questions honestly Thus, any act that a nurse performs on the patient against his will is considered assault and battery. - Cardiac arrest Active Assist - patient moves joints with help from nurse, Walker - only come in one width. - Airway obstruction due to swallowing small objects as drainage is being emptied out of reservoir, compress the device until bottom and top are in contact, quickly cleanse opening 20. A series of coughs throughout exhalations 10. Your performance has been rated as %%RATING%% All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation. Single one time dose In the event that a medication error occurs, the nurse should do the following first: The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? 43. Beets and urinary analgesics, such as pyridium, can color urine red. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice. Pulmonary function maintain privacy How are body alignment and mobility assessed? In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the torso and upper legs. use lancet to perform stick Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Wait until she knows more about the unit She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Question 25The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In the prone position, the patient lies on his abdomen with his face turned to the side. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. D. Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. - Do the goals matter to the patient? Chest x-ray In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. - Grams to milligrams (or vice versa) Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. An additional Vitamin C is required during all of the following periods except: Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Standing - give once a day for the rest of life Passive - The nurse moves the patient's joints 125 ml in 4 hours Disturbed body image Question 28Mrs. The body of an organ donor is available for burial. Are drugs interacting, does patient know why taking the drug? Exam 1 Fundamentals Of Nursing Flashcards Quizlet. Score Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Demonstrating the signal system and providing an opportunity for a return demonstration ensures that the patient knows how to operate the equipment and encourages him to call for assistance when needed. - Ex: "upon discharge, patient will be able to maintain air on own" Chronic pain Discuss the problem with her supervisor Love 32. Abdominal girth is unrelated to blood loss. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. Setting priorities The nurse documents this breathing as:AHyperventilation BOrthopneaCTachypneaDEupncaQuestion 42 Explanation: Orthopnea is difficulty of breathing except in the upright position. Stress Before rigor mortis occurs, the nurse is responsible for: Slander Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, and contributes to balance. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall.

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