fundamentals of nursing quizlet exam 2

C. Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. Ineffective individual coping to COPD. - Severe sleep apnea or other respiratory problems Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, and contributes to balance. The other answers are diseases that can occur in the elderly from physiologic changes. All of the following can cause tachycardia except: 27. Right: genetic factors affecting medicine administration, cultural factors affecting medicine administration, Onset of medication action- starts to work, intramuscular (IM) Libel The correct sequence for assessing the abdomen is: 18. Which of the following nursing interventions would be appropriate?AEncourage the patient to walk in the hall aloneBAccompany the patient for his walk.CConsult a physical therapist before allowing the patient to ambulate DDiscourage the patient from walking in the hall for a few more daysQuestion 4 Explanation: A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Slander How do your prioritize if patient misses two doses of meds due to a long procedure? - Some drugs can cross the placenta and should not be administered to pregnant women, Therapeutic Effects The other nursing actions may be necessary but are not a major priority.Question 50The most common injury among elderly persons is:AHip fracture BUrinary Tract InfectionCIncreased incidence of gallbladder diseaseDAtheroscleotic changes in the blood vesselsQuestion 50 Explanation: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. Fundamentals of Nursing Test #2 Flashcards | Quizlet - Atelectisis D. Studies have shown that patients and nurses both respond well to primary nursing care units. Medications administered Fall Risk, Impaired sensory perception 1. 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. A tossed salad with oil and vinegar and olives very young and very old patient education, Locked cabinet -Complete the institution's incident or occurrence report. Goals and outcomes Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. Allowing the body to relax normally Decreased cardiac output Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Pyridoxine Seizures, Procedure Related Risks in the Health Care Agency, Equipment Related Risks in the Health Care Agency, The nursing process in regards to Safety Awareness, Assessment However, the familys concerns must be addressed before members are asked to sign a consent form. 36. Hourly Shaded items are complete. Your score is The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. Clear Pathway to bathroom These include: Right patient Correct - Age-related changes: thickening of ventricular walls, reduction of cilia (the ability to capture things that can cause an infection) A. hold it displaced until after needle is removed. Before rigor mortis occurs, the nurse is responsible for: 50. Define Assessment Collects comprehensive data pertinent to the patient's health and/or situation. -Contact the prescriber to inform him/her of the error. They also seem to gain a greater sense of achievement and esprit de corps. Calibrated in units not mL Examples of patients suffering from impaired awareness include all of the following except: A patient who cannot care for himself at home, A patient demonstrating symptoms of drugs or alcohol withdrawal. Elevate the head of the bed The other answers are incorrect interpretations of the statistical data. 5. Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams), NCLEX Practice Exam for Blood Transfusion, The patient will find pureed or soft foods, such as custards, easier to swallow than water, Fowlers or semi Fowlers position reduces the risk of aspiration during swallowing. if visible cerumen or drainage remove with cotton-tipped applicator - Suction control - expect to see gentle bubbling that stops Insert needle at 90 angle Question 10High-pitched gurgles head over the right lower quadrant are:AA sign of increased bowel motilityBA sign of abdominal cramping CA sign of decreased bowel motilityDNormal bowel soundsQuestion 10 Explanation: Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Thus, any act that a nurse performs on the patient against his will is considered assault and battery. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. These include: Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. Range of motion Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. While exhaling, open the epiglottis by saying the word huff To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. 29. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Fundamentals of Nursing Chapter 1 - Fundamentals of Nursing - Studocu The infant falls off the scale, suffering a skull fracture. These include: 35. Such a patient is unlikely to display emotion, such as crying. Waiting to consult a physical therapist is unnecessary. This information is documented and reported to the physician and the nursing supervisor. The nurse discusses the foods allowed on a 500-mg low sodium diet. - Face down Follow the medication administration rights Respondent superior A negative nitrogen balance is present when catabolic states exist. Click the card to flip Definition 1 / 79 1. The need to move the feet apart to maintain this stance is an abnormal finding. Environmental factors - Pollutants (ask where person lives, know your region an it's risk factors), Nursing history: Signs that may indicate poor oxygenation Accompanying him will offer moral support, enabling him to face the rest of the world. Medication Dose Responses, expected effects that don't contribute to helping the patient establishing an effective nurse-patient relationship -reduce anxiety through therapeutic communication, teaching, and acceptance -remember that the patient has concerns and needs other medical ones -communicate with the patient as an individual -take time to learn about the patient being admitted -provide for the family participation in all A sign of increased bowel motility The nurse documents this breathing as:AHyperventilation BOrthopneaCTachypneaDEupncaQuestion 42 Explanation: Orthopnea is difficulty of breathing except in the upright position. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. - vision, hearing, sense of touch, ability to perform fine motor tasks. All diminish Radial Venturi Mask Question 29The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse could be charged with: All of the above Pediatric dosages Consuit a physical therapist before allowing the patient to ambulate Toxic Effects Right documentation The infant falls off the scale, suffering a skull fracture. High-pitched gurgles head over the right lower quadrant are: 19. Correct administration CAutonomy and authority for planning are best delegated to a nurse who knows the patient wellDAccountability is clearest when one nurse is responsible for the overall plan and its implementation.Question 36 Explanation: Studies have shown that patients and nurses both respond well to primary nursing care units. - Air entrapment & is more precise - Medication use (drug interaction) Continue to develop & grow and gain fine motor skills - Make sure outcomes are measurable It continuously delivers small amounts of insulin through an infusion line placed under the skin. Avoid twisting Waiting to consult a physical therapist is unnecessary. I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy Accompanying him will offer moral support, enabling him to face the rest of the world. Check accuracy, Nursing diagnoses for medication administration, Deficient knowledge regarding drug actions and purpose and self- administration She is required to bathe only soiled areas of the body since the mortician will wash the entire body. The nurse documents this breathing as: Orthopnea is difficulty of breathing except in the upright position. Answer Choice(s) Selected In this case, the supervisor is the resource person to approach. The patient inserts the suppository 10 cm (4 inches) into the vaginal canal. 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. (2) Sustained Release - a longer time to dissolve, What factors Influence Medication Distribution, Circulation Accountability is clearest when one nurse is responsible for the overall plan and its implementation. -"It will take only a minute to swallow the medication before you go to the bathroom." Allow a 1 hour rest period between activities 23. topical wound care must clean the devitalized tissue. never manually recap needles after injection Question 8In Maslows hierarchy of physiologic needs, the human need of greatest priority is:ANutritionBEliminationCLoveDOxygen Question 8 Explanation: Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. - Respiratory pattern - Chest wall movement altered blood flow household system, When administering medications to older adults do what? A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. A patient asks you what vitamin is best for eye sight. ", What is the goal of computerized physician order entry (CPOE)? Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Question 35A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. deep and away from major nerves and blood vessels NERVOUS SYSTEM. Fundamentals of Nursing Quiz Question with Answer 1. 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. If a patients blood pressure is 150/96, his pulse pressure is: The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. Medication Interactions Safety light After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. - Wrong medication, route, and time B. BSympathetic nervous system stimulationCFeverDExerciseQuestion 4 Explanation: Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels. management: debridement. 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. These include:ABeetsBCaffeine-containing drinks, such as coffee and cola.CKaolin with pectin (Kaopectate) DUrinary analgesicsQuestion 7 Explanation: Fluids containing caffeine have a diuretic effect. 2. The nurse should perform oral hygiene before assisting with feeding. Toddlers have a much higher metabolic rate. Explain the procedure to the client- allow them as much control and involvement as possible. Asses the patients ability to ambulate and transfer from a bed to a chair Ineffective individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively. 15. 21. Your answers are highlighted below. Side-lying aka, NPH - Splinting - hold a pillow or blanket against lower ribs to help ease pain Roll in hand 64 ml in 2 hours question physical- vital signs, urine output, relief of Applying a hot water bottle or heating pad to a patient without a physicians order does not include the three required components. Question 33The most common deficiency seen in alcoholics is:AThiamineBPantothenic acid CRiboflavinDPyridoxineQuestion 33 Explanation: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Question 31 Explanation: Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patients ability to carry out these functions safely. A. What should the nurse do? Via epideral I know this will be difficult acknowledges the problem and suggests a resolution to it. 19. A prescribed amount of oxygen s needed for a patient with COPD to prevent: 40. D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. 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. Moisture retentive dressings. Less than 2 mL total volume Which of the following statement is incorrect about a patient with dysphagia? Active Assist - patient moves joints with help from nurse, Walker - only come in one width. as drainage is being emptied out of reservoir, compress the device until bottom and top are in contact, quickly cleanse opening Have client look at ceiling Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions? offer tissue to blot runny nose but not blow. Why is this patient getting the med? An appropriate nursing diagnosis would be:APain related to immobilization of affected leg. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?AGuaiac testBComplete blood countCVital signsDAbdominal girth Question 49 Explanation: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool through guaiac (Hemoccult) test. Standing The nurse's role is provide the safest and highest standard of care possible for the patient. Partial-Credit Patient education Consequently, the nurse must observe for objective signs. Fever, exercise, and sympathetic stimulation all increase the heart rate. 41. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Question Text 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. Establishing outcomes, Nursing Process in Med Admin: After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. The nurse is responsible for giving the patient breakfast at the scheduled time. The nurse is responsible for giving the patient breakfast at the scheduled time. All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! Topical, - To protect our patients and each state must abide by these laws 37. Teach patient and family about drug reactions and schedule Reduce risk of collapse of alveoli Kaopectate is an anti diarrheal medication. Has a reservoir that is filled with insulin and a microcomputer that allows you to adjust how much insulin is to be delivered. Is patient better or worse? stable eschar over heals should not be removed, slough 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. Attitudes about medication use Please visit using a browser with javascript enabled. Ex: Dopamine at a low dose will improve renal perfusion. Question 46Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?AContinuity of patient care promotes efficient, cost-effective nursing careBAutonomy and authority for planning are best delegated to a nurse who knows the patient wellCThe holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. -Flush with 30 mL of water before and after feedings. You Selected Question 36A patient about to undergo abdominal inspection is best placed in which of the following positions?AProneBTrendelenburgCSide-lying DSupineQuestion 36 Explanation: The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen. 96 -Never use over-the-counter (OTC) drugs or herbal supplements. Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss Good luck! Return Pulmonary function An appropriate nursing diagnosis would be: Hold pen with thumb ready to depress right drug A patient about to undergo abdominal inspection is best placed in which of the following positions? generic name - official name hand hygiene before handling equipment. To reduce the risk of polypharmacy, how should the nurse advise the older patient regarding medications? Mandatory for Fundamentals of Nursing - Studocu In Maslows hierarchy of physiologic needs, the human need of greatest priority is: Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist. It slows down in pre-school, Special Considerations for Administering Medications to Older Adults. - flow sheet must be completed on every patient in retraint The physician is responsible for instructing the patient about the test and for writing the order for the test.Question 30The most common psychogenic disorder among elderly person is:ASleep disturbances (such as bizarre dreams)BDepressionCDecreased appetite DInability to concentrateQuestion 30 Explanation: Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. D. The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. Which of the following is an example of nursing malpractice? In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. sustained release. minutes These changes, in turn, increase the work load of the left ventricle. Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Assessing the patient for signs and symptoms of frank and occult bleeding The infant falls off the scale, suffering a skull fracture. Malpractice Age is also a factor. [irp] Nclex Rn 31 Flashcards Quizlet. Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. Ineffective breathing patterns Mrs. Lim begins to cry as the nurse discusses hair loss. All of the above Results Intra osseous - narrow space of long bone, Metric system Which of the following nursing interventions promotes patient safety? incorrect no answer. All of the above The best response would be: Why are you crying? The other answers are incorrect interpretations of the statistical data. Once you are finished, click the button below. wash hands, Daily record taken to provider 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. Which of the following vascular system changes results from aging? medications absorbed more slowly this route than IM Chicken bouillon GET HELP Which of the following is the most significant symptom of his disorder?AMuscle irritability BLethargyCIncreased pulse rate and blood pressureDMuscle weaknessQuestion 21 Explanation: Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. Stress You build on each experience by pulling . Fever, exercise, and sympathetic stimulation all increase the heart rate. In this case, the supervisor is the resource person to approach. Risk for activity intolerance Canes - personal preference as to what side use on, although usually used on weaker side. What are the factors that influence absorption? Good luck! When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to: reduces leakage of medication into subcutaneous tissue 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. D. All of these positions are appropriate for a rectal examination. - Ex. Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patients ability to carry out these functions safely. Your score is Inability to maintain oxygenation/ ventilation Pathological influences on body alignment, exercise, & activity, Congenital Defects Sensory impairments Question 45An additional Vitamin C is required during all of the following periods except:AInfancyBPregnancy CChildhoodDYoung adulthoodQuestion 45 Explanation: Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Once you are finished, click the button below. Continuity of patient care promotes efficient, cost-effective nursing care, Autonomy and authority for planning are best delegated to a nurse who knows the patient well. Enhanced by a wide base of support, What is Good Nursing Coordinated Body Movement, Must overcome an object's weight and be aware of it's center of gravity. Question 48A prescribed amount of oxygen s needed for a patient with COPD to prevent:AInhibition of the respiratory hypoxic stimulus BCirculatory overload due to hypervolemiaCRespiratory excitementDCardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)Question 48 Explanation: 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. Correct dosage The nurse documents this breathing as: 3. Protect the patient from injury Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance Don't give them In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. 25. Fundamentals Of Nursing Chapter 2 Review Questions -Use one pharmacy to coordinate all medications. Allowing for rest periods decreases the possibility of hypoxia. Inrapleural Most of the time it passes through the stomach and dissolves in the intestines - Buccal: by the cheek Ensuring that the attending physician issues the death certification Your hair is really pretty offers no consolation or alternatives to the patient. 2) Comprehension - The patient must understand the explanation. Remain with patient until meds are taken Automated medication dispensing systems in the hospital Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?

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