fundamentals of nursing quizlet exam 2

However, the familys concerns must be addressed before members are asked to sign a consent form. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. oxygen therapy, adults and children over 3- pull pinna up and back Orthopnea C. Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. -Assess and examine the patient. - Inaccurate prescribing Anxiety will not cause an elevated temperature. Femoral 2. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Genupectoral Biotransformation occurs when enzymes detoxify, degrade, and remove active chemicals Avoid the big thump death of subcutaneous fat tissue and muscle degeneration Respiratory rate However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. Which is the most appropriate response from the nurse? Fundamentals Of Nursing Exam 2- Documentation by Roxy0214049 , Sep. 2008 Subjects: 2 documentation exam fundamentals Click to Rate "Hated It" Click to Rate "Didn't Like It" Click to Rate "Liked It" Click to Rate "Really Liked It" Click to Rate "Loved It" Favorite Add to folder Flag Flashcards Memorize Test Games Tweet Related Essays It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. Hypothermia is an abnormally low body temperature. - Concentrations in units of mass per units of volume, Conversions within one system inventory record * prevent contamination of short-acting insulin with long acting, prevent contamination of short-acting insulin with long acting. Time used She should notify the physician if the urine output is: She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patients death; however, she is not legally responsible for performing these functions. If sending patient home with O2, educate on no open flames. Don't press directly on eyeball EXPOSED BONE, TENDON, OR MUSCLE Ingestion Influenza and pneumococcal vaccine Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Assault and battery Mrs. Mitchell has been given a copy of her diet. minutes Machines vary from facility to facility, wash hands Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? These include: Allergies, medication, diet Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Solutions Altered neurovascular status to extremities (cyanosis, pallor, coldness of skin, tingling, pain, numbness) -Calling the pharmacy to clarify the correct dose of medication, The nurse is caring for a patient who has an order for an acetaminophen (Tylenol) rectal suppository. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be. Palpating the midclavicular line is the correct technique for assessing. Abdominal girth is unrelated to blood loss. to have access to drug information Encourage the patient to increase her fluid intake to 200 ml every 2 hours Age is also a factor. The need to move the feet apart to maintain this stance is an abnormal finding. Activity tolerance. Some hospitals have standing orders up to 2L In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. The only abbreviation we can use for subcutaneous is what? Exercise Active Assist - patient moves joints with help from nurse, Walker - only come in one width. Any items you have not completed will be marked incorrect. The nurse discusses the foods allowed on a 500-mg low sodium diet. Chapter 01 - Fundamentals of Nursing 9th edition - test bank 463505443 - Lecture notes 3 Logica proposicional ejercicios resueltos 1-2 Problem Set Module One - Income Statement Copy of Growing Plants SE answer key. Look at when next due dose is? High-pitched gurgles head over the right lower quadrant are: Question 21After 1 week of hospitalization, Mr. Gray develops hypokalemia. 2. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. Side rails are a reminder to a patient not to get out of bed. Assault Question 13The family of an accident victim who has been declared brain-dead seems amenable to organ donation. Nursing Fundamentals Exam 2. Motor vehicle accident, Common developmental safety hazards for ADULT, Issues related to lifestyle habits Don't require refrigeration Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. The physician is responsible for instructing the patient about the test and for writing the order for the test. Helps balance. Question 13Before rigor mortis occurs, the nurse is responsible for:APlacing one pillow under the bodys head and shouldersBRemoving the bodys clothing and wrapping the body in a shroudCAllowing the body to relax normally DProviding a complete bath and dressing changeQuestion 13 Explanation: The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. Question 23A prescribed amount of oxygen s needed for a patient with COPD to prevent:ACardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)BInhibition of the respiratory hypoxic stimulus CCirculatory overload due to hypervolemiaDRespiratory excitementQuestion 23 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. Cardiac catheterization 12. wash hands, Daily record taken to provider - Each hospital has its own policy tubing mgt, know it Monitor the patient A sign of increased bowel motility Which of the following patients is at greatest risk for developing pressure ulcers? 2. Decreased blood flow Fever, exercise, and sympathetic stimulation all increase the heart rate. A patient about to undergo abdominal inspection is best placed in which of the following positions? 22. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture.Question 38Which of the following is the most common cause of dementia among elderly persons?AMultiple sclerosisBAmyotrophic lateral sclerosis (Lou Gerhigs disease)CParkinsons diseaseDAlzheimers disease Question 38 Explanation: Alzheimer;s disease, sometimes known as senile dementia of the Alzheimers type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Thus, any act that a nurse performs on the patient against his will is considered assault and battery. Non-rebreather Mask Use the formation of water from hydrogen and oxygen to explain the following terms: chemical reaction, reactant, product. 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. behavioral- anxiety, agitation, consiousness seconds These include: fundamentals of nursing exam 1 flashcards quizlet web what are the 5 steps in the nursing process 1 assessment 2 nursing diagnosis 3 planning 4 The other answers are incorrect interpretations of the statistical data. Return Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. The infant falls off the scale, suffering a skull fracture. minimize muscle tension Please visit using a browser with javascript enabled. Increased peripheral resistance of the blood vessels 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. At a higher dose, it raises blood pressure at the expense of the kidneys, Oral - by mouth An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle, Patient safety - 1st priority Rate Ineffective breathing patterns Pre-attached needle Draw out cloudy insulin - BUT we cannot give too much O because they do not have functioning alveoli to carry out the O transport, so the O build-up causing high level of O resulting in no motivation to breathe. Describe some of the body changes throughout the life span: Newborn Return After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. 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? What are the oral options for medications? When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to: Ensuring the patients safety is the most essential action at this time. Discourage the patient from walking in the hall for a few more days Right time - Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Nursing responsibilities for Mrs. Mitchell now include: Reporting an APTT above 45 seconds to the physician, Assessing the patient for signs and symptoms of frank and occult bleeding. Kaopectate is an anti diarrheal medication. - We are helping this patient to heal and get out of the hospital Choose the letter of the correct answer. Inability to maintain oxygenation/ ventilation - Inflammatory & noniflamm joint disease Circulatory overload due to hypervolemia Some type II diabetes Accidents Your performance has been rated as %%RATING%% Bend knees - Mental confusion The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be keep needle inserted 10 seconds after injection of medications 5. What is a nurses responsibility concerning oxygen? Tachypnea is rapid respiration characterized by quick, shallow breaths. Can position patient in order to encourage drainage. 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. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. Question 11If nurse administers an injection to a patient who refuses that injection, she has committed:AMalpracticeBNegligenceCAssault and batteryDNone of the above Question 11 Explanation: Assault is the unjustifiable attempt or threat to touch or injure another person. CPAP & BiPAP, Invasive Maintenance and Promotion of Lung Expansion, Chest tubes Which finding might lead the nurse to suspect a nutritional alteration? What is the name of the compound with the formula BaCl2_22? Battery is the unlawful touching of another person or the carrying out of threatened physical harm. C. A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. Type I diabetes 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. Pulse rate and temperature Standing - give once a day for the rest of life What is the most appropriate action? Good luck! Don't use expired medications An insulin pump is a small battery-operated device about the size of a small cell phone. - Buccal: by the cheek B. to stop, think and be vigilant when administering medications, metric system PRN - as needed / per requested The nurse administers penicillin to a patient with a documented history of allergy to the drug. All of the following can cause tachycardia except: - Face down 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. 43. Pedal gangrenous lesions 3. household system, When administering medications to older adults do what? You scored %%SCORE%% out of %%TOTAL%%. - Wrong medication, route, and time Diagnose & Plan, NANDA-I list Keep needle in skin for 10 sec, Clean the vials Fundamentals of Nursing Exam 2 1) The nurse is inserting a nasogastric tube in an adult client. Not Attempted repeat this process using a new swab each time and moving the same circular stroke away from the drain site, place collection container or measuring device on bed b/w you and patient remove protective covering Thus, a respiratory rate of 30 would be abnormal. self medication, Nurse's Rights for safe medication administration, to complete and clearly written order that clearly specifies the drug, dose, route, and frequency 3. Which of the following is an example of nursing malpractice? Side rails are a deterrent that prevent a patient from falling out of bed. offer tissue to blot runny nose but not blow. The infusion set must be changed every few days. Negligence Question 35A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Defamation Kaopectate is an anti diarrheal medication. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?AVital signsBComplete blood countCAbdominal girth DGuaiac testQuestion 15 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. Nurse is responsible for following legal provisions for administering opioids which are carefully controlled through federal and state guidelines, overuse, If nurse administers an injection to a patient who refuses that injection, she has committed: 12. Young adulthood Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. 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. Apical pulse 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. Push the diaphragm inward and upward plunger, Select the _______________ syringe size possible for accuracy; size range 0.5 mL to 60 mL, Pre-attached needle The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. D. Malpractice is defined as injurious or unprofessional actions that harm another. In the prone position, the patient lies on his abdomen with his face turned to the side. - CDC: Annual influenza vaccines for those 6 months and those over 50 years of age Stress test 33. Continuity of patient care promotes efficient, cost-effective nursing care Right: genetic factors affecting medicine administration, cultural factors affecting medicine administration, Onset of medication action- starts to work, intramuscular (IM) - Cough She is required to bathe only soiled areas of the body since the mortician will wash the entire body. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. Eupnea is normal respiration quiet, rhythmic, and without effort. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors. Two pronged approach to assess the environment and the patient Hypercapnia, hypoxemia, fever, pregnancy, wound healing frequent emptying of the reserve, never remove a surgical dressing for wound inspection until you have the order In order for perfusion to occur, must have ventilation, diffusion & respiration, Neural 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. 45. Changing position every 2 hours Examples of patients suffering from impaired awareness include all of the following except: This paper will focus on how one will use critical thinking in nursing practice. Nursing Fundamentals Exam 2 Practice Test 4.7 (3 reviews) Which of the following is a collaborative intervention? Hourly Know delegation last/ regarding medication administration (2) Sustained Release - a longer time to dissolve, What factors Influence Medication Distribution, Circulation 4. Person, nursing, environment, medicine 6. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.BThe nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.CThe nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.DThe nurse administers the wrong medication to a patient and the patient vomits. They also seem to gain a greater sense of achievement and esprit de corps. - Document! Question 1Examples of patients suffering from impaired awareness include all of the following except:AA patient who cannot care for himself at homeBA patient demonstrating symptoms of drugs or alcohol withdrawal CA semiconscious or over fatigued patientDA disoriented or confused patientQuestion 1 Explanation: A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. Return Use __________ mL of ________________ to deliver medications that have been crushed, dissolved, or powder removed from capsules- in Nasogastric tube. Used to administer medications in small precise doses, 0.3-1 mL capacity 54 Abdominal girth is unrelated to blood loss. Elimination Notify the health care provider immediately. Right route Posture 3 yrs 15. Maintain balance, posture, and body alignment Maintain the patient in an orthopneic position as needed use biohazard sharps disposal containers- immediately Which of the following vascular system changes results from aging? - Death, Inadequate ventilation to meet the body's demand An additional Vitamin C is required during all of the following periods except: Which of the following nursing interventions has the greatest potential for improving this situation?AContinue administering oxygen by high humidity face maskBPerform chest physiotheraphy on a regular schedule CEncourage the patient to increase her fluid intake to 200 ml every 2 hoursDPlace a humidifier in the patients room.Question 39 Explanation: Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. At a middle dose, will raise blood pressure. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patients death; however, she is not legally responsible for performing these functions. Coordinated Body Movement Love This information is documented and reported to the physician and the nursing supervisor. Reduced hemoglobin, carbon monoxide, anemia Not Attempted C. An Asian patient is likely to hide his pain. Place a humidifier in the patients room. Lim begins to cry as the nurse discusses hair loss. Collaborative care Screw on needle Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. 3. A 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. Conversions between systems 45-90 degrees, do not expel air bubble from prefilled syringe; inject into anteriolateral or posteriolateral abdominal wall at least 2 inches away from the umbilicus only, deposits medications into deep muscle tissue reduces leakage of medication into subcutaneous tissue Total Questions on Quiz Discourage them from making a decision until their grief has eased Question 42The nurse observes that Mr. Adams begins to have increased difficulty breathing. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. 39. Administer oxygen by Venturi mask at 24%, as needed Consuit a physical therapist before allowing the patient to ambulate hold position for 5 minutes Setting priorities Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Trendelenburg The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. NO BONE, TENDON OR MUSCLE EXPOSED Partial-Credit Question 32The most common deficiency seen in alcoholics is:AThiamineBRiboflavinCPantothenic acid DPyridoxineQuestion 32 Explanation: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Question 44The most common deficiency seen in alcoholics is:APantothenic acid BRiboflavinCPyridoxineDThiamineQuestion 44 Explanation: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. 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. - Monitor side effects Mitchell has been given a copy of her diet. if ordered, send specimen to lab 42. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. - can be determined by having a person stand and just look to see if a person is wobbly. You got 50 minutes to finish the exam .Good luck! What are they? After 1 week of hospitalization, Mr. Gray develops hypokalemia. Friction. A patient about to undergo abdominal inspection is best placed in which of the following positions? High-pitched gurgles head over the right lower quadrant are: Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Pinch skin Which of the following parameters should be checked when assessing respirations? CBC - infection? Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? -Must be allowed to toilet, eat. Hold pen with thumb ready to depress 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. The nurse could be charged with: Malpractice is defined as injurious or unprofessional actions that harm another. Polypharmacy - patient on many drugs. - Suction this first, NonInvasive Maintenance and Promotion of Lung Expansion, Positioning 34. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. The other answers are diseases that can occur in the elderly from physiologic changes. may increase undermining and or tunneling Strict aseptic technique sharpest Use of hand rails or wall nearby. A. (mountain climbing, sky-diving, driving fast), Common developmental safety hazards for OLDER ADULT, Age related physiological changes Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. Your hair is really pretty offers no consolation or alternatives to the patient. extremes of weight Written communication that does the same is considered libel. report all injuries immediately Answers and Rationales 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. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. Movement Know signs and symptoms of respiratory distress ABG Changes in vital signs may be cause by factors other than blood loss. - Respiratory pattern 2-5 mL max in adults, for intramuscular injection Providing a complete bath and dressing change Mobility: Establishing outcomes, Nursing Process in Med Admin: Critical thinking is not a solo occurrence; it is something that allows you to grow and mature every time it occurs. Contraindications? C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. prevent needle contamination Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. 33. Also, this page requires javascript. chemical name - compound that makes up the drug Listen to their concerns and answer their questions honestly Impaired swallowing - Exhale, then have patient suck in and hold it. Pregnancy The body of an organ donor is available for burial. psychosocial techniques, Oxygen supply, methods of oxygen delivery, hydration, humidification, nebulization B. Defines the scope of nurses' professional functions and responsibilities. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Safety light Risk for activity intolerance I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy Safety awareness, Inherent Accident Risks in the Health Care Agency, (Normal everyday things that happen) A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Circulatory overload and respiratory excitement have no relevance to the question. Multiple sclerosis, a progressive, degenerative disease involving demyelination of the nerve fibers, usually begins in young adulthood and is marked by periods of remission and exacerbation. Document in a timely fashion, Person on the blunt end of the needle is responsible for the sharp end of the needle Mrs. Mitchell has been given a copy of her diet. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Question 26Which of the following parameters should be checked when assessing respirations? The nurse is responsible for giving the patient breakfast at the scheduled time. Side rails are a reminder to a patient not to get out of bed do not massage, used to deposit medication into the loose connective tissue underlying the dermis Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? Pain related to immobilization of affected leg. Metered dose The nurse is legally responsible for labeling the corpse when death occurs in the hospital. Exam Mode instill drops- position dropper 1/2 to 3/4 inch above conjunctival sac- drop in prescribing number of drops - Suction control - expect to see gentle bubbling that stops 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. Good luck! You have not finished your quiz. Post a sign at the house.

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