Any items you have not completed will be marked incorrect. What are the 3 muscle signs for IM injections? Med chemicals bind to proteins to help meds get to where they need to go, Can only occur after the medication reaches the site of action Two patient identifiers Which of the following nursing interventions has the greatest potential for improving this situation? Question 6Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?ADecreased blood pressure and heart rate and shallow respirationsBImmobility, diaphoresis, and avoidance of deep breathing or coughingCQuiet cryingDChanging position every 2 hours Question 6 Explanation: An Asian patient is likely to hide his pain. 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. Side rails are a reminder to a patient not to get out of bed Sensory impairments Allergies, medication, diet 11. Which nursing action has the highest priority for a patient receiving medication via a nasogastric feeding tube? What is causing the quick breathing Check vitals in response to the medication Hypercapnia, hypoxemia, fever, pregnancy, wound healing After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. A sign of decreased bowel motility - Grams to milligrams (or vice versa) Sometimes based on weight or body surface area. Encourage them to sign the consent form right away Return 9. 24. red- pink wound bed Inrapleural 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. 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End Hyperventilation Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. 2. Recumbent Questions Not Attempted open plug or cap on drainage device make sure enough insulin - Fragrance free zones, Medications 15. What is Friction in Nursing Body Mechanics? If this activity does not load, try refreshing your browser. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. B. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse's role is provide the safest and highest standard of care possible for the patient. Rhythm Insert an airway - Head of bed elevated, support and align hips and spine Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. use biohazard sharps disposal containers- immediately Such a patient is unlikely to display emotion, such as crying. Right time - Idiosyncratic Reactions Impaired swallowing 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). The nurse is responsible for giving the patient breakfast at the scheduled time. Adverse Effects Which of the following vascular system changes results from aging? Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Check accuracy, Nursing diagnoses for medication administration, Deficient knowledge regarding drug actions and purpose and self- administration Waiting to consult a physical therapist is unnecessary. Quad Nurse safety - 2nd priority Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. Nausea Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. Can you document that you gave a medication before you give it to the client? gluteus medis and minimus muscles Question 32 Explanation: 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). All of the above Reduced hemoglobin, carbon monoxide, anemia 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. 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. Beets and urinary analgesics, such as pyridium, can color urine red. Risk for infection Have client look at ceiling After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. A. Protect the patient from injury Pulmonary function The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. The brain-dead patients family needs support and reassurance in making a decision about organ donation. Which is the most appropriate response from the nurse? Question 14Palpating the midclavicular line is the correct technique for assessingARespiratory rateBApical pulse CBaseline vital signsDSystolic blood pressureQuestion 14 Explanation: The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. Fundamentals of Nursing Flashcards Quizlet.pdf - Course Hero The four main concepts common to nursing that appear in each of the current conceptual models are: Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. The infant falls off the scale, suffering a skull fracture. EXPOSED BONE, TENDON, OR MUSCLE Elevate the head of the bed 27. 150 Question 27Examples of patients suffering from impaired awareness include all of the following except:AA patient who cannot care for himself at homeBA semiconscious or over fatigued patientCA patient demonstrating symptoms of drugs or alcohol withdrawal DA disoriented or confused patientQuestion 27 Explanation: A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. All of these positions are appropriate for a rectal examination. If this activity does not load, try refreshing your browser. Two forms of identification: name and birthdate Household measurements The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be. Fundamentals of Nursing Practice Exam 2 - RNpedia Exam Mode Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for: 13. 1. 1. A. Rubbing patients back to facilitate relaxation B. measuring the patients blood pressure C. Assessing the patients educational needs related to discharge D. Administering prescribed medications to a patient Click the card to flip Young and middle-age adults 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. The most common deficiency seen in alcoholics is: 11. - Mental confusion -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. Achieved by a low center of gravity Question 11Which of the following nursing interventions promotes patient safety?A All of the above death of subcutaneous fat tissue and muscle degeneration use middle third of muscle, easily accessible In Maslows hierarchy of physiologic needs, the human need of greatest priority is: 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. Groups PDF Fundamental Concept 3 Edition Nursing Test Answer Pdf Respiration should be between 16-20 CFeverDSympathetic nervous system stimulationQuestion 45 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. 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. Know interactions/ compatibilities Reduce risk of collapse of alveoli Wrong Fundamentals of Nursing Practice Exam 2 (PM) 5. The brain-dead patients family needs support and reassurance in making a decision about organ donation. Which of the following nursing interventions has the greatest potential for improving this situation? Abdominal girth slough or eschar present in parts of the wound bed The only abbreviation we can use for subcutaneous is what? 3. - Respiratory infection The nurse discusses the foods allowed on a 500-mg low sodium diet. 16. Who can prescribe? The physician is responsible for instructing the patient about the test and for writing the order for the test. Palpating the midclavicular line is the correct technique for assessing Circulatory overload and respiratory excitement have no relevance to the question. Tracheal To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. 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. Intraocular: eye drops or eye ointment (intraopthalmic) Your hair is really pretty offers no consolation or alternatives to the patient. If you leave this page, your progress will be lost. Faith6 months ago excellent read back the telephone order to the prescriber. Temperature and respiratory rate 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. 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. Airway protection -Change the feeding pump bag and tubing every 24 hours. 25 quizlet name written questions what position is easiest to assess the anus and rectum? instruct client to breathe through mouth Fundamentals of Nursing Exam 2 1) The nurse is inserting a nasogastric tube in an adult client. Question 22A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. - other places: lungs, kidneys, blood, and intestines 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 31. A prescribed amount of oxygen s needed for a patient with COPD to prevent: (med math in another set). For a rectal examination, the patient can be directed to assume which of the following positions? Question 24Which of the following vascular system changes results from aging?AIncreased peripheral resistance of the blood vesselsBAll of the above CDecreased blood flowDIncreased work load of the left ventricleQuestion 24 Explanation: Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. Person, health, psychology, nursing Performing activities of daily living, Body Alignment Answer Choice(s) Selected * Try to strategically plan how far walking by having a chair available nearby. Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. Fundamentals of Nursing Chapter 1 - Fundamentals of Nursing - Studocu The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. Route of administration (fastest I.V.) Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. In this case, the supervisor is the resource person to approach. Which of the following parameters should be checked when assessing respirations? a. Fluid status b. Potassium c. Lipids d. Nitrogen balance Click the card to flip Nitrogen Balance Nitrogen balance is important to determining serum protein status. Demonstrate the signal system to the patient Obtaining a consent of an autopsy Inform the staff that they must volunteer to rotate. Side rails should not be used - Pulmonary edema ( no gas exchange with the lungs) Friction. Question 28A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Written report within 24 hours of occurrence, Comparison of medications taken at home and prescribed when in the health care setting, Change in patient's condition Written communication that does the same is considered libel. Continue administering oxygen by high humidity face mask, Perform chest physiotheraphy on a regular schedule, Encourage the patient to increase her fluid intake to 200 ml every 2 hours. Which of the following vascular system changes results from aging? This is for parapalegics & drink, Impaired skin integrity hold syringe steady while needle is in tissue Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. 30. The nurse administers the wrong medication to a patient and the patient vomits. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. - interferes with blood supply to lower extremities due to intermittent claudication Anxiety will not cause an elevated temperature. Side rails are ineffective Horizontal recumbent Physical Exam Radial Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? 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. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Tachypnea is rapid respiration characterized by quick, shallow breaths. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Check with the dyspnea scale Encourage the patient to walk in the hall alone, Consult a physical therapist before allowing the patient to ambulate, Discourage the patient from walking in the hall for a few more days. - Anticoagulants 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. The most common psychogenic disorder among elderly person is: 46. rotate sites. Via epideral 15. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. - Do not strip the tubing, need to milk it instead. Has a reservoir that is filled with insulin and a microcomputer that allows you to adjust how much insulin is to be delivered. The nurse is responsible for: 4. I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy Question 6Mrs. -"I will wait until noon, when you have more medication ordered, and will bring it back to you then. occlude nasolacrimal duct for 30-60 seconds if medication causes systematic effects, Warm drops by running water over the bottle Once you are finished, click the button below. -Allow a family member to coordinate all prescriptions. outer aspect of upper arms These include: A ham and Swiss cheese sandwich on whole wheat bread, A tossed salad with oil and vinegar and olives. 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 - Monitor side effects Knowledge and understanding of medication use After 1 week of hospitalization, Mr. Gray develops hypokalemia. rich in blood supply and absorbed faster Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Apical Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. In the prone position, the patient lies on his abdomen with his face turned to the side. Not Attempted Decreased appetite CPAP & BiPAP, Invasive Maintenance and Promotion of Lung Expansion, Chest tubes Riboflavin The infant falls off the scale, suffering a skull fracture. Pulse rate and temperature - body has become used to CO build-up, therefore excess CO does not motivate to breathe Battery It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. Strict aseptic technique Question 16When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:AInsert an airwayBWithdraw all pain medications CProtect the patient from injuryDElevate the head of the bedQuestion 16 Explanation: Ensuring the patients safety is the most essential action at this time. Before rigor mortis occurs, the nurse is responsible for: 50. Consuit a physical therapist before allowing the patient to ambulate Roll in hand Mrs. Lim begins to cry as the nurse discusses hair loss. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. A patient about to undergo abdominal inspection is best placed in which of the following positions? Non-rebreather Mask Pain related to immobilization of affected leg. 28. - Reposition every two hours to reduce the risk of infection Question 12The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would beAMaintain the patient on strict bed rest at all timesBMaintain the patient in an orthopneic position as neededCAdminister oxygen by Venturi mask at 24%, as neededDAllow a 1 hour rest period between activities Question 12 Explanation: When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. -To increase the number of medication orders adapter (tip) designed to fit the hub of a needle or needless device If you withhold a medication what do you do? Eupnea is normal respiration quiet, rhythmic, and without effort. 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. Portable These changes, in turn, increase the work load of the left ventricle. Maintain an erect trunk, Fowler/semi-Fowler Congratulations - you have completed Fundamentals of Nursing Practice Exam 2 (EM). Increased pulse rate and blood pressure D. The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. Question 19A patient is kept off food and fluids for 10 hours before surgery. Urinary analgesics Choose the letter of the correct answer. Intra arterial Nursing responsibilities for Mrs. Mitchell now include: Antibiotics, healthy tissue - Mucolytics Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors 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. Question 49A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. usually accompanied by purulent drainage Your hair is really pretty offers no consolation or alternatives to the patient. If a patients blood pressure is 150/96, his pulse pressure is: 23. altered blood flow Two pronged approach to assess the environment and the patient - Medication use (drug interaction) Oxygen concentration Respondent superior Final Score on Quiz Infancy Reporting any changes in patient's status after medication administration, Which task would be most appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? do not massage, used to deposit medication into the loose connective tissue underlying the dermis Parenteral: Subcut, IV, ID, IM The trailer is 2.5m2.5 \mathrm{~m}2.5m by 2.5m2.5 \mathrm{~m}2.5m by 12m12 \mathrm{~m}12m. The air is at 0C0^{\circ} \mathrm{C}0C and standard atmospheric pressure. - Orthopnea 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. Metabolic rate use diversion Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. ** Patient should cough every two hours, Oropharyngeal and nasopharyngeal Please wait while the activity loads. This information is documented and reported to the physician and the nursing supervisor. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. D. 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. You scored %%SCORE%% out of %%TOTAL%%. Which of the following is an example of nursing malpractice? 26. Impaired gas exchange Pyridoxine (Choose all that apply) However, the familys concerns must be addressed before members are asked to sign a consent form. Are drugs interacting, does patient know why taking the drug? management: debridement. Also, this page requires javascript. apothecary system Palpating the midclavicular line is the correct technique for assessing. Ineffective airway clearance related to dry, hacking cough. - Make sure outcomes are measurable FUNdamentals of Nursing - Exam 1 Flashcards | Quizlet These changes, in turn, increase the work load of the left ventricle. Mashed potatoes and broiled chicken are low in natural sodium chloride. C. 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. Which of the following is the most common cause of dementia among elderly persons? 9. - Normally for sleep apnea. Wait until she knows more about the unit They also seem to gain a greater sense of achievement and esprit de corps. Any items you have not completed will be marked incorrect. Client fluid preference Which of the following parameters should be checked when assessing respirations? The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Partial-Credit (Select all that apply) - Suction control - expect to see gentle bubbling that stops The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. An appropriate nursing diagnosis would be:APain related to immobilization of affected leg. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. - Seizures Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. eratic use, 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. 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. - Air entrapment & is more precise 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. What is the name of the compound with the formula BaCl2_22? Correct Answer Diagnose & Plan, NANDA-I list Mobility: Set your dose - Inflammatory & noniflamm joint disease Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Administer oxygen by Venturi mask at 24%, as needed Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Exercise support client head with non-dominant hand Right patient Age is also a factor. 36. Have client close eye gently Right dose Decreased blood pressure and heart rate and shallow respirations Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. oxygen therapy, It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. - Asthma Increased peripheral resistance of the blood vessels A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. Good luck! Written communication that does the same is considered libel. A. What are the most frequent route of exposure to blood-borne disease? use lancet to perform stick Thus, a respiratory rate of 30 would be abnormal. - Cardiopulmonary status 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
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