. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Dehydration Have client look at ceiling Then put air into clear vial St.Johns Wart is the worst. Lifting, bending, and moving 96 Your score is The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. O2 saturation Inhalation: via the mouth or nasal passages (breathed in) 2. Radial If nurse administers an injection to a patient who refuses that injection, she has committed: 12. - the body requires insulin in order to convert sugar into energy. Musculoskeletal Trauma 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. 11. 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 34For a rectal examination, the patient can be directed to assume which of the following positions?AHorizontal recumbentBAll of the above CSimsDGenupecterolQuestion 34 Explanation: All of these positions are appropriate for a rectal examination. Injection is given subcut, CLOUDY Answer Choice(s) Selected Continuity of patient care promotes efficient, cost-effective nursing care report descrepencies The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be, Administer oxygen by Venturi mask at 24%, as needed, Maintain the patient on strict bed rest at all times, Allow a 1 hour rest period between activities, Maintain the patient in an orthopneic position as needed. SKELETAL MUSCLE, Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. Which of the following is the most significant symptom of his disorder? depth dependent upon location, over boney prominence it will not be as deep as over areas with abundant subcutaneous tissue, Full thickness rotate sites. Age is also a factor. Place a humidifier in the patients room. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Which of the following nursing interventions promotes patient safety? Writing the order for this test Your response is Vitamin C Good luck! Question 34For a rectal examination, the patient can be directed to assume which of the following positions?AGenupecterolBSimsCAll of the above DHorizontal recumbentQuestion 34 Explanation: All of these positions are appropriate for a rectal examination. Effects of medications Which of the following parameters should be checked when assessing respirations? The infant falls off the scale, suffering a skull fracture. However, the familys concerns must be addressed before members are asked to sign a consent form. 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. anterior lateral aspect of thigh - CDC: Annual influenza vaccines for those 6 months and those over 50 years of age Assault The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Teach patient and family about drug reactions and schedule Question 3The most common psychogenic disorder among elderly person is:ADecreased appetite BInability to concentrateCDepressionDSleep disturbances (such as bizarre dreams)Question 3 Explanation: Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. Such a patient is unlikely to display emotion, such as crying. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. Ineffective individual coping to COPD. The nurse is responsible for: Most people get insulin from endogenous means. Person, nursing, environment, medicine Return (more prone to trips & falls throw rugs are a death trap), Other Issues/Risk Factors that are concerns for safety, Lifestyle 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. 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. Discourage them from making a decision until their grief has eased, Tell them the body will not be available for a wake or funeral, Listen to their concerns and answer their questions honestly, Encourage them to sign the consent form right away. SKELETAL SYSTEM, Provides attachments for muscles and ligaments and the leverage necessary for movement: Question 16If 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:ASlanderBLibelCAssaultDRespondent superior Question 16 Explanation: Oral communication that injures an individuals reputation is considered slander. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. A. Mrs. Lim begins to cry as the nurse discusses hair loss. Standing Before rigor mortis occurs, the nurse is responsible for: Transdermal patches Auscultation, percussion, and palpation - Splinting - hold a pillow or blanket against lower ribs to help ease pain Trendelenburg Defamation position-supine use meticulous hand hygiene and clean gloves Respondent superior Fundamentals Exam 2 The nurse evaluates which laboratory values to assess a patient's potential for wound healing? (can be as low as 12) 43. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. Press plunger down until reads zero The infusion set must be changed every few days. Please visit using a browser with javascript enabled. Crutches - 3 fingertips below the armpit and arms should be at an angle with the hand grip. open plug or cap on drainage device client should remain side-lying for 5-10 minutes gently massage triages with finger Accompanying him will offer moral support, enabling him to face the rest of the world. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. 42. Supine The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. 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. 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. -To increase the number of medication orders 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. What should the nurse do?AEncourage them to sign the consent form right awayBTell them the body will not be available for a wake or funeral CListen to their concerns and answer their questions honestlyDDiscourage them from making a decision until their grief has easedQuestion 29 Explanation: The brain-dead patients family needs support and reassurance in making a decision about organ donation. - Medicare is not going to pay if patient comes back to hospital w/in 30 days. 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. What are the oral options for medications? Location of ET tube in airway (nose or mouth) Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. Anxiety will not cause an elevated temperature. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. people who are overly stressed may require insulin to regulate blood glucose for a short period of time. The most common psychogenic disorder among elderly person is: Sleep disturbances (such as bizarre dreams), Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.Question 18 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). Written communication that does the same is considered libel. How many patient identifiers should you use? Fowlers or semi Fowlers position reduces the risk of aspiration during swallowing Disturbed body image Absorption is the passage of medications into the blood from the site of administration turn on machine and assure calibration plunger, Select the _______________ syringe size possible for accuracy; size range 0.5 mL to 60 mL, Pre-attached needle Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. Reported to provider at time of test Mitchell has been given a copy of her diet. Which of the following parameters should be checked when assessing respirations? What are the most frequent route of exposure to blood-borne disease? Diabetes Nclex Questions And Rationale Rnspeak. The nurse documents this breathing as: List 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. 10. What are the 3 muscle signs for IM injections? Substance abuse What is the most appropriate action? You got 50 minutes to finish the exam .Good luck! These changes, in turn, increase the work load of the left ventricle. System much more like the beta cells of your pancreas Household measurements In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. 90 ml in 3 hours 4. If nurse administers an injection to a patient who refuses that injection, she has committed: Assault is the unjustifiable attempt or threat to touch or injure another person. Autonomy and authority for planning are best delegated to a nurse who knows the patient well - This is sterile 2. Ineffective airway clearance Keep it simple Document injury, Special Considerations for Administering Medications to Infants and Children, Age, weight, surface area What should she do?AInform the staff that they must volunteer to rotate BDiscuss the problem with her supervisorCComplain to her fellow nursesDWait until she knows more about the unitQuestion 35 Explanation: 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. 17-20% patients have to come back related to initial hospitalization. The other answers are incorrect interpretations of the statistical data. 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. The nurse is responsible for giving the patient breakfast at the scheduled time. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. - 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. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. Avoid twisting right drug 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. Which of the following is an example of nursing malpractice? Check to see that the patient is wearing his identification band Circulatory overload and respiratory excitement have no relevance to the question. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Record administration of medication on the MAR before leaving the client room, Expected outcomes If not, container tends to be left off and pets or children can get into it. Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. Management: debridement and infection control. Temperature only Eupnea is normal respiration quiet, rhythmic, and without effort. Documentation, Expected vs. actual response This information is documented and reported to the physician and the nursing supervisor. Documented on patient medical record, Movement of gases between air spaces and blood stream, Movement of blood into and out of the lungs to organs and tissues A sign of decreased bowel motility Your hair is really pretty offers no consolation or alternatives to the patient. Used to administer medications in small precise doses, 0.3-1 mL capacity Administration of Meds: It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. You scored %%SCORE%% out of %%TOTAL%%. The need to move the feet apart to maintain this stance is an abnormal finding. Correct Answer sustained release. Posture 15. Standing 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: They also seem to gain a greater sense of achievement and esprit de corps. Question 35A 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. Which of the following is the most significant symptom of his disorder? dx of depression or anxiety Follow the medication administration rights Verify calculations Palpating the midclavicular line is the correct technique for assessing. 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. Congratulations - you have completed Fundamentals of Nursing Practice Exam 2 (PM). Beets and urinary analgesics, such as pyridium, can color urine red. reduces leakage of medication into subcutaneous tissue The nurse is responsible for: Instructing the patient about this diagnostic test. Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. Allergic Reactions ALess than 30 ml/hourB64 ml in 2 hoursC125 ml in 4 hours D90 ml in 3 hoursQuestion 5 Explanation: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. Assault and battery - Teach kids and parents how to manage situations 2. Hourly -Rectal bleeding Thus, any act that a nurse performs on the patient against his will is considered assault and battery. Immediately dispose of needle in sharps container seconds Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? High- humidity air and chest physiotherapy help liquefy and mobilize secretions. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. 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. An additional Vitamin C is required during all of the following periods except: Inability to concentrate The correct sequence for assessing the abdomen is: 18. I know this will be difficult acknowledges the problem and suggests a resolution to it. Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss - Assess ability for patient self medication A complete blood count does not provide immediate results and does not always immediately reflect blood loss. You Selected Allowing for rest periods decreases the possibility of hypoxia. - Severe sleep apnea or other respiratory problems A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. If loading fails, click here to try again. Use needleless systems/ avoid use of needles not well developed in many adults Using the data given below, find the largest permissible bending moment when the composite bar is bent about a horizontal axis. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors The best response would be: Why are you crying? Adverse Effects Fever, exercise, and sympathetic stimulation all increase the heart rate.Question 5If 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:AAssaultBSlanderCRespondent superior DLibelQuestion 5 Explanation: Oral communication that injures an individuals reputation is considered slander. Are drugs interacting, does patient know why taking the drug? The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. 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. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. The greater the surface area of the object that is moved, the greater the friction. Arthritis - can patient get lid off container? 19. Screw on needle Which finding might lead the nurse to suspect a nutritional alteration? The need to move the feet apart to maintain this stance is an abnormal finding. 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. rich in blood supply and absorbed faster Question 36Which 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 careBThe holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. - A decimal system organized into units of 10 A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. 90 degree angle Safety light Practice Mode Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. 25. read & record results Groups 29. 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 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. 6. - Ex. Herbal drugs can interact negatively with prescribed meds. A. Toxic Effects Also, this page requires javascript. right patient -Keep head of bed elevated above 30 degrees for at least 30 to 60 minutes after feeding. Simple Face Mask Impaired swallowing - body has become used to CO build-up, therefore excess CO does not motivate to breathe Regulates movement and posture, proprioception and balance with the precentral gyrus (motor strip) in the cerebral cortex. Please wait while the activity loads. DOCUMENT, Chapter 9: Nursing Process STUDY QUESTIONS Pe, Chapter 5-9, Nursing Process Lecture Study, Julie S Snyder, Linda Lilley, Shelly Collins, Barbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh, CRM UNIT 2: Emotions, Money, and Planning. Medication reconciliation: whenever a patient transfers to a new hospital, or new floor, or is discharged
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