An Asian patient is likely to hide his pain. Monitor - Chest wall movement no sloughing/ bruising 31. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. The nurse is responsible for giving the patient breakfast at the scheduled time. - muscle-skeletal changes occur B. abdomen from costal margins to the iliac crests CBC - infection? Hold pen with thumb ready to depress 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. use diversion 21. Its only temporary outer aspect of upper arms All of the following can cause tachycardia except: 27. Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Certain substances increase the amount of urine produced. Impaired gas exchange Trendelenburg Gently press downward with thumb or forefinger against bony orbit. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. 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. allowed an hour window of time Allowing for rest periods decreases the possibility of hypoxia. Which of the following nursing interventions would be appropriate? What is a nurses responsibility concerning Nutrition? - protects against aspiration, Nurse's Role in an Endotracheal Intubation, Know the proper equipment and its use Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. - Harder time fighting off infection, Lifestyle Factors that Affect Oxygenation, Nutrition/Hydration 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. Immobility, diaphoresis, and avoidance of deep breathing or coughing, Decreased blood pressure and heart rate and shallow respirations. 2. Good luck! 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. Question 30An additional Vitamin C is required during all of the following periods except:APregnancy BInfancyCYoung adulthoodDChildhoodQuestion 30 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. 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. Urinary Tract Infection - This is sterile Question 10The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would beAAdminister oxygen by Venturi mask at 24%, as neededBMaintain the patient on strict bed rest at all timesCAllow a 1 hour rest period between activities DMaintain the patient in an orthopneic position as neededQuestion 10 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. Topical, - To protect our patients and each state must abide by these laws Please visit using a browser with javascript enabled. Due to ability to contract and relax are the working elements of movement. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. Performing activities of daily living, Body Alignment Which of the following is the most significant symptom of his disorder? Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. AMashed potatoes and broiled chickenBChicken bouillon CA ham and Swiss cheese sandwich on whole wheat breadDA tossed salad with oil and vinegar and olivesQuestion 28 Explanation: Mashed potatoes and broiled chicken are low in natural sodium chloride. use meticulous hand hygiene and clean gloves Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Which of the following parameters should be checked when assessing respirations? Avoid twisting Oral communication that injures an individuals reputation is considered slander. None of the above Start aqueous solution Written communication that does the same is considered libel. Question 41The nurse observes that Mr. Adams begins to have increased difficulty breathing. secure with transparent dressing or tape, remove old patch before applying a new one Caffeine-containing drinks, such as coffee and cola. Expectations, Nursing Process in Med Admin: Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss 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? 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. Notifying the coroner or medical examiner [irp] Nclex Rn 31 Flashcards Quizlet. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. 28. The nurse discusses the foods allowed on a 500-mg low sodium diet. O2 saturation Learning needs frequent emptying of the reserve, never remove a surgical dressing for wound inspection until you have the order The correct sequence for assessing the abdomen is: Assessment for distention, tenderness, and discoloration around the umbilicus. 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. (2) Sustained Release - a longer time to dissolve, What factors Influence Medication Distribution, Circulation 4. - Analgesic (pain) seconds The greater the surface area of the object that is moved, the greater the friction. 14. CNS Damage Acute pain Question Details topical wound care must clean the devitalized tissue. Defamation 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 patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. 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. - Assess ability for patient self medication The other answers are incorrect interpretations of the statistical data. You have completed Readiness for enhanced self- health management 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 absence of which pulse may not be a significant finding when a patient is admitted to the hospital? High- humidity air and chest physiotherapy help liquefy and mobilize secretions. Once you are finished, click the button below. Pumps only use buffered short-acting or rapid-acting insulin (not long- or intermediate-acting insulin). to have access to drug information - Ex: "upon discharge, patient will be able to maintain air on own" Goals and outcomes Side rails are a reminder to a patient not to get out of bed I will take it after I use the restroom." D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? APerson, nursing, environment, medicineBPerson, environment, health, nursing CPerson, health, nursing, support systemsDPerson, health, psychology, nursingQuestion 44 Explanation: The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs. For a rectal examination, the patient can be directed to assume which of the following positions? ARhythmBRateCAll of the above DSymmetryQuestion 26 Explanation: The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. The need to move the feet apart to maintain this stance is an abnormal finding. Return - Patient must be checked every 15 minutes She is required to bathe only soiled areas of the body since the mortician will wash the entire body. If loading fails, click here to try again Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. do not massage, used to deposit medication into the loose connective tissue underlying the dermis In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the torso and upper legs. - Medication use (drug interaction) 33. Exercise Inability to maintain oxygenation/ ventilation Coordinated Body Movement Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? 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. Stress test Receiving, transcribing, and communicating medication orders Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Such a patient is unlikely to display emotion, such as crying. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? Two patient identifiers Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. Return Time used 1. In the prone position, the patient lies on his abdomen with his face turned to the side. The nurse observes that Mr. Adams begins to have increased difficulty breathing. 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. Changing position every 2 hours Don't give them Question 42The physician orders a platelet count to be performed on Mrs. Smith after breakfast. shallow open Consuit a physical therapist before allowing the patient to ambulate. Recording medication administration Diagnose & Plan, NANDA-I list Increased peripheral resistance of the blood vessels, Increased work load of the left ventricle. A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. Obtaining a consent of an autopsy & drink, Impaired skin integrity Advantages of insulin pen: Accurate dosage calculation and measurement Medication Dose Responses, expected effects that don't contribute to helping the patient The most common deficiency seen in alcoholics is: 32. What do nurses need to be aware of regarding patient safety, A safe environment reduces the risk for accidents, Safety, Moving & transferring patients, Medication Administration, Insulin, Oxygenation Capsules Topical: anything you can put on the skin, to include patches Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. - lying on side with proper spine alignment Which of the following nursing interventions has the greatest potential for improving this situation? Cigarette smoking - Dialogue on how to quit After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. 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. No-interruption zones Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. 2) Comprehension - The patient must understand the explanation. Which of the following is an example of nursing malpractice? 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. Nursing responsibilities for Mrs. Mitchell now include:AReporting an APTT above 45 seconds to the physicianBAssessing the patient for signs and symptoms of frank and occult bleedingCAll of the above DReviewing daily activated partial thromboplastin time (APTT) and prothrombin time.Question 3 Explanation: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. Which of the following nursing interventions has the greatest potential for improving this situation? Allpatients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation. During the procedure, the client begins to cough and has difficulty breathing. 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). Altered neurovascular status to extremities (cyanosis, pallor, coldness of skin, tingling, pain, numbness) Sitting Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. You build on each experience by pulling . The act protects patients from unskilled, undereducated and unlicensed personnel. Respiration should be between 16-20 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. Which of the following patients is at greatest risk for developing pressure ulcers? Environmental factors - Pollutants (ask where person lives, know your region an it's risk factors), Nursing history: Signs that may indicate poor oxygenation disposable, prefilled, sterile, cartridge units, glass container with a constricted, pre-scored neck - Atelectisis Ensuring the patients safety is the most essential action at this time. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. 2. 5. Side rails are ineffective She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Via epideral - Splinting - hold a pillow or blanket against lower ribs to help ease pain Nurses feel personal satisfaction, much of it related to positive feedback from the patients. Allergies, medication, diet The other nursing actions may be necessary but are not a major priority. Air or blood is trapped in the pleural space; use proper injection angle polypharmacy 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. The other nursing actions may be necessary but are not a major priority. 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. - Antipyretic (fever) Radial You scored %%SCORE%% out of %%TOTAL%%. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Childhood Remain with patient until meds are taken To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Accompanying him will offer moral support, enabling him to face the rest of the world. D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. - can be determined by having a person stand and just look to see if a person is wobbly. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. In the lateral position, the patient lies on his side. Allowing for rest periods decreases the possibility of hypoxia. to administer medications safely and identify problems with the system You can program different amounts of insulin for different times of the day and night. 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. 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. - Fragrance free zones, Medications Which of the following vascular system changes results from aging? Demonstrate the signal system to the patient, Asses the patients ability to ambulate and transfer from a bed to a chair, Check to see that the patient is wearing his identification band. Your performance has been rated as %%RATING%% The infusion set must be changed every few days. What is comfort level (any pain?) Supine Ensure that client has taken medications before leaving the room (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) Age is also a factor. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. Maintain the patient in an orthopneic position as needed -To decrease the number of medication orders Reduced hemoglobin, carbon monoxide, anemia 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? Safety awareness, Inherent Accident Risks in the Health Care Agency, (Normal everyday things that happen) When your patient eats, you use buttons on the pump to give additional or "bolus" insulin to cover the carbohydrates in the meal. Document injury, Special Considerations for Administering Medications to Infants and Children, Age, weight, surface area 3. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. Nursing Fundamentals Exam 2 Practice Test 4.7 (3 reviews) Which of the following is a collaborative intervention? The patient lies on her left side. ..I didnt get to the bad news yet would be inappropriate at any time. Body surface area Toddlers have a much higher metabolic rate. Don't use needles if needleness alternatives are available shiny or dry Describe some of the body changes throughout the life span: Newborn 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. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. What should she do? Monitor the patient Injection is given subcut, CLOUDY inject med slowly and smoothly - Chemical structure of medication determines where excretion occurs Simple Face Mask Increased work load of the left ventricle These changes, in turn, increase the work load of the left ventricle. 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. Calibrated in units not mL Use technology The nurses most important legal responsibility after a patients death in a hospital is: hold syringe steady while needle is in tissue Groups Intraperiteneal injection sites for local effects ** people in liver failure are at rate of liver failure b/c metabolism of meds is very poor, After metabolism, excretion occurs through Infants and children Question 29The family of an accident victim who has been declared brain-dead seems amenable to organ donation. Bones, joints, ligaments, tendons, cartilage, Physiology & Regulation of Movement gently apply antiseptic pad or dry sterile gauze pad to site Safety light If not, container tends to be left off and pets or children can get into it. This information is documented and reported to the physician and the nursing supervisor. Waiting to consult a physical therapist is unnecessary. Your answers are highlighted below. - Rates if 8-15 liters - Work with the families so that care is followed Quad Question 25The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Exam Mode Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. Final Score on Quiz Right medication 3 yrs Pain related to immobilization of affected leg. School-aged children and adolescents - Some drugs can cross the placenta and should not be administered to pregnant women, Therapeutic Effects Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors Question 4A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. question - Normally for sleep apnea. death of subcutaneous fat tissue and muscle degeneration Congratulations - you have completed Fundamentals of Nursing Practice Exam 2 (PM). Medications administered A. Nclex Practice Questions 1 Free Test Bank 2022 Nurseslabs. patient education, Locked cabinet Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Hypothermia Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Hourly -Rectal hemorrhoids If loading fails, click here to try again. NEVER recap needle When a patient self-administers a vaginal suppository, which behavior would require further teaching? Illness The nurse should perform oral hygiene before assisting with feeding. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2) Question 15A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. abuse, Circulatory overload and respiratory excitement have no relevance to the question. The nurse is responsible for: Instructing the patient about this diagnostic test. - 2 t to milliliters A prescribed amount of oxygen s needed for a patient with COPD to prevent: Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2), Inhibition of the respiratory hypoxic stimulus. During a Romberg test, the nurse asks the patient to assume which position? Setting goals Risk for aspiration, Prepare medications Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Genupecterol Guaiac test Question 39Palpating the midclavicular line is the correct technique for assessingARespiratory rateBApical pulse CBaseline vital signsDSystolic blood pressureQuestion 39 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. Completely black on CXR indicated a collapsed lung sharpest - anxiety attacks/pain/fear Tachypnea is rapid respiration characterized by quick, shallow breaths. Question 21After 1 week of hospitalization, Mr. Gray develops hypokalemia. The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. Nutrition O transport Thus, a respiratory rate of 30 would be abnormal. 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). A. Fluids containing caffeine have a diuretic effect. Sympathetic nervous system stimulation After 1 week of hospitalization, Mr. Gray develops hypokalemia. O2 can be extremely drying. Put air into the cloudy vial first Check to see that the patient is wearing his identification band Mashed potatoes and broiled chicken Results Question 8A 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. Check vitals in response to the medication What should the nurse do? Route of administration (fastest I.V.) Anxiety will not cause an elevated temperature. UNSTAGEABLE UNTIL SLOUGH/ESCHAR IS REMOVED A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Protect your own body 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. Answer Choice(s) Selected - slow reaction time & dull the senses List factors required for informed consent. Discourage the patient from walking in the hall for a few more days The nurse documents this breathing as:ATachypneaBEupncaCOrthopneaDHyperventilation Question 41 Explanation: Orthopnea is difficulty of breathing except in the upright position. 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. Pain related to immobilization of affected leg. - Ex. She should notify the physician if the urine output is: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. 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.

Portrait Photography Workflow, Andrew Heiberger Net Worth, Articles F