fundamentals of nursing quizlet exam 2
C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. Chicken bouillon Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. Good luck! Which of the following is an example of nursing malpractice? date, time, and initial outer side of the patch read & record results 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. 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. Right medication red- pink wound bed The most common deficiency seen in alcoholics is: Ability to absorb, metabolize, and excrete people who are overly stressed may require insulin to regulate blood glucose for a short period of time. right patient Push the diaphragm inward and upward The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. The nurses most important legal responsibility after a patients death in a hospital is: C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. Post a sign at the house. BCheck to see that the patient is wearing his identification bandCAsses the patients ability to ambulate and transfer from a bed to a chairDDemonstrate the signal system to the patientQuestion 11 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. - Rates if 8-15 liters C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. All of the above Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Question 25The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. Hip fracture 17. The infant falls off the scale, suffering a skull fracture. - Each hospital has its own policy tubing mgt, know it Usually used in aging and rehab Placing one pillow under the bodys head and shoulders 125 ml in 4 hours Which of the following is the most common cause of dementia among elderly persons? cleanse site using circular stroke starting with area immediately next to drain and moving away 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 nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. hold position for 5 minutes 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. Discuss the problem with her supervisor - Nurse needs to know # of mLs and what to expect The other nursing actions may be necessary but are not a major priority.Question 17A 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. - Make sure outcomes are measurable Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Cotton ball to outermost part of ear canal is acceptable if prescriber orders-do not press into canal, remove after 15 minutes, instruct client to clear nose unless contraindicated Beets and urinary analgesics, such as pyridium, can color urine red. O transport Person, nursing, environment, medicine The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. adults and children over 3- pull pinna up and back The nurse is responsible for: 4. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. During a Romberg test, the nurse asks the patient to assume which position? - lying on side with proper spine alignment intravenous (IV), first time administration Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. What is the name of the compound with the formula BaCl2_22? Thus, a respiratory rate of 30 would be abnormal. 48. 90 degree angle Return - Wrong medication, route, and time What should the nurse do?ADiscourage them from making a decision until their grief has easedBTell them the body will not be available for a wake or funeral CListen to their concerns and answer their questions honestlyDEncourage them to sign the consent form right awayQuestion 13 Explanation: The brain-dead patients family needs support and reassurance in making a decision about organ donation. Accompanying him will offer moral support, enabling him to face the rest of the world. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. If a patients blood pressure is 150/96, his pulse pressure is: 23. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:AAnxietyBDehydration CHypothermiaDInfectionQuestion 19 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. 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. Feeding himself is a long-range expected outcome. 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. Horizontal recumbent Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. Nasal Sprays Which of the following nursing interventions has the greatest potential for improving this situation? Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. - Medication use (drug interaction) 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. Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. 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. troche Which of the following nursing interventions promotes patient safety? It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? Please wait while the activity loads. Which of the following is the most significant symptom of his disorder? 41. Ask the patient What is a nurses responsibility concerning Temperature? 7. Such a patient is unlikely to display emotion, such as crying. Question 9Studies 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?ASide rails are ineffectiveBSide rails are a reminder to a patient not to get out of bed CSide rails are a deterrent that prevent a patient from falling out of bed.DSide rails should not be usedQuestion 9 Explanation: Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Radial -Assess and examine the patient. Nausea Body surface area Portable Venturi Mask The nurse is responsible for: Instructing the patient about this diagnostic test. Continue administering oxygen by high humidity face mask The nurse discusses the foods allowed on a 500-mg low sodium diet. 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. 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. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. These include: 2) Comprehension - The patient must understand the explanation. Bones, joints, ligaments, tendons, cartilage, Physiology & Regulation of Movement hand hygiene before handling equipment. However, the familys concerns must be addressed before members are asked to sign a consent form. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. client should remain side-lying for 5-10 minutes gently massage triages with finger Orotracheal and nasotracheal Trendelenburg Adverse reactions 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. An insulin pump is a small battery-operated device about the size of a small cell phone. What are the most frequent route of exposure to blood-borne disease? If you withhold a medication what do you do? The body of an organ donor is available for burial. Your hair is really pretty offers no consolation or alternatives to the patient. 3. altered blood flow Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. depth varies by location, full thickness tissue loss 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. What are they? Medication Interactions The nurse documents this breathing as:ATachypneaBEupncaCOrthopneaDHyperventilation Question 41 Explanation: Orthopnea is difficulty of breathing except in the upright position. B. Question 29The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The need to move the feet apart to maintain this stance is an abnormal finding. Nursing responsibilities for Mrs. Mitchell now include: C. Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. B. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. Pediatric dosages D. Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. Documentation, Expected vs. actual response The nurse observes that Mr. Adams begins to have increased difficulty breathing. The nurse observes that Mr. Adams begins to have increased difficulty breathing. Question 35A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Ineffective airway clearance related to dry, hacking cough. offer tissue to blot runny nose but not blow. as drainage is being emptied out of reservoir, compress the device until bottom and top are in contact, quickly cleanse opening In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. Once you are finished, click the button below. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? Be vigilant 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. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. 3 yrs 6. Nursing diagnosis Auscultation, percussion, and palpation Normal bowel sounds The physician orders a platelet count to be performed on Mrs. Smith after breakfast. Choose the letter of the correct answer. . 25. Certain substances increase the amount of urine produced. Also, this page requires javascript. Adverse Effects 1) Completeness (Disclosure) - tell patient everything regarding a treatment decision. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2) D. 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. Not Attempted 4. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. make sure enough insulin 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. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Your hair is really pretty offers no consolation or alternatives to the patient. Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. rotate sites, Position cotton ball or tissue with non-dominant hand on cheekbone just below lower lid Establishing outcomes, Nursing Process in Med Admin: 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. Pain related to immobilization of affected leg. Providing a complete bath and dressing change Hypothermia is an abnormally low body temperature. Synergistic - A synergist muscle is a muscle which works in concert with another muscle to generate movement. Question Text Ineffective airway clearance related to thick, tenacious secretions. - Suction control - expect to see gentle bubbling that stops Teach patient and family about drug reactions and schedule 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 Aging If you prepare the med, who should administer it? adapter (tip) designed to fit the hub of a needle or needless device psychosocial techniques, Oxygen supply, methods of oxygen delivery, hydration, humidification, nebulization Allowing for rest periods decreases the possibility of hypoxia. - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle, Patient safety - 1st priority usually accompanied by purulent drainage ABGs minutes secure with transparent dressing or tape, remove old patch before applying a new one Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. 14. The other nursing actions may be necessary but are not a major priority.Question 50The most common injury among elderly persons is:AHip fracture BUrinary Tract InfectionCIncreased incidence of gallbladder diseaseDAtheroscleotic changes in the blood vesselsQuestion 50 Explanation: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. History A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Text Mode Text version of the exam do not rub or massage into skin express blood from site Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. - Drops, teaspoons, tablespoons, cups, pints, quarts (more prone to trips & falls throw rugs are a death trap), Other Issues/Risk Factors that are concerns for safety, Lifestyle CBC - infection? Which of the following patients is at greatest risk for developing pressure ulcers? The nurse administers penicillin to a patient with a documented history of allergy to the drug.
