Clear knowledge Start 110 Report Document Comments Please sign inor registerto post comments. 43. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. During a Romberg test, the nurse asks the patient to assume which position? apply gentle pressure to the injection site unless contraindicated Clear insulin is the short acting insulin, Remove cap Practice Mode However, the familys concerns must be addressed before members are asked to sign a consent form. -Must be allowed to toilet, eat. - Specific prescribed amt. RN, BSN, PHN. Allowing for rest periods decreases the possibility of hypoxia. Clarify unclear orders Any items you have not completed will be marked incorrect. NO BONE, TENDON OR MUSCLE EXPOSED Question 2The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?AFemoral BApicalCRadialDPedalQuestion 2 Explanation: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. 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). 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. I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy The nurse discusses the foods allowed on a 500-mg low sodium diet. - Inflammatory & noniflamm joint disease How do your prioritize if patient misses two doses of meds due to a long procedure? Dehydration It slows down in pre-school, Special Considerations for Administering Medications to Older Adults. D. 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. - Splinting - hold a pillow or blanket against lower ribs to help ease pain inject med slowly and smoothly question Route of administration (fastest I.V.) Side rails should not be used Which of the following is the most common cause of dementia among elderly persons? 44. Urinary Tract Infection 96 Range of motion Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Risk for injury test: fundamentals of nursing 8th edition ch. - anxiety attacks/pain/fear All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! Fluids containing caffeine have a diuretic effect. Body Balance During a Romberg test, the nurse asks the patient to assume which position? Your answers are highlighted below. Attempted Questions Correct 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. Mitchell has been given a copy of her diet. The nurse documents this breathing as:ATachypneaBEupncaCOrthopneaDHyperventilation Question 41 Explanation: Orthopnea is difficulty of breathing except in the upright position. - Postural drainage In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. Such a patient is unlikely to display emotion, such as crying. What factors affect ventilation and O transport? The nurse is responsible for: She should notify the physician if the urine output is: 34. Fundamentals Exam 2 The nurse evaluates which laboratory values to assess a patient's potential for wound healing? 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: 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. 7. Completely black on CXR indicated a collapsed lung never manually recap needles after injection Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. 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. Right: genetic factors affecting medicine administration, cultural factors affecting medicine administration, Onset of medication action- starts to work, intramuscular (IM) These include: Caffeine-containing drinks, such as coffee and cola. - muscle-skeletal changes occur 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 Hip fracture She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Ineffective breathing patterns 15. Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. apply prescribed number of inches over paper measuring guide The correct sequence for assessing the abdomen is: Assessment for distention, tenderness, and discoloration around the umbilicus. Total Questions on Quiz How to minimize discomfort with injections? Time allowed Strict aseptic technique Slide patient down knee do not rub or massage into skin Anxiety Nursing responsibilities for Mrs. Mitchell now include: Reporting an APTT above 45 seconds to the physician, Assessing the patient for signs and symptoms of frank and occult bleeding. 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. B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Polypharmacy - patient on many drugs. 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) - Do not strip the tubing, need to milk it instead. Via epideral - bag must be full A complete blood count does not provide immediate results and does not always immediately reflect blood loss. A negative nitrogen balance is present when catabolic states exist. Monitor determined by the physician as well as the frequency Impaired gas exchange Absorption is the passage of medications into the blood from the site of administration - Scoliosis Accompany the patient for his walk. -Keep head of bed elevated above 30 degrees for at least 30 to 60 minutes after feeding. troche Shaded items are complete. Question 9Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?AImmobility, diaphoresis, and avoidance of deep breathing or coughingBDecreased blood pressure and heart rate and shallow respirationsCChanging position every 2 hours DQuiet cryingQuestion 9 Explanation: An Asian patient is likely to hide his pain. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. An Asian patient is likely to hide his pain. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. physical techniques and Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. -To increase the number of medication orders 8. Eupnca An additional Vitamin C is required during all of the following periods except: Aging A) Instruction was done at the bedside by a physician in the U.S. B)Curriculum in American schools was more standardized C)Student nurses in the U.S. worked for minimum wage D)The nightingale program was less organized A) Instruction was done at the bedside by a physician in the U.S. 2/8 Fundamentals of Nursing Ch. Bones, joints, ligaments, tendons, cartilage, Physiology & Regulation of Movement A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Accompanying him will offer moral support, enabling him to face the rest of the world. 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. allowed an hour window of time Recumbent - Teach kids and parents how to manage situations 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. A tossed salad with oil and vinegar and olives liver, injection sites for local effects However, the familys concerns must be addressed before members are asked to sign a consent form. Ineffective airway clearance Draw out cloudy insulin (claudication = limping, relieved by a short period of rest). 2. Question 28A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Childhood Exam Mode Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. & drink, Impaired skin integrity Hint Ask the patient Fever, exercise, and sympathetic stimulation all increase the heart rate.Question 46The four main concepts common to nursing that appear in each of the current conceptual models are: Infancy Incentive spirometry (IS) adapter (tip) designed to fit the hub of a needle or needless device She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Posture Ensure that client has taken medications before leaving the room counts Environmental factors - Pollutants (ask where person lives, know your region an it's risk factors), Nursing history: Signs that may indicate poor oxygenation 17. 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. All four side rails up is considered a restraint Increased peripheral resistance of the blood vessels - Bruises/Contusions Venturi Mask -Use one pharmacy to coordinate all medications. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Question 50A 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. open plug or cap on drainage device The nurses most important legal responsibility after a patients death in a hospital is: maintain privacy Risk for activity intolerance CO transport, CNS sends signal to chest wall to control rate, depth, and rhythm, Carbon dioxide and hydrogen ions affect rate and depth of ventilation, Dissolved in plasma, carbamino compounds, bicarbonate UNSTAGEABLE UNTIL SLOUGH/ESCHAR IS REMOVED Text Mode 14. 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: Please wait while the activity loads. 1 mL capacity -Reporting any changes in patient's status after medication administration In this case, the supervisor is the resource person to approach. A patient is kept off food and fluids for 10 hours before surgery. 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. All of the above Air or blood is trapped in the pleural space; 32. Question 3The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Inability to concentrate "I will bring the medication back to your room once you return from the bathroom", The nurse is ready to administer a patient's morning medication when the patient states, "Please leave the medication on my table. 30. Tracheal In the prone position, the patient lies on his abdomen with his face turned to the side. use middle third of muscle, easily accessible Preoxygenate the patient Intracardiac 24. Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Helps balance. Sympathetic nervous system stimulation sustained release. Start Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. How are body alignment and mobility assessed? Assessment for distention, tenderness, and discoloration around the umbilicus. Decreased blood pressure and heart rate and shallow respirations High- humidity air and chest physiotherapy help liquefy and mobilize secretions. Question 14Mrs. abuse, 25 quizlet name written questions what position is easiest to assess the anus and rectum? always draw up medication with a filter needle, plastic or glass container with rubber seal, insert 5-15 degrees - This is sterile Supositories Patient's tolerance of procedure, Coughing Techniques to prevent poor oxygenation, Cascade Adverse reactions 22. After 1 week of hospitalization, Mr. Gray develops hypokalemia. The nurse documents this breathing as: Orthopnea is difficulty of breathing except in the upright position. Biotransformation occurs when enzymes detoxify, degrade, and remove active chemicals - Respiratory pattern Solutions Correct Answer Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Pyridoxine Arthritis - can patient get lid off container? -"It will take only a minute to swallow the medication before you go to the bathroom." These include: Asses the patients ability to ambulate and transfer from a bed to a chair Question 26Which of the following parameters should be checked when assessing respirations? taken into the body or administered in a manner other than through the digestive tract- intradermal, subcutaneous, intramuscular, intravenous. Assault and battery Implementation, Patient and family teaching Supine Lim begins to cry as the nurse discusses hair loss. management: debridement. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. Inability to maintain oxygenation/ ventilation 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. This information is documented and reported to the physician and the nursing supervisor. (mountain climbing, sky-diving, driving fast), Common developmental safety hazards for OLDER ADULT, Age related physiological changes 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. - Anti-anxiety drugs Inhibition of the respiratory hypoxic stimulus Tachypnea is rapid respiration characterized by quick, shallow breaths. Amyotrophic lateral sclerosis (Lou Gerhigs disease) 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. household system, When administering medications to older adults do what? 2. Ensuring that the attending physician issues the death certification 6. - Administer medication correctly Abdominal girth is unrelated to blood loss. 2. Perform chest physiotheraphy on a regular schedule Respiration should be between 16-20 None of the above (2) Sustained Release - a longer time to dissolve, What factors Influence Medication Distribution, Circulation Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. 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. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. Abdominal girth is unrelated to blood loss. The other nursing actions may be necessary but are not a major priority. Which of the following vascular system changes results from aging? - Normally for sleep apnea. - Protein binding If this activity does not load, try refreshing your browser. B. Evaluation, Place call light within reach Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Can you document that you gave a medication before you give it to the client? Synergistic - A synergist muscle is a muscle which works in concert with another muscle to generate movement. ..I didnt get to the bad news yet would be inappropriate at any time. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Do not apply to hairy surfaces or scar tissue Safety awareness, Inherent Accident Risks in the Health Care Agency, (Normal everyday things that happen) Fever Infection In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. At a higher dose, it raises blood pressure at the expense of the kidneys, Oral - by mouth The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. proper skin prep A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Older adults Atheroscleotic changes in the blood vessels keep needle inserted 10 seconds after injection of medications Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. Question 49A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. CThe nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.DThe nurse administers penicillin to a patient with a documented history of allergy to the drug. adults and children over 3- pull pinna up and back 26. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. Right patient Allowing for rest periods decreases the possibility of hypoxia. The force that occurs in a direction to oppose movement. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Good luck! In the prone position, the patient lies on his abdomen with his face turned to the side. The best response would be:ADont worry. Most people get insulin from endogenous means. Abdominal girth is unrelated to blood loss. Keep needle in skin for 10 sec, Clean the vials Setting priorities Verify calculations Goals and outcomes - 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. -Allow a family member to coordinate all prescriptions. -trauma, Developmental Factors that impair oxygenation, Premature infants Environmental modifications If you leave this page, your progress will be lost. Define Assessment Collects comprehensive data pertinent to the patient's health and/or situation. Waiting to consult a physical therapist is unnecessary. - Respiratory infection Before rigor mortis occurs, the nurse is responsible for: Placing one pillow under the bodys head and shoulders, Providing a complete bath and dressing change, Removing the bodys clothing and wrapping the body in a shroud. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? chemical name - compound that makes up the drug position head depending upon where instillation is desired Question 39The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Diabetes Nclex Questions And Rationale Rnspeak. 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. STAT - give immediately 31. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Use needleless systems/ avoid use of needles Obtain baseline data (serves as baseline for comparison as the pt.'s health status changes) 2. Listen to their concerns and answer their questions honestly Then put air into clear vial Question 7The most common injury among elderly persons is:AHip fracture BAtheroscleotic changes in the blood vesselsCIncreased incidence of gallbladder diseaseDUrinary Tract InfectionQuestion 7 Explanation: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Mrs. Mitchell has been given a copy of her diet. The nurse's role is provide the safest and highest standard of care possible for the patient. 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. Such a patient is unlikely to display emotion, such as crying. The most common injury among elderly persons is: 45. position-supine use meticulous hand hygiene and clean gloves Exercise Sims Certain substances increase the amount of urine produced. - Smoking - Osteoporosis Nclex Practice Questions 1 Free Test Bank 2022 Nurseslabs. Temperature and respiratory rate minimizes pain and irritation The nurse could be charged with: Malpractice is defined as injurious or unprofessional actions that harm another. Must be used for insulin and nothing else, 3/8-3 inches in length, gauge indicates diameter, part that fits onto the tip of the syringe, reusable plastic syringe holders Hypothermia is an abnormally low body temperature. - Suction control - expect to see gentle bubbling that stops Beets Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. remove protective covering 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. Fatigue Everyone! Which findings should be reported? eratic use, The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be PRN - as needed / per requested The four main concepts common to nursing that appear in each of the current conceptual models are: 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. Don't use expired medications 16. These muscles can work with the so-called agonists or prime movers which surround a joint, or the antagonistic muscles, which move in the opposite direction The nurse discusses the foods allowed on a 500-mg low sodium diet. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors. 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 What should the nurse do? self medication, Nurse's Rights for safe medication administration, to complete and clearly written order that clearly specifies the drug, dose, route, and frequency 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. An appropriate nursing diagnosis would be: Ineffective airway clearance related to thick, tenacious secretions. 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. Things they like doing but can't Readiness for enhanced self- health management Impaired mobility - Do the goals matter to the patient? - Pursed lip breathing to slow down breathing rate subcutaneous fat may be visible A prescribed amount of oxygen s needed for a patient with COPD to prevent: 40. St.Johns Wart is the worst. 49. Love DAccountability is clearest when one nurse is responsible for the overall plan and its implementation.Question 46 Explanation: Studies have shown that patients and nurses both respond well to primary nursing care units. date, time, and initial paper During a Romberg test, the nurse asks the patient to assume which position? - peripheral arterial disease abdomen from costal margins to the iliac crests - the body requires insulin in order to convert sugar into energy. Body alignment: Muscle weakness Laboratory data apply to chest, back, upper arm, or legs. Beets and urinary analgesics, such as pyridium, can color urine red. instill prescribed number of drops administer pain meds 30-40 minutes before scheduled dressing change 26. seconds 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. deep and away from major nerves and blood vessels stable eschar over heals should not be removed, slough Thus, any act that a nurse performs on the patient against his will is considered assault and battery. O2 is a drug and must have doctor's orders anterieor aspects of thighs Now - give it now, without breaking neck to do so Applying a hot water bottle or heating pad to a patient without a physicians order does not include the three required components. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. The nurse is responsible for: Increased pulse rate and blood pressure Which of the following nursing interventions would be appropriate?AEncourage the patient to walk in the hall aloneBAccompany the patient for his walk.CConsult a physical therapist before allowing the patient to ambulate DDiscourage the patient from walking in the hall for a few more daysQuestion 17 Explanation: A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Ts To Know For Nclex Flashcards Quizlet. Toddlers have a much higher metabolic rate. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. - Each hospital has its own policy tubing mgt, know it A semiconscious or over fatigued patient Mrs. Lim begins to cry as the nurse discusses hair loss. Fundamentals of Nursing Practice Exam 2 Practice Mode Exam Mode Text Mode 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. intradermal report descrepencies The nurse discusses the foods allowed on a 500-mg low sodium diet. All of the above A complete blood count does not provide immediate results and does not always immediately reflect blood loss. - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle, Patient safety - 1st priority collect blood in test strip A client has been admitted to a nursing home, and the nurse completes an assessment. - may need assistance to cross the blood brain barrier Documentation, Expected vs. actual response
Ang Pamana Simbolismo, Harlem Hospital Center Program Gastroenterology Fellowship, Articles F