Less than 30 ml/hour When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominalorgans from pressing against the diaphragm, thus improving ventilation. A sign of abdominal cramping The nurses most important legal responsibility after a patients death in a hospital is: Implementation, Patient and family teaching Attempted Questions Correct Parasympathetic nervous system stimulation inventory record enteric coated right drug With that being said, critical thinking is the backbone of the nursing world. Relationship of one body part to another Ineffective breathing patterns Question 45An additional Vitamin C is required during all of the following periods except:AInfancyBPregnancy CChildhoodDYoung adulthoodQuestion 45 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. calibrated to 1/100 mL During a Romberg test, the nurse asks the patient to assume which position? All of the above B. Groups Collaborative care Prone What position should patient be in for rectal suppositories? Question 4All of the following can cause tachycardia except:AParasympathetic nervous system stimulation These changes, in turn, increase the work load of the left ventricle. Which of the following is the most significant symptom of his disorder? Impaired mobility - amputations Inhalation: via the mouth or nasal passages (breathed in) An appropriate nursing diagnosis would be: CBC - infection? instill prescribed number of drops Document in a timely fashion, Person on the blunt end of the needle is responsible for the sharp end of the needle I didnt get to the bad news yetDI know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy Question 14 Explanation: I know this will be difficult acknowledges the problem and suggests a resolution to it. usually accompanied by purulent drainage Anxiety Kaopectate is an anti diarrheal medication. depth varies by location, full thickness tissue loss Battery as drainage is being emptied out of reservoir, compress the device until bottom and top are in contact, quickly cleanse opening - Work with the families so that care is followed C. An Asian patient is likely to hide his pain. I didnt get to the bad news yetBI know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy CDont worry. instill drops holding dropper 1/2 inch above ear canal Start 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). read & record results (can be as low as 12) Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. generic name - official name Which of the following nursing interventions has the greatest potential for improving this situation?AContinue administering oxygen by high humidity face maskBPerform chest physiotheraphy on a regular schedule CEncourage the patient to increase her fluid intake to 200 ml every 2 hoursDPlace a humidifier in the patients room.Question 25 Explanation: Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. Accompanying him will offer moral support, enabling him to face the rest of the world. Swallowing - patient may not be able to swollow and patient should sit upright when taking meds 42. 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. - Smoking Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. The act protects patients from unskilled, undereducated and unlicensed personnel. Diabetes Nclex Questions And Rationale Rnspeak. - Patient must be checked every 15 minutes In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. Preoxygenate the patient Right documentation plan to safely handle and dispose of needles before procedure begins Question 2Mrs. - Fragrance free zones, Medications Avoid the big thump Ineffective individual coping to COPD. -To decrease the number of medication orders These changes, in turn, increase the work load of the left ventricle. 30. Exam 1 Fundamentals Of Nursing Flashcards Quizlet. Tell them the body will not be available for a wake or funeral In the prone position, the patient lies on his abdomen with his face turned to the side. Which of the following patients is at greatest risk for developing pressure ulcers? These include: B. Mashed potatoes and broiled chicken are low in natural sodium chloride. 6. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? Circulatory overload and respiratory excitement have no relevance to the question. Defamation Oxygen concentration express blood from site Substance abuse 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. Two pronged approach to assess the environment and the patient Type I diabetes Infants and children Dehydration A disoriented or confused patient 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 25Before rigor mortis occurs, the nurse is responsible for:AAllowing the body to relax normally BPlacing one pillow under the bodys head and shouldersCProviding a complete bath and dressing changeDRemoving the bodys clothing and wrapping the body in a shroudQuestion 25 Explanation: The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? administer pain meds 30-40 minutes before scheduled dressing change ..I didnt get to the bad news yet would be inappropriate at any time. Pre-attached needle - Each hospital has its own policy tubing mgt, know it -Locate the prescriber and obtain a signature. D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. - Make sure outcomes are measurable What is the first thing the nurse should do after writing down the order? 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. a. Insert the tube quickly. RN, BSN, PHN. right dose, Administration of Meds: The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. Intracardiac Waiting to consult a physical therapist is unnecessary. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. An additional Vitamin C is required during all of the following periods except: 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. Discourage the patient from walking in the hall for a few more days The other answers are incorrect interpretations of the statistical data. ..I didnt get to the bad news yet would be inappropriate at any time. All patients 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. 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. 2. A patient is kept off food and fluids for 10 hours before surgery. 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. What is the name of the compound with the formula BaCl2_22? NEVER recap needle 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. -Have the prescriber call in all prescriptions to the patient's preferred pharmacy instead of providing written prescriptions to the patient. Start Which of the following is the most common cause of dementia among elderly persons? fundamentals of nursing exam 1 flashcards quizlet web what are the 5 steps in the nursing process 1 assessment 2 nursing diagnosis 3 planning 4 Libel use proper injection angle - Osteoporosis 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. You have not finished your quiz. Circulatory overload and respiratory excitement have no relevance to the question. Which of the following nursing interventions has the greatest potential for improving this situation? 1. 96 Continuity of patient care promotes efficient, cost-effective nursing care - Drops, teaspoons, tablespoons, cups, pints, quarts O2 is a drug and must have doctor's orders Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Tympanic percussion, measurement of abdominal girth, and inspection The nurse is responsible for giving the patient breakfast at the scheduled time. Evaluation, Place call light within reach 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. intact or open serum filled blister A prescribed amount of oxygen s needed for a patient with COPD to prevent: Total Questions on Quiz BSympathetic nervous system stimulationCFeverDExerciseQuestion 4 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. injection sites for local effects Abdominal girth is unrelated to blood loss. If a patients blood pressure is 150/96, his pulse pressure is: Discuss the problem with her supervisor household system, When administering medications to older adults do what? All of the above Tachypnea test: fundamentals of nursing 8th edition ch. Reduce risk of collapse of alveoli Ineffective individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively. The infant falls off the scale, suffering a skull fracture. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. Pull out clear insulin The nurse should perform oral hygiene before assisting with feeding. Apical cleanse selected collection site 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. Parenteral: Subcut, IV, ID, IM rotate sites. 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. Intra arterial Nurse safety - 2nd priority Membrane permeability Inadequate tissue oxygenation at the cellular level Hourly Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance A bar having the cross section shown has been formed by securely bonding brass and aluminum stock. potential for injury of axillary, radial, brachial, and ulnar nerves and brachial artery 9. 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. The other nursing actions may be necessary but are not a major priority. 1. verify rights if visible cerumen or drainage remove with cotton-tipped applicator 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 hand hygiene before handling equipment. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Press plunger down until reads zero Bend knees Patient's perspectives After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. 3. 43. Recumbent However, the familys concerns must be addressed before members are asked to sign a consent form. Fundamentals of Nursing Test #2 Flashcards | Quizlet Fundamentals of Nursing Test #2 Term 1 / 97 Patient Medication Dose Route Time Documentation Effect To be educated To refuse Click the card to flip Definition 1 / 97 What are the nine rights medication administration? Polypharmacy - patient on many drugs. Kaopectate is an anti diarrheal medication. Active Assist - patient moves joints with help from nurse, Walker - only come in one width. This information is documented and reported to the physician and the nursing supervisor. keep needle inserted 10 seconds after injection of medications nonviable tissue 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. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Question 36A patient about to undergo abdominal inspection is best placed in which of the following positions?AProneBTrendelenburgCSide-lying DSupineQuestion 36 Explanation: 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. Establishing outcomes, Nursing Process in Med Admin: The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. -Contact the pharmacy to have the medication sent to the nursing unit STAT. Allowing for rest periods decreases the possibility of hypoxia. Question 17In Maslows hierarchy of physiologic needs, the human need of greatest priority is:AOxygen BEliminationCNutritionDLoveQuestion 17 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. 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. A patient is kept off food and fluids for 10 hours before surgery. How to minimize discomfort with injections? - Analgesic (pain) Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. If this activity does not load, try refreshing your browser. Clear knowledge The most common injury among elderly persons is: 45. A 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. Sensory impairments A 38-year old patients vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. The other answers are incorrect interpretations of the statistical data. right patient Thiamine 48. High-pitched gurgles head over the right lower quadrant are: 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. A. Rubbing patients back to facilitate relaxation B. measuring the patients blood pressure C. Assessing the patients educational needs related to discharge D. Administering prescribed medications to a patient Click the card to flip Maintain an erect trunk, Fowler/semi-Fowler Changes in laboratory values. Patient education Question 5To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. The other answers are diseases that can occur in the elderly from physiologic changes. use one pharmacy to coordinate all medications. Please visit using a browser with javascript enabled. 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). Blood flow from the area of absorption (poor blood flow leads to decreased effectiveness) - Harder time fighting off infection, Lifestyle Factors that Affect Oxygenation, Nutrition/Hydration Return Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. ", What is the goal of computerized physician order entry (CPOE)? 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. In the lateral position, the patient lies on his side. Posture Also, this page requires javascript. 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. - Cupping your hand and pat the back creating a vibration to move fluids along Ability of the medication to dissolve Older adults 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. Your hair is really pretty offers no consolation or alternatives to the patient. How do your prioritize if patient misses two doses of meds due to a long procedure? Setting priorities Fever, exercise, and sympathetic stimulation all increase the heart rate. Abdominal girth is unrelated to blood loss. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be. Roll in hand Question 11Which of the following nursing interventions promotes patient safety?A All of the above Chicken bouillon The trailer is 2.5m2.5 \mathrm{~m}2.5m by 2.5m2.5 \mathrm{~m}2.5m by 12m12 \mathrm{~m}12m. The air is at 0C0^{\circ} \mathrm{C}0C and standard atmospheric pressure. Score The nurse is responsible for: 4. ASittingBTrendelenburg CStandingDGenupectoralQuestion 47 Explanation: During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sidesfirst with eyes open, then with eyes closed. Kaolin with pectin (Kaopectate) 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. 49. 29. Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. 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. Time used occlude nasolacrimal duct for 30-60 seconds if medication causes systematic effects, Warm drops by running water over the bottle In the lateral position, the patient lies on his side. Toddlers have a much higher metabolic rate. [irp] Nclex Rn 31 Flashcards Quizlet. (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) She should notify the physician if the urine output is: 34. Decreased cardiac output Anna Curran. Eupnea is normal respiration quiet, rhythmic, and without effort. (mountain climbing, sky-diving, driving fast), Common developmental safety hazards for OLDER ADULT, Age related physiological changes 32. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? 31. subcutaneous (subcut) Which of the following nursing interventions has the greatest potential for improving this situation? B. behavioral- anxiety, agitation, consiousness abuse of alcohol, nicotine, or street durgs - can be determined by having a person stand and just look to see if a person is wobbly. Demonstrate the signal system to the patient Please wait while the activity loads. Mrs. Mitchell has been given a copy of her diet. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Wrong Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Hypothermia is an abnormally low body temperature. Which of the following is the most significant symptom of his disorder?AMuscle irritability BIncreased pulse rate and blood pressureCLethargyDMuscle weaknessQuestion 43 Explanation: Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The nurse is responsible for: - interferes with blood supply to lower extremities due to intermittent claudication Location of ET tube in airway (nose or mouth) Riboflavin 4. Right dose Ingestion Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. if ordered, send specimen to lab His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: 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. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. A semiconscious or over fatigued patient Abdominal girth is unrelated to blood loss. Writing the order for this test Beets and urinary analgesics, such as pyridium, can color urine red. Return Non-rebreather Mask 17-20% patients have to come back related to initial hospitalization. Mrs. Mitchell has been given a copy of her diet. Check vitals in response to the medication Your response is Vitamin C I will take it after I use the restroom." Good luck! Genupectoral C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. Its only temporaryBYour hair is really prettyCWhy are you crying? side-lying position with ear to be treated facing up ABG - 2 t to milliliters full tissue destruction Fundamentals of Nursing Exam 2 Term 1 / 79 What are the 4 purposes of a physical exam? B. Insert an airway A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Certain substances increase the amount of urine produced. Its only temporaryDYour hair is really prettyQuestion 2 Explanation: I know this will be difficult acknowledges the problem and suggests a resolution to it. All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! * prevent contamination of short-acting insulin with long acting, prevent contamination of short-acting insulin with long acting. -"I will wait until noon, when you have more medication ordered, and will bring it back to you then. Diagnose & Plan, NANDA-I list What should she do? - Cardiopulmonary status Young and middle-age adults hold it displaced until after needle is removed. red- pink wound bed 17. Guaiac test Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Assault -Read back the telephone order to the prescriber. -Contact the prescriber to inform him/her of the error. Inability to maintain oxygenation/ ventilation 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.

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