His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: 24. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. What factors affect ventilation and O transport? - Medication use (drug interaction) Choose the letter of the correct answer. - Inflammatory & noniflamm joint disease management: debridement. Avoid the big thump It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. Question 15A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Kaolin with pectin (Kaopectate) collect blood in test strip 17. plan to safely handle and dispose of needles before procedure begins Labeling the corpse appropriately slough Get Results What is the first thing the nurse should do after writing down the order? D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. 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. questions Reusability - Chest percussion Assessing the patient for signs and symptoms of frank and occult bleeding 125 ml in 4 hours Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. Oral communication that injures an individuals reputation is considered slander. Results Nursing responsibilities for Mrs. Mitchell now include:AReporting an APTT above 45 seconds to the physicianBAll of the above CAssessing the patient for signs and symptoms of frank and occult bleedingDReviewing daily activated partial thromboplastin time (APTT) and prothrombin time.Question 38 Explanation: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. Abdominal girth is unrelated to blood loss. C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Question 48A prescribed amount of oxygen s needed for a patient with COPD to prevent:AInhibition of the respiratory hypoxic stimulus BCirculatory overload due to hypervolemiaCRespiratory excitementDCardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)Question 48 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. ice to site before injection Riboflavin - don't twist Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. If over 5L you need to humidify the O2, Nasal Cannula 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. Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, and contributes to balance. Questions Not Attempted An Asian patient is likely to hide his pain. Intraocular: eye drops or eye ointment (intraopthalmic) Obstruction, decreased environmental oxygen Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. Accompanying him will offer moral support, enabling him to face the rest of the world. Written communication that does the same is considered libel. - Occurs in liver (major site of drug metabolism) people having trouble with this are older adults or people with liver diseases. Abdominal girth is unrelated to blood loss. Question 40The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?APedalBApicalCRadialDFemoral Question 40 Explanation: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. Person, environment, health, nursing Right dose Dont worry.. offers some relief but doesnt recognize the patients feelings. Question Details Evaluation, Place call light within reach - Harder time fighting off infection, Lifestyle Factors that Affect Oxygenation, Nutrition/Hydration Good luck! instill prescribed number of drops Battery 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. epidural The nurse should perform oral hygiene before assisting with feeding. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Hypothermia is an abnormally low body temperature. - Air entrapment & is more precise Disturbed body image Respiratory rate women - interferes with blood supply to lower extremities due to intermittent claudication Clear Pathway to bathroom 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). The greater the surface area of the object that is moved, the greater the friction. make sure enough insulin -Documenting patient's response to medication Now - give it now, without breaking neck to do so Fundamentals Of Nursing Exam 2- Documentation by Roxy0214049 , Sep. 2008 Subjects: 2 documentation exam fundamentals Click to Rate "Hated It" Click to Rate "Didn't Like It" Click to Rate "Liked It" Click to Rate "Really Liked It" Click to Rate "Loved It" Favorite Add to folder Flag Flashcards Memorize Test Games Tweet Related Essays - vision, hearing, sense of touch, ability to perform fine motor tasks. All diminish What is a nurses responsibility concerning Humidity? It slows down in pre-school, Special Considerations for Administering Medications to Older Adults. Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance 5. elixir adults and children over 3- pull pinna up and back -Have the prescriber call in all prescriptions to the patient's preferred pharmacy instead of providing written prescriptions to the patient. Thus, any act that a nurse performs on the patient against his will is considered assault and battery. Nausea An 88-year old incontinent patient with gastric cancer who is confined to his bed at home 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. administer pain meds 30-40 minutes before scheduled dressing change abuse of alcohol, nicotine, or street durgs Symmetry 40. 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. 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. aqueous solution Eupnea is normal respiration quiet, rhythmic, and without effort. - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle, Patient safety - 1st priority A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. 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. 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 16If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:ASlanderBLibelCAssaultDRespondent superior Question 16 Explanation: Oral communication that injures an individuals reputation is considered slander. - the body requires insulin in order to convert sugar into energy. Autolytic debridement, protective, prevents wound dehydration, absorbs small to moderate drainage, Localized skin intact, non-blanchable and reddened. B. A sign of decreased bowel motility Dependent edema, Activity intolerance- quality of life? Is patient better or worse? household system, When administering medications to older adults do what? 16. -Constipation. Solutions 7. D. 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. 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. Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. Some hospitals have standing orders up to 2L Side rails are a deterrent that prevent a patient from falling out of bed. C. A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. 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. date, time, and initial outer side of the patch Complain to her fellow nurses Beets Stress test Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Keep it simple Abdominal girth is unrelated to blood loss. Household measurements 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. Lethargy Intra arterial After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Question 13Before rigor mortis occurs, the nurse is responsible for:APlacing one pillow under the bodys head and shouldersBRemoving the bodys clothing and wrapping the body in a shroudCAllowing the body to relax normally DProviding a complete bath and dressing changeQuestion 13 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 physician is responsible for instructing the patient about the test and for writing the order for the test.Question 43After 1 week of hospitalization, Mr. Gray develops hypokalemia. In the prone position, the patient lies on his abdomen with his face turned to the side. 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. -Locate the prescriber and obtain a signature. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Love 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). Radial An alert, chronic arthritic patient treated with steroids and aspirin Insert an airway Placing one pillow under the bodys head and shoulders Date The nurse's role is provide the safest and highest standard of care possible for the patient. Please visit using a browser with javascript enabled. She should notify the physician if the urine output is: 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End Circulatory overload and respiratory excitement have no relevance to the question. Pregnancy Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. A ham and Swiss cheese sandwich on whole wheat bread Not Attempted Don't use needles if needleness alternatives are available ABGs Changes in vital signs may be cause by factors other than blood loss. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Draw out cloudy insulin Question 12If a patients blood pressure is 150/96, his pulse pressure is:A96B246C150D54Question 12 Explanation: The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. A bar having the cross section shown has been formed by securely bonding brass and aluminum stock. tilt the evacuator in the direction of the plug Everyone! The other answers are diseases that can occur in the elderly from physiologic changes. support client head with non-dominant hand The patient will find pureed or soft foods, such as custards, easier to swallow than water The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. What should she do? - Assess ability for patient self medication Which of the following parameters should be checked when assessing respirations? prevent contamination of solution Ensure that client has taken medications before leaving the room Implementation 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. The other answers are incorrect interpretations of the statistical data. Administer oxygen by Venturi mask at 24%, as needed 36. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. The best response would be:ADont worry. These include: Machines vary from facility to facility, wash hands Answers and Rationales 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. 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. Its only temporaryBYour hair is really prettyCWhy are you crying? Time used Discourage them from making a decision until their grief has eased, Tell them the body will not be available for a wake or funeral, Listen to their concerns and answer their questions honestly, Encourage them to sign the consent form right away. - Age-related changes: thickening of ventricular walls, reduction of cilia (the ability to capture things that can cause an infection) APerson, environment, health, nursing BPerson, health, psychology, nursingCPerson, nursing, environment, medicineDPerson, health, nursing, support systemsQuestion 46 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. Patient education Consequently, the nurse must observe for objective signs. -To increase the number of medication orders Eupnea is normal respiration quiet, rhythmic, and without effort. b. Side rails are ineffective Palpating the midclavicular line is the correct technique for assessing. 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. After 1 week of hospitalization, Mr. Gray develops hypokalemia. To reduce the risk of polypharmacy, how should the nurse advise the older patient regarding medications? Unit 4: The Roles Of Nurses In Different Health Care System I health educate the patients and families on ways to maintain a healthy lifestyles and how to prevent diseases. Disorders of Bones, Joints, & Muscles Fundamentals of Nursing Practice Exam 2 (PM) Continuity of patient care promotes efficient, cost-effective nursing care, Autonomy and authority for planning are best delegated to a nurse who knows the patient well. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Shaded items are complete. 5. The other nursing actions may be necessary but are not a major priority. subcutaneous fat may be visible shiny or dry Can you document that you gave a medication before you give it to the client? 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. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. allowed an hour window of time A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. The nurse observes that Mr. Adams begins to have increased difficulty breathing. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. Skip to document. Question 11Which of the following nursing interventions promotes patient safety?A All of the above Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice. Reporting an APTT above 45 seconds to the physician Written communication that does the same is considered libel. Crutches - 3 fingertips below the armpit and arms should be at an angle with the hand grip. How are body alignment and mobility assessed? - Cardiopulmonary status -Must be allowed to toilet, eat. How to minimize discomfort with injections? Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Assess for orthostatic hypotension, Active - patient can move joints on own Hyperventilation nonviable tissue - Scoliosis 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. Do not apply to hairy surfaces or scar tissue Which of the following nursing interventions would be appropriate? D. I know this will be difficult acknowledges the problem and suggests a resolution to it. The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. 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.
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