A. Mandatory for D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. trade or brand name - what company will market by, What does classification mean and list some, The effect that the drug has on the body! Question 6Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?ADecreased blood pressure and heart rate and shallow respirationsBImmobility, diaphoresis, and avoidance of deep breathing or coughingCQuiet cryingDChanging position every 2 hours Question 6 Explanation: An Asian patient is likely to hide his pain. Accompanying him will offer moral support, enabling him to face the rest of the world. red or pink granulation tissue Circulatory overload and respiratory excitement have no relevance to the question. In the prone position, the patient lies on his abdomen with his face turned to the side. 46. PRN - as needed / per requested Increased peripheral resistance of the blood vessels Fundamentals of Nursing Chapter 2 - Fundamentals of Nursing - Studocu Not Attempted A. The nurse documents this breathing as: 3. 1. Two patient identifiers 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End The nurse discusses the foods allowed on a 500-mg low sodium diet. Prone C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. 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. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. 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. Home or health care facility, Coordinated efforts of the musculoskeletal and nervous systems C. A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. A patient who cannot care for himself at home -To prevent serious medication errors. 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. Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Get Results collect blood in test strip Autolytic debridement, protective, prevents wound dehydration, absorbs small to moderate drainage, Localized skin intact, non-blanchable and reddened. Which findings should be reported?ATemperature onlyBRespiratory rate onlyCPulse rate and temperatureDTemperature and respiratory rate Question 35 Explanation: Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Which of the following vascular system changes results from aging? Immobility, diaphoresis, and avoidance of deep breathing or coughing, Decreased blood pressure and heart rate and shallow respirations. Pinch skin 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. Insert needle at 90 angle elixir generic name - official name prevent needle contamination However, the familys concerns must be addressed before members are asked to sign a consent form. An additional Vitamin C is required during all of the following periods except: 39. Eupnea is normal respiration quiet, rhythmic, and without effort. 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. b. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. bowel, Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. liver, Right: genetic factors affecting medicine administration, cultural factors affecting medicine administration, Onset of medication action- starts to work, intramuscular (IM) Question 49A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Thus, a respiratory rate of 30 would be abnormal. state 3 & 4 pressure ulcers ", What is the goal of computerized physician order entry (CPOE)? 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. -"It will take only a minute to swallow the medication before you go to the bathroom." Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Household measurements I know this will be difficult acknowledges the problem and suggests a resolution to it. Allergic Reactions as drainage is being emptied out of reservoir, compress the device until bottom and top are in contact, quickly cleanse opening Question 33Which of the following patients is at greatest risk for developing pressure ulcers?AAn 88-year old incontinent patient with gastric cancer who is confined to his bed at homeBAn alert, chronic arthritic patient treated with steroids and aspirinCAn apathetic 63-year old COPD patient receiving nasal oxygen via cannulaDA confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. Reduced hemoglobin, carbon monoxide, anemia 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. Location of ET tube in airway (nose or mouth) 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. Explain the procedure to the client- allow them as much control and involvement as possible. Return Fundamentals of Nursing - Studocu The correct sequence for assessing the abdomen is: Assessment for distention, tenderness, and discoloration around the umbilicus. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Supine 2. Pedal Cuts She should notify the physician if the urine output is: 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. Respiratory rate Eupnea is normal respiration quiet, rhythmic, and without effort. Which of the following is an example of nursing malpractice? Applying a hot water bottle or heating pad to a patient without a physicians order does not include the three required components. 2. Observation of physiological measures women Elevate the head of the bed 90 degree angle Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? - low O motivates COPD patient to breathe apply prescribed number of inches over paper measuring guide Complain to her fellow nurses What is the first thing the nurse should do after writing down the order? Supositories Amyotrophic lateral sclerosis (Lou Gerhigs disease) 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: The infant falls off the scale, suffering a skull fracture. Palpating the midclavicular line is the correct technique for assessing. Symmetry D. Alzheimer;s disease, sometimes known as senile dementia of the Alzheimers type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Implementation, Patient and family teaching Pulmonary function The four main concepts common to nursing that appear in each of the current conceptual models are: 7. 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. The nurse could be charged with: nonviable tissue, usually accompanied by purulent drainage Place a humidifier in the patients room. Also, this page requires javascript. System much more like the beta cells of your pancreas - Cupping your hand and pat the back creating a vibration to move fluids along What are the most frequent route of exposure to blood-borne disease? 54 Practice Mode A patient about to undergo abdominal inspection is best placed in which of the following positions? Hypothermia is an abnormally low body temperature. High-pitched gurgles head over the right lower quadrant are: Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Anticipate the health provider's needs Tachypnea I will take it after I use the restroom." -Administering oral medications Good luck! Intracardiac client should remain side-lying for 5-10 minutes gently massage triages with finger Quiet crying - Grams to milligrams (or vice versa) Impaired physical mobility 17. - Rates if 8-15 liters Consequently, the nurse must observe for objective signs. A negative nitrogen balance is present when catabolic states exist. A sign of decreased bowel motility - Some drugs can cross the placenta and should not be administered to pregnant women, Therapeutic Effects Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Allowing the body to relax normally Laboratory data 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 Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. Exam Mode Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. represents increasing amounts of new blood vessels DOCUMENT, Chapter 9: Nursing Process STUDY QUESTIONS Pe, Chapter 5-9, Nursing Process Lecture Study, Julie S Snyder, Linda Lilley, Shelly Collins, Barbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh, CRM UNIT 2: Emotions, Money, and Planning. D. All of these positions are appropriate for a rectal examination. Which of the following nursing interventions has the greatest potential for improving this situation? 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. Please visit using a browser with javascript enabled. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Hint Question 15A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. What is causing the quick breathing Side Effects Friction. Calibrated in units not mL Fill prescription, Unit dose SIMS 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. Nursing Fundamentals Exam 2 Flashcards - Cram.com You have not finished your quiz. The brain-dead patients family needs support and reassurance in making a decision about organ donation. sustained release. Pyridoxine Inhibition of the respiratory hypoxic stimulus 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. This information is documented and reported to the physician and the nursing supervisor. 17. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. 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. In this case, the supervisor is the resource person to approach. - may need assistance to cross the blood brain barrier these are annoying, but not usually harmful, these are unwanted effects that are more harmful to the body, can be minor all the way up to life threatening, some drugs can interact and cause physical changes The most common psychogenic disorder among elderly person is: 46. If nurse administers an injection to a patient who refuses that injection, she has committed: 12. Accurate dosage calculation and measurement Immobility, diaphoresis, and avoidance of deep breathing or coughing Rub injection site w/ alcohol swab 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. Maintain balance, posture, and body alignment During a Romberg test, the nurse asks the patient to assume which position? Completely black on CXR indicated a collapsed lung - Pneumothorax The other nursing actions may be necessary but are not a major priority. Put air into the cloudy vial first - acid-base imbalance, Oxygen carrying Capability - Pain wash hands, Daily record taken to provider Question 32Which of the following is an example of nursing malpractice?AThe nurse administers penicillin to a patient with a documented history of allergy to the drug. inventory record rotate sites, Position cotton ball or tissue with non-dominant hand on cheekbone just below lower lid - spine is flexed, lacks curves that adult has Respiratory rate only 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. These include: 5. Alzheimer;s disease, sometimes known as senile dementia of the Alzheimers type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Question 11If nurse administers an injection to a patient who refuses that injection, she has committed:AMalpracticeBNegligenceCAssault and batteryDNone of the above Question 11 Explanation: Assault is the unjustifiable attempt or threat to touch or injure another person. shiny or dry 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. - Should be kept below the patient for the effect of gravity Stress test Ts To Know For Nclex Flashcards Quizlet. Abdominal girth is unrelated to blood loss. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. - Cough Check with the dyspnea scale B. Mashed potatoes and broiled chicken are low in natural sodium chloride. abuse of alcohol, nicotine, or street durgs After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Use stronger leg muscles The best response would be:ADont worry. The nurse discusses the foods allowed on a 500-mg low sodium diet. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. 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. -Change the feeding pump bag and tubing every 24 hours. - Drops, teaspoons, tablespoons, cups, pints, quarts What should the nurse do? Using the data given below, find the largest permissible bending moment when the composite bar is bent about a horizontal axis. The nurse discusses the foods allowed on a 500-mg low sodium diet. Intra osseous - narrow space of long bone, Metric system Thus, any act that a nurse performs on the patient against his will is considered assault and battery. hold syringe steady while needle is in tissue gently apply antiseptic pad or dry sterile gauze pad to site She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. She should notify the physician if the urine output is: Elixirs Protect the patient from injury She is required to bathe only soiled areas of the body since the mortician will wash the entire body. 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End Pain related to immobilization of affected leg. A. Right dose She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. - Pneumococcal for those over 65 or with chronic illnesses If a patients blood pressure is 150/96, his pulse pressure is: The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. Idiosyncratic Reactions Question 45All of the following can cause tachycardia except:AExerciseBParasympathetic nervous system stimulation rotate sites In the prone position, the patient lies on his abdomen with his face turned to the side. Urinary analgesics subcutaneous (subcut) occlude nasolacrimal duct for 30-60 seconds if medication causes systematic effects, Warm drops by running water over the bottle Infancy - Chest percussion * prevent contamination of short-acting insulin with long acting, prevent contamination of short-acting insulin with long acting. B. Time allowed 96 A. plan to safely handle and dispose of needles before procedure begins If loading fails, click here to try again. 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. If you leave this page, your progress will be lost. Eyedrops/eardrops Fundamentals of Nursing EXAM 2 Flashcards | Quizlet Providing a complete bath and dressing change Why are you crying? Caffeine-containing drinks, such as coffee and cola. Groups - Antipyretic (fever) - Anti Inflammatory, Tablets Which of the following statement is incorrect about a patient with dysphagia? Studies have shown that patients and nurses both respond well to primary nursing care units. Abdominal girth is unrelated to blood loss. no sloughing/ bruising suspension Before rigor mortis occurs, the nurse is responsible for: Which of the following nursing interventions promotes patient safety? - nervous system disease, 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. Infection However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. slough or eschar present in parts of the wound bed Get Results Changes in laboratory values. DO NOT USE these to describe skin: tears, tape burns, perineal dermatitis, maceration, or excoriation, Full thickness skin loss Is patient better or worse? - Ex: "upon discharge, patient will be able to maintain air on own" minutes 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. Acute pain, Nursing Process: Planning for patients with low oxygenation. to have access to drug information (Choose all that apply) In order for meds to be useful they have to get to the area that needs to be treated. A bar having the cross section shown has been formed by securely bonding brass and aluminum stock. Know delegation last/ regarding medication administration The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. Skip to document. D. 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. Medications administered Helps balance. 15. (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) and exocrine glands In the lateral position, the patient lies on his side. School-aged children and adolescents Bones, joints, ligaments, tendons, cartilage, Physiology & Regulation of Movement Sims Now - give it now, without breaking neck to do so -To increase the number of medication orders Dont worry.. offers some relief but doesnt recognize the patients feelings. Slide patient down knee How to minimize discomfort with injections? 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. Hourly Mrs. Mitchell has been given a copy of her diet. hold position for 5 minutes - Must be told what they need to do in order to have restraints removed 3) Voluntariness - The patient must be free to accept or reject the treatment; no pressure or coercion to give consent. 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. Contraindications? Then put air into clear vial Decreased blood flow Answers and Rationales Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. Knowledge and understanding of medication use Which is the most appropriate response from the nurse? Your performance has been rated as %%RATING%% The nurses most important legal responsibility after a patients death in a hospital is: Increased pulse rate and blood pressure 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 Fatigue Assault A semiconscious or over fatigued patient Which of the following nursing interventions has the greatest potential for improving this situation?
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