A. Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Hourly Right medication - Inaccurate prescribing - If too premature, it can be born before surfactant develops allowed an hour window of time "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. Final Score on Quiz If nurse administers an injection to a patient who refuses that injection, she has committed: Question 27Which of the following vascular system changes results from aging?ADecreased blood flowBIncreased peripheral resistance of the blood vesselsCIncreased work load of the left ventricleDAll of the above Question 27 Explanation: Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. Stress Continue administering oxygen by high humidity face mask In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. 2. Are drugs interacting, does patient know why taking the drug? Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. Allow a 1 hour rest period between activities Once you are finished, click the button below. A patient is kept off food and fluids for 10 hours before surgery. - Work with the families so that care is followed Risk for aspiration For a rectal examination, the patient can be directed to assume which of the following positions? Fundamentals Of Nursing Exam #1 - Legal Aspects In Nursing Intracardiac Side rails are a reminder to a patient not to get out of bed. 12. Draw out cloudy insulin Use needleless systems/ avoid use of needles Moisture retentive dressings. Dont worry. Maintain an erect trunk, Fowler/semi-Fowler SKELETAL MUSCLE, Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. Assessing the patient for signs and symptoms of frank and occult bleeding turn on machine and assure calibration - This is sterile The nurse is responsible for giving the patient breakfast at the scheduled time. Allowing for rest periods decreases the possibility of hypoxia. Your score is High-pitched gurgles head over the right lower quadrant are: 19. rich in blood supply and absorbed faster ice to site before injection D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. Tympanic percussion, measurement of abdominal girth, and inspection. - Pulmonary edema ( no gas exchange with the lungs) right patient Nurse's role Increased work load of the left ventricle Which is the most appropriate response from the nurse? -Locate the prescriber and obtain a signature. Person, health, psychology, nursing 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. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Question 39Palpating the midclavicular line is the correct technique for assessingARespiratory rateBApical pulse CBaseline vital signsDSystolic blood pressureQuestion 39 Explanation: 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. Pumps only use buffered short-acting or rapid-acting insulin (not long- or intermediate-acting insulin). 22. Nutrition These include: Clear Pathway to bathroom The act protects patients from unskilled, undereducated and unlicensed personnel. Stress test Question 10High-pitched gurgles head over the right lower quadrant are:AA sign of increased bowel motilityBA sign of abdominal cramping CA sign of decreased bowel motilityDNormal bowel soundsQuestion 10 Explanation: Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. What are the 3 muscle signs for IM injections? Eupnca Complain to her fellow nurses 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. hold it displaced until after needle is removed. The nurse could be charged with: Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. - Move from side to side allows for secretions and expansion If heart is not working properly then we don't get perfusion Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. research shows the least injury from injections here elixir The nurse administers penicillin to a patient with a documented history of allergy to the drug. Total Questions on Quiz The nurse should perform oral hygiene before assisting with feeding. 1. Infants and children Notify the health care provider immediately. abdomen from costal margins to the iliac crests Attempted Questions Correct Chest x-ray The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. Critical thinking is not a solo occurrence; it is something that allows you to grow and mature every time it occurs. Collaborative care D. 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. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. shiny or dry use one pharmacy to coordinate all medications. 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. A prescribed amount of oxygen s needed for a patient with COPD to prevent: behavioral- anxiety, agitation, consiousness What are they? A patient demonstrating symptoms of drugs or alcohol withdrawal 10. Certain substances increase the amount of urine produced. Score 14. The nurses most important legal responsibility after a patients death in a hospital is: 49. - Reposition every two hours to reduce the risk of infection 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 Waiting to consult a physical therapist is unnecessary. 110 Report Document Comments Please sign inor registerto post comments. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. Complete blood count Laboratory data 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. Malpractice Who can prescribe? 21. Patient's tolerance of procedure, Coughing Techniques to prevent poor oxygenation, Cascade Knowledge deficit 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. If you leave this page, your progress will be lost. Environmental factors - Pollutants (ask where person lives, know your region an it's risk factors), Nursing history: Signs that may indicate poor oxygenation Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. Learning needs Adverse Effects generic name - official name 90 degree angle ", What is the goal of computerized physician order entry (CPOE)? establishing an effective nurse-patient relationship -reduce anxiety through therapeutic communication, teaching, and acceptance -remember that the patient has concerns and needs other medical ones -communicate with the patient as an individual -take time to learn about the patient being admitted -provide for the family participation in all Automated medication dispensing systems in the hospital Encourage the patient to increase her fluid intake to 200 ml every 2 hours Which findings should be reported? Fundamentals of Nursing EXAM 2 Term 1 / 142 What do nurses need to be aware of regarding patient safety Click the card to flip Definition 1 / 142 A safe environment reduces the risk for accidents Vulnerable groups require help to achieve a safe environment Desired effect The nurse manager and the bedside nurses must collaborate on i. Question 22A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. Nausea Nurse is responsible for following legal provisions for administering opioids which are carefully controlled through federal and state guidelines, overuse, to stop, think and be vigilant when administering medications, metric system - 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. Placing one pillow under the bodys head and shoulders Start 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. BCheck to see that the patient is wearing his identification bandCAsses the patients ability to ambulate and transfer from a bed to a chairDDemonstrate the signal system to the patientQuestion 11 Explanation: Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patients ability to carry out these functions safely. secure with transparent dressing or tape, remove old patch before applying a new one questions Intraocular: eye drops or eye ointment (intraopthalmic) 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. - Cupping your hand and pat the back creating a vibration to move fluids along Right patient Question 33 Explanation: Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Chemical Discuss the problem with her supervisor Beets and urinary analgesics, such as pyridium, can color urine red. Some of the pumps monitors your blood glucose level. 11. What should she do?ADiscuss the problem with her supervisorBComplain to her fellow nursesCInform the staff that they must volunteer to rotate DWait until she knows more about the unitQuestion 28 Explanation: Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. Management: debridement and infection control. Beets and urinary analgesics, such as pyridium, can color urine red. Rub injection site w/ alcohol swab can I get a witness, caplet B. Some hospitals have standing orders up to 2L What is the first thing the nurse should do after writing down the order? Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. - may need assistance to cross the blood brain barrier Dont worry.. offers some relief but doesnt recognize the patients feelings. DIneffective airway clearance related to dry, hacking cough.Question 37 Explanation: Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. However, the familys concerns must be addressed before members are asked to sign a consent form. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to: Please wait while the activity loads. A sign of increased bowel motility In Maslows hierarchy of physiologic needs, the human need of greatest priority is: 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. You scored %%SCORE%% out of %%TOTAL%%. Answer Choice(s) Selected Thus, a respiratory rate of 30 would be abnormal. Choose the letter of the correct answer. Respiration should be between 16-20 and exocrine glands 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. The nurse administers the wrong medication to a patient and the patient vomits. If this activity does not load, try refreshing your browser. The patient will find pureed or soft foods, such as custards, easier to swallow than water 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. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home Providing a complete bath and dressing change Fundamentals of Nursing - Studocu Regulates movement and posture, proprioception and balance with the precentral gyrus (motor strip) in the cerebral cortex. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. Kaopectate is an anti diarrheal medication. 31. 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. express blood from site Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Muscle weakness They also seem to gain a greater sense of achievement and esprit de corps. 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. death of subcutaneous fat tissue and muscle degeneration Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. Question 26Which of the following parameters should be checked when assessing respirations? STAT - give immediately Assault Question 42The physician orders a platelet count to be performed on Mrs. Smith after breakfast. 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. apply gentle pressure to the injection site unless contraindicated What is a nurses responsibility concerning Temperature? Which of the following nursing interventions has the greatest potential for improving this situation? - low O motivates COPD patient to breathe Monitor the patient In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. These include:AKaolin with pectin (Kaopectate) BCaffeine-containing drinks, such as coffee and cola.CBeetsDUrinary analgesicsQuestion 41 Explanation: Fluids containing caffeine have a diuretic effect. Use technology Hypothermia ABGs Right documentation Question 1The nurses most important legal responsibility after a patients death in a hospital is:ALabeling the corpse appropriatelyBEnsuring that the attending physician issues the death certification CNotifying the coroner or medical examinerDObtaining a consent of an autopsyQuestion 1 Explanation: The nurse is legally responsible for labeling the corpse when death occurs in the hospital. Assault 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. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Has a reservoir that is filled with insulin and a microcomputer that allows you to adjust how much insulin is to be delivered. The correct sequence for assessing the abdomen is: Assessment for distention, tenderness, and discoloration around the umbilicus. 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. It continuously delivers small amounts of insulin through an infusion line placed under the skin. The brain-dead patients family needs support and reassurance in making a decision about organ donation. Alzheimers disease The other answers are incorrect interpretations of the statistical data. 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 require refrigeration Fill prescription, Unit dose The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. - Protein binding Organize. Ineffective airway clearance related to dry, hacking cough. Orthopnea - Antipyretic (fever) Ineffective individual coping to COPD. Allergic Reactions B. patient education, Locked cabinet -Have the prescriber call in all prescriptions to the patient's preferred pharmacy instead of providing written prescriptions to the patient. All of the following can cause tachycardia except: It slows down in pre-school, Special Considerations for Administering Medications to Older Adults. Nursing responsibilities for Mrs. Mitchell now include: Question Details -Read back the telephone order to the prescriber. Patient releases the restraint and falls and injures him/herself, Smoke detectors 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. The nurse documents this breathing as: Right to refuse (try to educate patient, document and notify provider) 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. Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance Your hair is really pretty offers no consolation or alternatives to the patient. abuse, Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? - amputations Right dose This paper will focus on how one will use critical thinking in nursing practice. Altered neurovascular status to extremities (cyanosis, pallor, coldness of skin, tingling, pain, numbness) All of these positions are appropriate for a rectal examination. Non-rebreather Mask Intraperiteneal Side rails are a deterrent that prevent a patient from falling out of bed. - Ex. Final Score on Quiz Fatigue 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. Temperature and respiratory rate In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. At a higher dose, it raises blood pressure at the expense of the kidneys, Oral - by mouth Don't press directly on eyeball Also, this page requires javascript. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. Nursing responsibilities for Mrs. Mitchell now include: 6. All of the above His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: Contraindications? 19. What is comfort level (any pain?) Which of the following is an example of nursing malpractice? Fundamentals Of Nursing Exam 2- Documentation - Cram.com 45. These changes, in turn, increase the work load of the left ventricle. - Mental confusion -Flush with 30 mL of water before and after feedings. The nurse is responsible for giving the patient breakfast at the scheduled time. 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. ATI Quiz Fundamentals 1 Flashcards Quizlet - Studocu 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. 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 Apical pulse Once you are finished, click the button below. Obtaining a consent of an autopsy This information is documented and reported to the physician and the nursing supervisor. A. The greater the surface area of the object that is moved, the greater the friction. Topical: anything you can put on the skin, to include patches 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. remove protective covering (more prone to trips & falls throw rugs are a death trap), Other Issues/Risk Factors that are concerns for safety, Lifestyle Tachypnea is rapid respiration characterized by quick, shallow breaths.
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