Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Which of the following nursing interventions promotes patient safety? - We are helping this patient to heal and get out of the hospital This information is documented and reported to the physician and the nursing supervisor. A patient is kept off food and fluids for 10 hours before surgery. Describe some of the body changes throughout the life span: Newborn The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. 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. What position should patient be in for rectal suppositories? 26. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. 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. Written communication that does the same is considered libel. - Cardiac arrest In the lateral position, the patient lies on his side. Incentive spirometry (IS) -Keep head of bed elevated above 30 degrees for at least 30 to 60 minutes after feeding. Inrapleural Ensure that client has taken medications before leaving the room Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. How are body alignment and mobility assessed? 22. The nurse observes that Mr. Adams begins to have increased difficulty breathing. Can position patient in order to encourage drainage. Any items you have not completed will be marked incorrect. B. 31. generic name - official name patient education, Locked cabinet If heart is not working properly then we don't get perfusion Also, this page requires javascript. - Extra doses or failing to administer Tachypnea is rapid respiration characterized by quick, shallow breaths. These include: Caffeine-containing drinks, such as coffee and cola. Bones, joints, ligaments, tendons, cartilage, Physiology & Regulation of Movement His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: 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. subcutaneous fat may be visible Maintaining patient's rights, History Mobility: Don't use needles if needleness alternatives are available self medication, Nurse's Rights for safe medication administration, to complete and clearly written order that clearly specifies the drug, dose, route, and frequency 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. Toddlers have a much higher metabolic rate. Correct Movement 19. read & record results However, the familys concerns must be addressed before members are asked to sign a consent form. Question 20The nurses most important legal responsibility after a patients death in a hospital is:ANotifying the coroner or medical examinerBObtaining a consent of an autopsyCLabeling the corpse appropriatelyDEnsuring that the attending physician issues the death certification Question 20 Explanation: The nurse is legally responsible for labeling the corpse when death occurs in the hospital. Allergic Reactions Roll in hand Position the patient Question 21If nurse administers an injection to a patient who refuses that injection, she has committed:AAssault and batteryBNone of the above CMalpracticeDNegligenceQuestion 21 Explanation: Assault is the unjustifiable attempt or threat to touch or injure another person. What are the 3 muscle signs for IM injections? Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. 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. Nursing Fundamentals Final Exam; Nursing Fundamentals oxygenation; Nursing Fundamentals Quiz; Preview text. Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. questions Get Results Pedal Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. keep needle inserted 10 seconds after injection of medications Question 34For a rectal examination, the patient can be directed to assume which of the following positions?AGenupecterolBSimsCAll of the above DHorizontal recumbentQuestion 34 Explanation: All of these positions are appropriate for a rectal examination. 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. All of the above The nurse is legally responsible for labeling the corpse when death occurs in the hospital. Femoral apply to skin firmly C. A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. Risk for impaired skin integrity, Nursing process: Planning for a patient that is immobile, Goals and outcomes The nurses most important legal responsibility after a patients death in a hospital is: Notifying the coroner or medical examiner, Ensuring that the attending physician issues the death certification. suspension What are the nine rights medication administration? The nurse is responsible for: - Hemothorax Plan disposal of needle and syringe prior to procedure Oral communication that injures an individuals reputation is considered slander. The infant falls off the scale, suffering a skull fracture. - Ex: "upon discharge, patient will be able to maintain air on own" The nurse contacts the prescriber and receives a STAT telephone order for a medication. incorrect no answer. What should the nurse do? These changes, in turn, increase the work load of the left ventricle. Hourly Side rails should not be used During a Romberg test, the nurse asks the patient to assume which position? necrotic tissue Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. Posture 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. D. Studies have shown that patients and nurses both respond well to primary nursing care units. 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. 3 yrs - Grams to milligrams (or vice versa) 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. 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. Standing -Rectal bleeding - Anticoagulants The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Removing the bodys clothing and wrapping the body in a shroud Waiting to consult a physical therapist is unnecessary. Orthopnea Accidents Learning needs Score The physician orders a platelet count to be performed on Mrs. Smith after breakfast. All of these positions are appropriate for a rectal examination. Examples of patients suffering from impaired awareness include all of the following except: Hypothermia is an abnormally low body temperature. Exercise ARhythmBRateCAll of the above DSymmetryQuestion 26 Explanation: The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. Be alert to important functioning equipment. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. 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. - Analgesic (pain) -Use one pharmacy to coordinate all medications. 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. Fundamentals of Nursing Quiz Question with Answer 1. Pain. Kidneys, D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Not Attempted - Age-related changes: thickening of ventricular walls, reduction of cilia (the ability to capture things that can cause an infection) Question 39The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Conversions between systems 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. "activity intolerance related to COPD as evidence by dyspenia when walking to car" AA ham and Swiss cheese sandwich on whole wheat breadBChicken bouillon CA tossed salad with oil and vinegar and olivesDMashed potatoes and broiled chickenQuestion 6 Explanation: Mashed potatoes and broiled chicken are low in natural sodium chloride. Oxygen concentration What should she do? - Work with the families so that care is followed The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Insert needle at 90 angle Kaopectate is an anti diarrheal medication. Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. A bar having the cross section shown has been formed by securely bonding brass and aluminum stock. 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. 31. 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. The nurse documents this breathing as: If loading fails, click here to try again. 1. The physician is responsible for instructing the patient about the test and for writing the order for the test. Two forms of identification: name and birthdate 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. Risk for injury position head depending upon where instillation is desired Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture.Question 23A patient about to undergo abdominal inspection is best placed in which of the following positions?ATrendelenburgBSide-lying CSupineDProneQuestion 23 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. Nursing Process: IMPLEMENTATION for patients with low oxygenation, Health Promotion: Such a patient is unlikely to display emotion, such as crying. 7. Such a patient is unlikely to display emotion, such as crying. (claudication = limping, relieved by a short period of rest). The nurse observes that Mr. Adams begins to have increased difficulty breathing. -To decrease the number of medication orders - Respiratory pattern read back the telephone order to the prescriber. Follow the medication administration rights C. Orthopnea is difficulty of breathing except in the upright position. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. Question 23A prescribed amount of oxygen s needed for a patient with COPD to prevent:ACardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)BInhibition of the respiratory hypoxic stimulus CCirculatory overload due to hypervolemiaDRespiratory excitementQuestion 23 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. The nurse administers penicillin to a patient with a documented history of allergy to the drug. Start The other answers are incorrect interpretations of the statistical data. slough present the does not obscure depth of tissue loss bowel, The nurse could be charged with: 14. She is required to bathe only soiled areas of the body since the mortician will wash the entire body. If a patients blood pressure is 150/96, his pulse pressure is: Amyotrophic lateral sclerosis (Lou Gerhigs disease). Inability to maintain oxygenation/ ventilation gluteus medis and minimus muscles Which findings should be reported? Body Balance Choose the letter of the correct answer. All of the above 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. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. taken into the body or administered in a manner other than through the digestive tract- intradermal, subcutaneous, intramuscular, intravenous. The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. Who can prescribe? Question 6Mrs. Maintain an erect trunk, Fowler/semi-Fowler 13. Injection is given subcut, CLOUDY - Suction control - expect to see gentle bubbling that stops - Scoliosis Which of the following patients is at greatest risk for developing pressure ulcers? - Antipyretic (fever) 23. Also, this page requires javascript. 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. In the event that a medication error occurs, the nurse should do the following first: Accountability is clearest when one nurse is responsible for the overall plan and its implementation. Your hair is really pretty offers no consolation or alternatives to the patient. 5. - Bronchodialators Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions? Ingestion Which of the following nursing interventions promotes patient safety? right patient For a rectal examination, the patient can be directed to assume which of the following positions? Tympanic percussion, measurement of abdominal girth, and inspection Management: debridement and infection control. Collaborative care Anxiety will not cause an elevated temperature. Complete blood count Polypharmacy - patient on many drugs. counts Your answers are highlighted below. 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. 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. You Selected Beets and urinary analgesics, such as pyridium, can color urine red. 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. 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. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. Thus, any act that a nurse performs on the patient against his will is considered assault and battery. The body of an organ donor is available for burial. Thus, a respiratory rate of 30 would be abnormal. - Teach kids and parents how to manage situations renal/hepatic disease Substance abuse What is a nurses responsibility concerning Temperature? sensory deprivation or overload Your response is Vitamin C - Head of bed elevated, support and align hips and spine Respiration should be between 16-20 Ensuring the patients safety is the most essential action at this time. frequent emptying of the reserve, never remove a surgical dressing for wound inspection until you have the order Capsules Please wait while the activity loads. These include: 35. Most people get insulin from endogenous means. Thus, a respiratory rate of 30 would be abnormal. This information is documented and reported to the physician and the nursing supervisor. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Minimize patient discomfort, shortest length She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patients death; however, she is not legally responsible for performing these functions. To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool through guaiac (Hemoccult) test. All of the following can cause tachycardia except: 27. plunger, Select the _______________ syringe size possible for accuracy; size range 0.5 mL to 60 mL, Pre-attached needle If you leave this page, your progress will be lost. -Constipation. You have not finished your quiz. Reduced hemoglobin, carbon monoxide, anemia A semiconscious or over fatigued patient potential for injury of axillary, radial, brachial, and ulnar nerves and brachial artery Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. aka, NPH The other answers are diseases that can occur in the elderly from physiologic changes. (more prone to trips & falls throw rugs are a death trap), Other Issues/Risk Factors that are concerns for safety, Lifestyle Reporting an APTT above 45 seconds to the physician Dont worry.. offers some relief but doesnt recognize the patients feelings. 26. - Splinting - hold a pillow or blanket against lower ribs to help ease pain Other conditions requiring extra vitamin C include wound healing, fever, infection and stress.