In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. syrup Question 49When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:AProtect the patient from injuryBElevate the head of the bedCWithdraw all pain medications DInsert an airwayQuestion 49 Explanation: Ensuring the patients safety is the most essential action at this time. During a Romberg test, the nurse asks the patient to assume which position? - Sublingual: under the tongue Question 38The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Know delegation last/ regarding medication administration Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss The nurse is responsible for: Reduced hemoglobin, carbon monoxide, anemia Collaborative care, Place object close to center of gravity 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 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. 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. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Changing position every 2 hours In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. 48. access to download your test bank fundamentals of nursing practice test questions final exam web answered 0 of 0 questions 1 when it comes to client education . The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. to have access to drug information What is a nurses responsibility concerning Temperature? What are they? The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. Pain. - the body requires insulin in order to convert sugar into energy. A series of coughs throughout exhalations Tachypnea is rapid respiration characterized by quick, shallow breaths. EXPOSED BONE, TENDON, OR MUSCLE 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. test: fundamentals of nursing 8th edition ch. Physical Exam 41. Defines the scope of nurses' professional functions and responsibilities. Allow a 1 hour rest period between activities Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Urinary analgesics 28. Elixirs Prone Incentive spirometry (IS) Avoid the big thump Muscle weakness - Inaccurate prescribing Correct administration Such a patient is unlikely to display emotion, such as crying. depth dependent upon location, over boney prominence it will not be as deep as over areas with abundant subcutaneous tissue, Full thickness - Should be kept below the patient for the effect of gravity Be vigilant inventory record Medication Dose Responses, expected effects that don't contribute to helping the patient D. Studies have shown that patients and nurses both respond well to primary nursing care units. 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. Withdraw all pain medications The patient inserts the suppository 10 cm (4 inches) into the vaginal canal. Type I diabetes 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. Nursing responsibilities for Mrs. Mitchell now include: Reporting an APTT above 45 seconds to the physician, Assessing the patient for signs and symptoms of frank and occult bleeding. chemical name - compound that makes up the drug Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. Fever, exercise, and sympathetic stimulation all increase the heart rate.Question 5If 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:AAssaultBSlanderCRespondent superior DLibelQuestion 5 Explanation: Oral communication that injures an individuals reputation is considered slander. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. 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. subcutaneous fat may be visible Changes in vital signs may be cause by factors other than blood loss. 15. Moisture retentive dressings. Nursing Fundamentals Exam 2. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Exam Mode In this case, the supervisor is the resource person to approach. The most common deficiency seen in alcoholics is: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Which of the following nursing interventions promotes patient safety? Pulmonary function 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. The nurse could be charged with: 14. Organize. All of the following can cause tachycardia except: Current condition 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. Hint to administer medications safely and identify problems with the system Congratulations - you have completed Fundamentals of Nursing Practice Exam 2 (PM). - swayed back, less coordination, budda belly apothecary system Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Please visit using a browser with javascript enabled. Knowledge deficit topical wound care must clean the devitalized tissue. 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? gangrenous lesions 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: Oral communication that injures an individuals reputation is considered slander. 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. The best response would be: - vision, hearing, sense of touch, ability to perform fine motor tasks. All diminish What is Friction in Nursing Body Mechanics? Such a patient is unlikely to display emotion, such as crying. The nurse is responsible for giving the patient breakfast at the scheduled time. Question 28A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Dont worry.. offers some relief but doesnt recognize the patients feelings. Date Question Text Don't press directly on eyeball There are 50 questions to complete. There are 50 questions to complete. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Antibiotics, healthy tissue The best response would be:ADont worry. 90 ml in 3 hours aerosol Click the card to flip Definition 1 / 79 1. 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 Written report within 24 hours of occurrence, Comparison of medications taken at home and prescribed when in the health care setting, Change in patient's condition physical techniques and Inability to concentrate An appropriate nursing diagnosis would be:APain related to immobilization of affected leg. The other nursing actions may be necessary but are not a major priority. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Wait until she knows more about the unit Impaired skin integrity Relationship of one body part to another Which of the following statement is incorrect about a patient with dysphagia? A. In the event that a medication error occurs, the nurse should do the following first: A patient is kept off food and fluids for 10 hours before surgery. Check to see that the patient is wearing his identification band Hypothermia is an abnormally low body temperature. Certain substances increase the amount of urine produced. 44. The most common injury among elderly persons is: 45. (Choose all that apply) use meticulous hand hygiene and clean gloves Influenza and pneumococcal vaccine - spine is flexed, lacks curves that adult has Hip fracture An additional Vitamin C is required during all of the following periods except: I know this will be difficult acknowledges the problem and suggests a resolution to it. Nursing Process: IMPLEMENTATION for patients with low oxygenation, Health Promotion: DO NOT USE these to describe skin: tears, tape burns, perineal dermatitis, maceration, or excoriation, Full thickness skin loss Location of ET tube in airway (nose or mouth) 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. If nurse administers an injection to a patient who refuses that injection, she has committed: 30. Question 9Studies 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?ASide rails are ineffectiveBSide rails are a reminder to a patient not to get out of bed CSide rails are a deterrent that prevent a patient from falling out of bed.DSide rails should not be usedQuestion 9 Explanation: 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. The best response would be: Why are you crying? 2. communicate with patient/ family How are body alignment and mobility assessed? hold position for 5 minutes 50. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. rotate sites An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Learning needs Person, environment, health, nursing After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Question 6Mrs. Pain related to immobilization of affected leg. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. What are the nine rights medication administration? Question 1Examples of patients suffering from impaired awareness include all of the following except:AA patient who cannot care for himself at homeBA patient demonstrating symptoms of drugs or alcohol withdrawal CA semiconscious or over fatigued patientDA disoriented or confused patientQuestion 1 Explanation: A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. What are the oral options for medications? Errors include Chicken bouillon Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. D. I know this will be difficult acknowledges the problem and suggests a resolution to it. Which of the following is the most significant symptom of his disorder? Please visit using a browser with javascript enabled. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. 1. Arthritis - can patient get lid off container? Notify the health care provider immediately. She should notify the physician if the urine output is: NO BONE, TENDON OR MUSCLE EXPOSED The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Higher level on inspiration and lower level on expiration 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. NERVOUS SYSTEM. At a higher dose, it raises blood pressure at the expense of the kidneys, Oral - by mouth If loading fails, click here to try again. Ineffective airway clearance Documentation, Expected vs. actual response Passive - The nurse moves the patient's joints Body alignment: - Make sure outcomes are measurable An appropriate nursing diagnosis would be: 37. The patient should always feed himself While exhaling, open the epiglottis by saying the word huff Your performance has been rated as %%RATING%% 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 Respiratory rate only -Constipation. Which of the following nursing interventions would be appropriate? Maintaining patient's rights, History 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. Examples of patients suffering from impaired awareness include all of the following except: An alert, chronic arthritic patient treated with steroids and aspirin A. 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. The nurse could be charged with:ADefamationBMalpractice CAssaultDBatteryQuestion 40 Explanation: Malpractice is defined as injurious or unprofessional actions that harm another. Setting priorities Ex: Dopamine at a low dose will improve renal perfusion. 7. offer tissue to blot runny nose but not blow. -Reporting any changes in patient's status after medication administration Which of the following nursing interventions would be appropriate?AEncourage the patient to walk in the hall aloneBAccompany the patient for his walk.CConsult a physical therapist before allowing the patient to ambulate DDiscourage the patient from walking in the hall for a few more daysQuestion 17 Explanation: A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. 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. "up to heaven, down to hell" means that you lead with good foot when going up the stairs and lead with bad leg when going down the stairs". Draw out cloudy insulin Age is also a factor. Which of the following patients is at greatest risk for developing pressure ulcers? Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. Implementation His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:AHypothermiaBInfectionCAnxietyDDehydration Question 15 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. Question 49A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. A patient demonstrating symptoms of drugs or alcohol withdrawal 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. What should the nurse do? 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. "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. 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. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. b. - Vibration **place heal of hand over greater trochanter of hip with wrist perpendicular to femur; point thumb toward client groin; point index finger toward anterior superior iliac spine; extend middle finger along the iliac crest toward buttock; injection site is in the triangle formed, preferred site of immunizations in infants, toddlers, and children; thick and well developed Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Asses the patients ability to ambulate and transfer from a bed to a chair 246 abuse of alcohol, nicotine, or street durgs The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.BThe nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.CThe nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.DThe nurse administers the wrong medication to a patient and the patient vomits. keep needle inserted 10 seconds after injection of medications 48. Any items you have not completed will be marked incorrect. Patient's tolerance of procedure, Coughing Techniques to prevent poor oxygenation, Cascade She should notify the physician if the urine output is: Discuss the problem with her supervisor These include: After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. What are the 5 steps in the nursing process? - damage to any component that regulates voluntary movements Is patient better or worse? Question Details 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. research shows the least injury from injections here Attempted Questions Correct physical- vital signs, urine output, relief of Decreased blood pressure and heart rate and shallow respirations 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 Risk for injury You can program different amounts of insulin for different times of the day and night. Explain in detailed medical terms Question 32The most common deficiency seen in alcoholics is:AThiamineBRiboflavinCPantothenic acid DPyridoxineQuestion 32 Explanation: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Listen to their concerns and answer their questions honestly Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. apply gentle pressure to the injection site unless contraindicated Faith6 months ago excellent Ingestion Choose the letter of the correct answer. 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. 21. altered blood flow Some hospitals have standing orders up to 2L Choose the letter of the correct answer. Risk for aspiration, Prepare medications Atheroscleotic changes in the blood vessels - Chest wall movement Nursing Fundamentals Exam 2 Practice Test 4.7 (3 reviews) Which of the following is a collaborative intervention? To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Prone If sending patient home with O2, educate on no open flames. Right medication D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. A patient about to undergo abdominal inspection is best placed in which of the following positions? Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. red- pink wound bed D. The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. Correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, and contributes to balance. Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. Right: genetic factors affecting medicine administration, cultural factors affecting medicine administration, Onset of medication action- starts to work, intramuscular (IM) Feeding himself is a long-range expected outcome. - Cupping your hand and pat the back creating a vibration to move fluids along Capsules Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. elixir The nurse is legally responsible for labeling the corpse when death occurs in the hospital. The other answers are diseases that can occur in the elderly from physiologic changes. - We are helping this patient to heal and get out of the hospital taken into the body or administered in a manner other than through the digestive tract- intradermal, subcutaneous, intramuscular, intravenous. Question 42The physician orders a platelet count to be performed on Mrs. Smith after breakfast. 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. Fever Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? Changes in laboratory values. Shaded items are complete. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. Impaired mobility Battery is the unlawful touching of another person or the carrying out of threatened physical harm. 16. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors Question 4A 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. Lim begins to cry as the nurse discusses hair loss. Demonstrate the signal system to the patient - Head of bed elevated, support and align hips and spine Fundamentals of Nursing Quiz Question with Answer 1. Setting priorities A patient is kept off food and fluids for 10 hours before surgery. - Cough This information is documented and reported to the physician and the nursing supervisor. Dont worry. In this case, the supervisor is the resource person to approach. The nurse discusses the foods allowed on a 500-mg low sodium diet. Exercise Normal bowel sounds A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Allowing for rest periods decreases the possibility of hypoxia. Final Score on Quiz Right documentation High- humidity air and chest physiotherapy help liquefy and mobilize secretions. 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. Which of the following is an example of nursing malpractice? 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. 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. Once you are finished, click the button below. Malpractice Encourage them to sign the consent form right away The correct sequence for assessing the abdomen is: 18. The body of an organ donor is available for burial. The need to move the feet apart to maintain this stance is an abnormal finding. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. An appropriate nursing diagnosis would be: cleanse selected collection site Reduce risk of collapse of alveoli - Assess ability for patient self medication If this activity does not load, try refreshing your browser. Fundamentals of Nursing Practice Exam 2 (PM) Stress test Toddler The physician is responsible for instructing the patient about the test and for writing the order for the test. 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. 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 physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. do not massage, used to deposit medication into the loose connective tissue underlying the dermis 8. Discourage them from making a decision until their grief has eased Mitchell has been given a copy of her diet. Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. use biohazard sharps disposal containers- immediately Tympanic percussion, measurement of abdominal girth, and inspection. Home or health care facility, Coordinated efforts of the musculoskeletal and nervous systems Canes - personal preference as to what side use on, although usually used on weaker side. To monitor the status of previously ID'ed problem 4. Attitudes about medication use Its only temporary Document injury, Special Considerations for Administering Medications to Infants and Children, Age, weight, surface area 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. Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance D. Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. calibrated to 1/100 mL - acid-base imbalance, Oxygen carrying Capability psychosocial techniques, Oxygen supply, methods of oxygen delivery, hydration, humidification, nebulization