- Chemical structure of medication determines where excretion occurs Side rails are a reminder to a patient not to get out of bed. 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. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home, An alert, chronic arthritic patient treated with steroids and aspirin. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. Pedal The brain-dead patients family needs support and reassurance in making a decision about organ donation. Ensuring that the attending physician issues the death certification -Reporting any changes in patient's status after medication administration It continuously delivers small amounts of insulin through an infusion line placed under the skin. Due to ability to contract and relax are the working elements of movement. Autonomy and authority for planning are best delegated to a nurse who knows the patient well CH 02 HW - Chapter 2 physics homework for Mastering Auditing Overview Newest Theology - yea Leadership class , week 3 executive summary Right time - Respiration should be between 16-20 Click the card to flip Definition 1 / 79 1. Most people get insulin from endogenous means. inject med slowly and smoothly Once you are finished, click the button below. A semiconscious or over fatigued patient These include: A ham and Swiss cheese sandwich on whole wheat bread, A tossed salad with oil and vinegar and olives. Substance abuse Total Questions on Quiz 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. Injectibles Patient's perspectives Allpatients 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. SIMS 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. These include: Elevate the head of the bed All of the above (mountain climbing, sky-diving, driving fast), Common developmental safety hazards for OLDER ADULT, Age related physiological changes ** Patient should cough every two hours, Oropharyngeal and nasopharyngeal 15. Do not apply to hairy surfaces or scar tissue Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors However, the familys concerns must be addressed before members are asked to sign a consent form. -Have the prescriber call in all prescriptions to the patient's preferred pharmacy instead of providing written prescriptions to the patient. A. In order for perfusion to occur, must have ventilation, diffusion & respiration, Neural Question 50A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. 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 - Do not strip the tubing, need to milk it instead. Notifying the coroner or medical examiner Dosage calculations An additional Vitamin C is required during all of the following periods except: An appropriate nursing diagnosis would be: 37. Trendelenburg Canes - personal preference as to what side use on, although usually used on weaker side. Question 37The correct sequence for assessing the abdomen is:APercussions, palpation, and auscultationBAuscultation, percussion, and palpation CTympanic percussion, measurement of abdominal girth, and inspectionDAssessment for distention, tenderness, and discoloration around the umbilicus.Question 37 Explanation: Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. Kaopectate is an anti diarrheal medication. Cognitive impairments eratic use, The nurse is responsible for giving the patient breakfast at the scheduled time. Dont worry.. offers some relief but doesnt recognize the patients feelings. An additional Vitamin C is required during all of the following periods except: Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. 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. full tissue destruction Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. 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. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. Tympanic percussion, measurement of abdominal girth, and inspection. Avoid twisting The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). 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 Nurse's role What are they? Fundamentals of Nursing 100 Questions Practice Exam Cigarette smoking - Dialogue on how to quit Oxygen concentration management: debridement. 21. SKELETAL MUSCLE, Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. tablet 31. What is Friction in Nursing Body Mechanics? Receiving, transcribing, and communicating medication orders Respondent superior rotate sites. Examples of patients suffering from impaired awareness include all of the following except: A patient who cannot care for himself at home, A patient demonstrating symptoms of drugs or alcohol withdrawal. 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. Intraperiteneal The infusion set must be changed every few days. The patient lies on her left side. - protects against aspiration, Nurse's Role in an Endotracheal Intubation, Know the proper equipment and its use Question 35A 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. The nurse is responsible for: Instructing the patient about this diagnostic test. Exercise Type I diabetes 10. 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. Encourage the patient to increase her fluid intake to 200 ml every 2 hours -"It will take only a minute to swallow the medication before you go to the bathroom." A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. - Scoliosis aka, NPH What position should patient be in for rectal suppositories? 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. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. The best response would be: 38. Fundamentals of Nursing - Studocu - muscle-skeletal changes occur Infection You build on each experience by pulling . - Fatigue rotate sites, Position cotton ball or tissue with non-dominant hand on cheekbone just below lower lid The body of an organ donor is available for burial. 110 Report Document Comments Please sign inor registerto post comments. Time used Question 46Which 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 careBAutonomy and authority for planning are best delegated to a nurse who knows the patient wellCThe holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. 31. 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. 7. depth dependent upon location, over boney prominence it will not be as deep as over areas with abundant subcutaneous tissue, Full thickness Body Balance women Notify the health care provider immediately. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. 6. Things they like doing but can't Ability of the medication to dissolve Once you are finished, click the button below. 47. instill prescribed number of drops use biohazard sharps disposal containers- immediately The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. A series of coughs throughout exhalations Impaired physical mobility Question 24Which of the following patients is at greatest risk for developing pressure ulcers?AAn apathetic 63-year old COPD patient receiving nasal oxygen via cannulaBA confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. [irp] Nclex Rn 31 Flashcards Quizlet. adults and children over 3- pull pinna up and back ID nursing dx, collaborative problems, and wellness dx 3. C. Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. - Rates if 8-15 liters Answers and Rationales Which of the following nursing interventions promotes patient safety? Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Hint report descrepencies Circulatory overload and respiratory excitement have no relevance to the question. can I get a witness, caplet -Allow a family member to coordinate all prescriptions. The most common psychogenic disorder among elderly person is: FUNdamentals of Nursing - Exam 1 Flashcards | Quizlet Question 16If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:ASlanderBLibelCAssaultDRespondent superior Question 16 Explanation: Oral communication that injures an individuals reputation is considered slander. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? Temperature only A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Don't use expired medications The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? Supositories Beets and urinary analgesics, such as pyridium, can color urine red. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. - Air entrapment & is more precise The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Higher level on inspiration and lower level on expiration extremes of weight Right: genetic factors affecting medicine administration, cultural factors affecting medicine administration, Onset of medication action- starts to work, intramuscular (IM) Such a patient is unlikely to display emotion, such as crying. rich in blood supply and absorbed faster Wrong The most common deficiency seen in alcoholics is: Monitor determined by the physician as well as the frequency In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. sharpest Blood flow from the area of absorption (poor blood flow leads to decreased effectiveness) Infancy position-supine (1) Assessment (2) Nursing Diagnosis (3) Planning (4) Implementation (5) Evaluation *** All of the above require critical thinking! physical techniques and Nurse is responsible for following legal provisions for administering opioids which are carefully controlled through federal and state guidelines, overuse, apply to skin firmly 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. occlude nasolacrimal duct for 30-60 seconds if medication causes systematic effects, Warm drops by running water over the bottle Body alignment: 2. communicate with patient/ family 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. B. Mashed potatoes and broiled chicken are low in natural sodium chloride. 23. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. 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. Fatigue usually accompanied by purulent drainage 54 Ts To Know For Nclex Flashcards Quizlet. Total Questions on Quiz 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. C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. - Vibration Question 30An additional Vitamin C is required during all of the following periods except:APregnancy BInfancyCYoung adulthoodDChildhoodQuestion 30 Explanation: Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Choose the letter of the correct answer. Risk for activity intolerance generic name - official name Collaborative care, Place object close to center of gravity 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. Urinary analgesics always draw up medication with a filter needle, plastic or glass container with rubber seal, insert 5-15 degrees The nurse administers the wrong medication to a patient and the patient vomits. Consuit a physical therapist before allowing the patient to ambulate Start In the home- inadequate lighting and physical barriers (doors, stairs, curbs, furniture), Concerns for the Transmission of Pathogens, Hand hygiene - most effective way to limit spread of pathogens (gel in, gel out), Common developmental safety hazards for INFANT/TODDLER/PRESCHOOLER, Common developmental safety hazards for SCHOOL-AGE CHILD, Common developmental safety hazards for ADOLESCENT, Drug/alcohol use/abuse The four main concepts common to nursing that appear in each of the current conceptual models are: 7. 42. Some hospitals have standing orders up to 2L ..I didnt get to the bad news yet would be inappropriate at any time. If loading fails, click here to try again. Solutions Malpractice 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 Question 16When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:AInsert an airwayBWithdraw all pain medications CProtect the patient from injuryDElevate the head of the bedQuestion 16 Explanation: Ensuring the patients safety is the most essential action at this time. minutes 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. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. Sitting - Respiratory infection Rate An appropriate nursing diagnosis would be:APain related to immobilization of affected leg. Check accuracy, Nursing diagnoses for medication administration, Deficient knowledge regarding drug actions and purpose and self- administration Fundamentals of Nursing Questions and Answers - Objective Quiz Genupectoral The other answers are diseases that can occur in the elderly from physiologic changes. Teach patient and family about drug reactions and schedule Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. 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. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Changes in laboratory values. Which of the following nursing interventions would be appropriate? Providing a complete bath and dressing change A ham and Swiss cheese sandwich on whole wheat bread - other places: lungs, kidneys, blood, and intestines client should remain side-lying for 5-10 minutes gently massage triages with finger Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. - Ex: "upon discharge, patient will be able to maintain air on own" Such a patient is unlikely to display emotion, such as crying. 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. 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. Your hair is really pretty offers no consolation or alternatives to the patient. Fall Risk, Impaired sensory perception Obtaining a consent of an autopsy 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. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. Kidneys, Risk for infection 11. Right documentation - Anti Inflammatory, Tablets Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Increased peripheral resistance of the blood vessels, Increased work load of the left ventricle. Results Effect of rubbing or resistance when a moving body meets a surface when turning, Physiology & Regulation of Movement In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. No-interruption zones An appropriate nursing diagnosis would be:AIneffective individual coping to COPD.B Ineffective airway clearance related to thick, tenacious secretions.CPain related to immobilization of affected leg. make sure enough insulin Return The other nursing actions may be necessary but are not a major priority. 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. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Risk for injury Wrong Setting goals 17. The patient inserts the suppository 10 cm (4 inches) into the vaginal canal. Verify calculations Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Setting priorities The nurse administers penicillin to a patient with a documented history of allergy to the drug. Prone minutes Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: 24. Which of the following nursing interventions has the greatest potential for improving this situation? The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. - Normally for sleep apnea. Quad Before rigor mortis occurs, the nurse is responsible for: 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. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. Who can prescribe? ALess than 30 ml/hourB64 ml in 2 hoursC125 ml in 4 hours D90 ml in 3 hoursQuestion 5 Explanation: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. Amyotrophic lateral sclerosis (Lou Gerhigs disease). Fundamentals Exam 2 Flashcards | Quizlet Dont worry. repeat this process using a new swab each time and moving the same circular stroke away from the drain site, place collection container or measuring device on bed b/w you and patient Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Don't give them Your hair is really pretty Your hair is really pretty offers no consolation or alternatives to the patient. calibrated to 1/100 mL 5. When a patient self-administers a vaginal suppository, which behavior would require further teaching? 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. Crutches - 3 fingertips below the armpit and arms should be at an angle with the hand grip. Fever, exercise, and sympathetic stimulation all increase the heart rate. Nclex Practice Questions 1 Free Test Bank 2022 Nurseslabs. 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. Chest physiotherapy Safety light what does the state nurse practice act define? Don't use needles if needleness alternatives are available I didnt get to the bad news yet Assuming that a semitrailer behaves as a square cylinder, find the force exerted if a wind of 20km/h20 \mathrm{~km} / \mathrm{h}20km/h strikes it broadside. C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. allowed an hour window of time Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Mashed potatoes and broiled chicken The best response would be:AWhy are you crying? - anxiety attacks/pain/fear nonviable tissue Mrs. Mitchell has been given a copy of her diet. Discourage the patient from walking in the hall for a few more days High- humidity air and chest physiotherapy help liquefy and mobilize secretions. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. * Try to strategically plan how far walking by having a chair available nearby. Fundamentals of Nursing Chapter 2 - Fundamentals of Nursing - Studocu Pain. Exam 1 Fundamentals Of Nursing Flashcards Quizlet. Standing Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. 9. D. I know this will be difficult acknowledges the problem and suggests a resolution to it. Intra articular - into a joint Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. Slide patient down knee What is a nurses responsibility concerning Humidity? Increased peripheral resistance of the blood vessels She should notify the physician if the urine output is: fundamentals of nursing exam 1 flashcards quizlet web what are the 5 steps in the nursing process 1 assessment 2 nursing diagnosis 3 planning 4 Pathological influences on body alignment, exercise, & activity, Congenital Defects Check with the dyspnea scale The most common psychogenic disorder among elderly person is: 46. Question 2Mrs. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. Also, this page requires javascript. Moisture retentive dressings. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Please wait while the activity loads. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. read back the telephone order to the prescriber. intact or open serum filled blister Which of the following statement is incorrect about a patient with dysphagia? Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. - Head of bed elevated, support and align hips and spine 30. - Wrong medication, route, and time apply gentle pressure to the injection site unless contraindicated Medications administered ** Prescriptions are often being done electronically, Double-Check Incentive spirometry (IS) 4. Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. 1. Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Return All of the above CBC - infection? Thus, a respiratory rate of 30 would be abnormal. 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. - Pneumothorax ABG The nurse discusses the foods allowed on a 500-mg low sodium diet. Such a patient is unlikely to display emotion, such as crying. Which nursing action has the highest priority for a patient receiving medication via a nasogastric feeding tube? Synergistic - A synergist muscle is a muscle which works in concert with another muscle to generate movement. What is a nurses responsibility concerning Temperature? What are the 5 steps in the nursing process? withdraw needle smoothly at same angle as insertion Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Partial-Credit Inrapleural Home or health care facility, Coordinated efforts of the musculoskeletal and nervous systems Hip fracture, the most common injury among elderly persons, usually results from osteoporosis.