The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. 5. Plan disposal of needle and syringe prior to procedure to administer medications safely and identify problems with the system The physician is responsible for instructing the patient about the test and for writing the order for the test. Consuit a physical therapist before allowing the patient to ambulate An appropriate nursing diagnosis would be: Accountability is clearest when one nurse is responsible for the overall plan and its implementation. Exercise 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. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Topical: anything you can put on the skin, to include patches 2. communicate with patient/ family - damage to any component that regulates voluntary movements The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. - Face down The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. Immediately dispose of needle in sharps container 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. Dont worry.. offers some relief but doesnt recognize the patients feelings. Supine D. 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. B. Soft foods, Fowlers or semi-Fowlers position, and oral hygiene before eating should be part of the feeding regimen. - Antipyretic (fever) Adverse Effects Remain with patient until meds are taken The nurse administers penicillin to a patient with a documented history of allergy to the drug. Physical Exam Crutches - 3 fingertips below the armpit and arms should be at an angle with the hand grip. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. Mobility: Inform the staff that they must volunteer to rotate (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) psychosocial techniques, Oxygen supply, methods of oxygen delivery, hydration, humidification, nebulization 41. How are body alignment and mobility assessed? What is comfort level (any pain?) Effects of medications use proper injection angle Question 20Which of the following is the most common cause of dementia among elderly persons?AAmyotrophic lateral sclerosis (Lou Gerhigs disease)BAlzheimers disease CMultiple sclerosisDParkinsons diseaseQuestion 20 Explanation: 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. HS = at bedtime The most common psychogenic disorder among elderly person is: Sleep disturbances (such as bizarre dreams), Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. How many patient identifiers should you use? Examples of patients suffering from impaired awareness include all of the following except: 44. A platelet count evaluates the number of platelets in the circulating blood volume. Document in a timely fashion, Person on the blunt end of the needle is responsible for the sharp end of the needle Advantages of insulin pen: withdraw needle smoothly at same angle as insertion Amyotrophic lateral sclerosis (Lou Gerhigs disease) "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. to have the correct drug route and dose dispensed The four main concepts common to nursing that appear in each of the current conceptual models are: 7. Score intradermal - Normally for sleep apnea. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping. - anxiety attacks/pain/fear apply to skin firmly Fundamentals of Nursing Exam 2 Term 1 / 79 What are the 4 purposes of a physical exam? - Death, Inadequate ventilation to meet the body's demand An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Consequently, the nurse must observe for objective signs. List Gait These include: A. Studies have shown that patients and nurses both respond well to primary nursing care units. household system, When administering medications to older adults do what? If you prepare the med, who should administer it? These include: Caffeine-containing drinks, such as coffee and cola. Start Your score is Discuss the problem with her supervisor 12. Nursing Fundamentals Exam 2 Practice Test 4.7 (3 reviews) Which of the following is a collaborative intervention? The infusion set must be changed every few days. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. red- pink wound bed The body of an organ donor is available for burial. - Pneumothorax A. -Documenting patient's response to medication -To decrease the number of medication orders 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 Impaired physical mobility Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. B. CPAP & BiPAP, Invasive Maintenance and Promotion of Lung Expansion, Chest tubes A disoriented or confused patient Such a patient is unlikely to display emotion, such as crying. 5. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. All of the above The infant falls off the scale, suffering a skull fracture. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. 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. Thus, a respiratory rate of 30 would be abnormal. Body Balance instill drops- position dropper 1/2 to 3/4 inch above conjunctival sac- drop in prescribing number of drops represents increasing amounts of new blood vessels The nurse observes that Mr. Adams begins to have increased difficulty breathing. 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. Please visit using a browser with javascript enabled. Hypothermia is an abnormally low body temperature. Using the data given below, find the largest permissible bending moment when the composite bar is bent about a horizontal axis. - Harder time fighting off infection, Lifestyle Factors that Affect Oxygenation, Nutrition/Hydration Its only temporaryBYour hair is really prettyCWhy are you crying? Elixirs **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 In the lateral position, the patient lies on his side. The body of an organ donor is available for burial. Accidents Mrs. Lim begins to cry as the nurse discusses hair loss. With that being said, critical thinking is the backbone of the nursing world. 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. date, time, and initial paper Question Text Attempted Questions Correct Made of water or glycerin, provided autolytic debridement, wound dressing: high absorption agent, for heavily graining wounds. Once you are finished, click the button below. If loading fails, click here to try again. altered blood flow - Cupping your hand and pat the back creating a vibration to move fluids along 50. (med math in another set). Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Stress test Planning In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. If nurse administers an injection to a patient who refuses that injection, she has committed: Assault is the unjustifiable attempt or threat to touch or injure another person. Fever, exercise, and sympathetic stimulation all increase the heart rate. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. 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 nurse could be charged with: O2 is a drug and must have doctor's orders Mashed potatoes and broiled chicken In the prone position, the patient lies on his abdomen with his face turned to the side. A prescribed amount of oxygen s needed for a patient with COPD to prevent: Faith6 months ago excellent Type I diabetes Prone - Extra doses or failing to administer The patient should always feed himself Immobility, diaphoresis, and avoidance of deep breathing or coughing, Decreased blood pressure and heart rate and shallow respirations. Antigravity - postural movement, Physiology & Regulation of Movement Thus, a respiratory rate of 30 would be abnormal. Person, nursing, environment, medicine These include: Side rails are a reminder to a patient not to get out of bed However, the familys concerns must be addressed before members are asked to sign a consent form. adults and children over 3- pull pinna up and back Are drugs interacting, does patient know why taking the drug? 4. 11. client should remain side-lying for 5-10 minutes gently massage triages with finger - Specific prescribed amt. desiccated tissue Certain substances increase the amount of urine produced. Which of the following is the most common cause of dementia among elderly persons? A tossed salad with oil and vinegar and olives Continue administering oxygen by high humidity face mask abdomen from costal margins to the iliac crests CAn 88-year old incontinent patient with gastric cancer who is confined to his bed at homeDAn alert, chronic arthritic patient treated with steroids and aspirinQuestion 24 Explanation: Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. - Administer medication correctly report all injuries immediately 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End Nursing Process: IMPLEMENTATION for patients with low oxygenation, Health Promotion: - If too premature, it can be born before surfactant develops Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Applying a hot water bottle or heating pad to a patient without a physicians order does not include the three required components. Used to administer medications in small precise doses, 0.3-1 mL capacity Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. - Buccal: by the cheek - The gov't must also regulate off-label use of medications. C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. patient education, Locked cabinet During a Romberg test, the nurse asks the patient to assume which position? express blood from site Attempted Questions Wrong Explain the procedure to the client- allow them as much control and involvement as possible. To monitor the status of previously ID'ed problem 4. Which of the following patients is at greatest risk for developing pressure ulcers? Tympanic percussion, measurement of abdominal girth, and inspection. DO NOT USE these to describe skin: tears, tape burns, perineal dermatitis, maceration, or excoriation, Full thickness skin loss -Allow a family member to coordinate all prescriptions. 22. Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. D. 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. - Exhale, then have patient suck in and hold it. always draw up medication with a filter needle, plastic or glass container with rubber seal, insert 5-15 degrees Please visit using a browser with javascript enabled. Roll the vials Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Nclex Practice Questions 1 Free Test Bank 2022 Nurseslabs. Quiet crying Elevate the head of the bed St.Johns Wart is the worst. Reporting an APTT above 45 seconds to the physician A bar having the cross section shown has been formed by securely bonding brass and aluminum stock. Accompany the patient for his walk. inject med slowly and smoothly Venturi Mask 43. 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 4 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. test: fundamentals of nursing 8th edition ch. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Unit 4: The Roles Of Nurses In Different Health Care System I health educate the patients and families on ways to maintain a healthy lifestyles and how to prevent diseases. Slander Encourage them to sign the consent form right away Time allowed Inhibition of the respiratory hypoxic stimulus Most of the time it passes through the stomach and dissolves in the intestines Question 45An additional Vitamin C is required during all of the following periods except:AInfancyBPregnancy CChildhoodDYoung adulthoodQuestion 45 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. Demonstrate the signal system to the patient, Asses the patients ability to ambulate and transfer from a bed to a chair, Check to see that the patient is wearing his identification band. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. 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. question 16. Quad make sure enough insulin If this activity does not load, try refreshing your browser. 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. What should the nurse do? An appropriate nursing diagnosis would be:APain related to immobilization of affected leg. Sitting 48. 2-5 mL max in adults, for intramuscular injection Question 18During a Romberg test, the nurse asks the patient to assume which position? 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. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. Toddlers have a much higher metabolic rate. Question 15A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. 4. behavioral- anxiety, agitation, consiousness - Chest percussion 4. Hypothermia is an abnormally low body temperature. Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. If this activity does not load, try refreshing your browser. Check with the dyspnea scale Why is this patient getting the med? Respiration should be between 16-20 What is the most appropriate action? Questions Not Attempted 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. usually accompanied by purulent drainage 44. 90 degree angle Battery Question 3The most common psychogenic disorder among elderly person is:ADecreased appetite BInability to concentrateCDepressionDSleep disturbances (such as bizarre dreams)Question 3 Explanation: Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. - Do not strip the tubing, need to milk it instead. Sometimes based on weight or body surface area. Home or health care facility, Coordinated efforts of the musculoskeletal and nervous systems The correct sequence for assessing the abdomen is: Assessment for distention, tenderness, and discoloration around the umbilicus. Which of the following nursing interventions has the greatest potential for improving this situation? extremes of weight SKELETAL SYSTEM, Provides attachments for muscles and ligaments and the leverage necessary for movement: Tachypnea is rapid respiration characterized by quick, shallow breaths. In Maslows hierarchy of physiologic needs, the human need of greatest priority is: 8. Place a humidifier in the patients room. Also, this page requires javascript. The nurse is responsible for giving the patient breakfast at the scheduled time. 6. The nurse discusses the foods allowed on a 500-mg low sodium diet. Total Questions on Quiz 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. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. Risk for impaired skin integrity, Nursing process: Planning for a patient that is immobile, Goals and outcomes Correct SKELETAL MUSCLE, Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. enteric coated - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle, Patient safety - 1st priority The other answers are diseases that can occur in the elderly from physiologic changes. 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. Sitting Notify the health care provider immediately. Fluids containing caffeine have a diuretic effect. Eupnca Roll in hand Nursing Fundamentals Exam 2. full tissue destruction -trauma, Developmental Factors that impair oxygenation, Premature infants base of ulcer covered by slough and/or eschar in the wound bed Applying a hot water bottle orheating pad to a patient without a physicians order does not include the three required components. We need to get O to the cells throughout the body!! Safety check to protect you waiting to see if you change your name - Sublingual: under the tongue An appropriate nursing diagnosis would be: Ineffective airway clearance related to thick, tenacious secretions. Know signs and symptoms of respiratory distress Lim begins to cry as the nurse discusses hair loss. 3. 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. Rate It slows down in pre-school, Special Considerations for Administering Medications to Older Adults. - vision, hearing, sense of touch, ability to perform fine motor tasks. All diminish ..I didnt get to the bad news yet would be inappropriate at any time.
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