Which of the following is the most common cause of dementia among elderly persons? Which of the following nursing interventions has the greatest potential for improving this situation? Immediately dispose of needle in sharps container Flush with 30 mL of water before and after feedings. report all injuries immediately I know this will be difficult acknowledges the problem and suggests a resolution to it. Question 6Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?ADecreased blood pressure and heart rate and shallow respirationsBImmobility, diaphoresis, and avoidance of deep breathing or coughingCQuiet cryingDChanging position every 2 hours Question 6 Explanation: An Asian patient is likely to hide his pain. These include: 5. questions 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. Defines the scope of nurses' professional functions and responsibilities. of O2 being given and does not dry out membranes, 2L is 28% Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis. 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 D. All of these positions are appropriate for a rectal examination. During the procedure, the client begins to cough and has difficulty breathing. Impaired mobility full tissue destruction An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Ts To Know For Nclex Flashcards Quizlet. She is required to bathe only soiled areas of the body since the mortician will wash the entire body. All four side rails up is considered a restraint Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? The only abbreviation we can use for subcutaneous is what? St.Johns Wart is the worst. **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 Be vigilant Dont worry.. offers some relief but doesnt recognize the patients feelings. Question 8In Maslows hierarchy of physiologic needs, the human need of greatest priority is:ANutritionBEliminationCLoveDOxygen Question 8 Explanation: 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. - protects against aspiration, Nurse's Role in an Endotracheal Intubation, Know the proper equipment and its use Written communication that does the same is considered libel. - can be determined by having a person stand and just look to see if a person is wobbly. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Don't do this on rib fractures, bleeding disorders, old person with osteoporosis 20. Follow the medication administration rights 2. Check accuracy, Nursing diagnoses for medication administration, Deficient knowledge regarding drug actions and purpose and self- administration 48. GET HELP 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. Accompanying him will offer moral support, enabling him to face the rest of the world. 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. The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations. What should the nurse do? Reporting any changes in patient's status after medication administration, Which task would be most appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle, Patient safety - 1st priority You got 50 minutes to finish the exam .Good luck! The family of an accident victim who has been declared brain-dead seems amenable to organ donation. Tighten abdominal muscles and tuck in the pelvis (claudication = limping, relieved by a short period of rest). Range of motion Question 42The physician orders a platelet count to be performed on Mrs. Smith after breakfast. (more prone to trips & falls throw rugs are a death trap), Other Issues/Risk Factors that are concerns for safety, Lifestyle never manually recap needles after injection Huff Which of the following is the most significant symptom of his disorder?AMuscle irritability BLethargyCIncreased pulse rate and blood pressureDMuscle weaknessQuestion 21 Explanation: Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. 15. Partial-Credit Which finding might lead the nurse to suspect a nutritional alteration? Which of the following nursing interventions has the greatest potential for improving this situation?AContinue administering oxygen by high humidity face maskBPerform chest physiotheraphy on a regular schedule CEncourage the patient to increase her fluid intake to 200 ml every 2 hoursDPlace a humidifier in the patients room.Question 25 Explanation: Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. 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? cleanse site using circular stroke starting with area immediately next to drain and moving away 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. 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. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. counts 47. Question 18During a Romberg test, the nurse asks the patient to assume which position? What are the nine rights medication administration? Monitor determined by the physician as well as the frequency 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). Which of the following statement is incorrect about a patient with dysphagia? - may need assistance to cross the blood brain barrier -Wait 30 to 60 minutes after feeding to reconnect to suctioning. Thus, a respiratory rate of 30 would be abnormal. Crutches - 3 fingertips below the armpit and arms should be at an angle with the hand grip. However, the familys concerns must be addressed before members are asked to sign a consent form. 14. Fundamentals of Nursing Chapter 1 - Fundamentals of Nursing - Studocu Attitudes about medication use Observation of physiological measures Pulmonary function Helps balance. liver, death of subcutaneous fat tissue and muscle degeneration -"It will take only a minute to swallow the medication before you go to the bathroom." There are 50 questions to complete. The other answers are incorrect interpretations of the statistical data. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. You have completed 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. Exercise 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. 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. psychosocial techniques, Oxygen supply, methods of oxygen delivery, hydration, humidification, nebulization - muscle-skeletal changes occur 2. Implementation, Patient and family teaching - the body requires insulin in order to convert sugar into energy. What should the nurse do? Regulates movement and posture, proprioception and balance with the precentral gyrus (motor strip) in the cerebral cortex. The nurse is responsible for: Before rigor mortis occurs, the nurse is responsible for: Placing one pillow under the bodys head and shoulders, Providing a complete bath and dressing change, Removing the bodys clothing and wrapping the body in a shroud. -"That's fine, please take it the minute you get back from the restroom. Lethargy She is required to bathe only soiled areas of the body since the mortician will wash the entire body. Canes - personal preference as to what side use on, although usually used on weaker side. Pain related to immobilization of affected leg. Machines vary from facility to facility, wash hands research shows the least injury from injections here What should she do?AInform the staff that they must volunteer to rotate BDiscuss the problem with her supervisorCComplain to her fellow nursesDWait until she knows more about the unitQuestion 35 Explanation: Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. Documented on patient medical record, Movement of gases between air spaces and blood stream, Movement of blood into and out of the lungs to organs and tissues 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. 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. gangrenous lesions Which of the following is the most common cause of dementia among elderly persons? turn on machine and assure calibration - RSV (respiratory syncytial virus) 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. state 3 & 4 pressure ulcers Disturbed body image A normal adult body temperature, as measured on an oral thermometer, ranges between 97 and 100F (36.1 and 37.8C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. -Reporting any changes in patient's status after medication administration Which of the following vascular system changes results from aging? Reusability Now - give it now, without breaking neck to do so The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? Thus, any act that a nurse performs on the patient against his will is considered assault and battery. Question 49A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. polypharmacy 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. aka, NPH The most common deficiency seen in alcoholics is: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. keep needle inserted 10 seconds after injection of medications Beets Total Questions on Quiz Placing one pillow under the bodys head and shoulders If not, container tends to be left off and pets or children can get into it. 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. Correct administration CH 02 HW - Chapter 2 physics homework for Mastering Auditing Overview Newest Theology - yea Leadership class , week 3 executive summary B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Mrs. Mitchell has been given a copy of her diet. Respondent superior often includes undermining and or tunneling Pain. Guaiac test Evaluation, Place call light within reach How to minimize discomfort with injections? - Anti Inflammatory, Tablets 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: 13. - low O motivates COPD patient to breathe Which of the following nursing interventions would be appropriate? Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Air or blood is trapped in the pleural space; women The nurse could be charged with: 14. sustained release. Most are U-100 and must be matched up with U-100 insulin Some of the pumps monitors your blood glucose level. Correct Answer 5. 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. - slow reaction time & dull the senses - Protein binding apply to skin firmly Question 40A 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. Studies have shown that patients and nurses both respond well to primary nursing care units. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture.Question 38Which of the following is the most common cause of dementia among elderly persons?AMultiple sclerosisBAmyotrophic lateral sclerosis (Lou Gerhigs disease)CParkinsons diseaseDAlzheimers disease Question 38 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. A disoriented or confused patient AGiving the patient breakfastBInstructing the patient about this diagnostic testCAll of the above DWriting the order for this testQuestion 29 Explanation: A platelet count evaluates the number of platelets in the circulating blood volume. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. Writing the order for this test 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. - Pain A bar having the cross section shown has been formed by securely bonding brass and aluminum stock. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Certain substances increase the amount of urine produced. The other answers are diseases that can occur in the elderly from physiologic changes. ID nursing dx, collaborative problems, and wellness dx 3. Ineffective individual coping to COPD. Orotracheal and nasotracheal I didnt get to the bad news yet Current condition Pregnancy Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. Less than 30 ml/hour In the lateral position, the patient lies on his side. 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 date, time, and initial paper All of the above 13. I didnt get to the bad news yetBI know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy CDont worry. Question 40The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?APedalBApicalCRadialDFemoral Question 40 Explanation: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. Its only temporaryDYour hair is really prettyQuestion 2 Explanation: I know this will be difficult acknowledges the problem and suggests a resolution to it. side-lying position with ear to be treated facing up The nurse observes that Mr. Adams begins to have increased difficulty breathing. Not Attempted Cotton ball to outermost part of ear canal is acceptable if prescriber orders-do not press into canal, remove after 15 minutes, instruct client to clear nose unless contraindicated Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice. - Clot in blood vessel and narrow blood vessels can impede circulation These include: Caffeine-containing drinks, such as coffee and cola. -Read back the telephone order to the prescriber. hold dropper 1/2 inch above nares gluteus medis and minimus muscles A normal adult body temperature, as measured on an oral thermometer, ranges between 97 and 100F (36.1 and 37.8C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. Written communication that does the same is considered libel. Insert an airway CPAP & BiPAP, Invasive Maintenance and Promotion of Lung Expansion, Chest tubes Readiness for enhanced self- health management The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? Monitor the patient The nurse is responsible for: A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. A patient is kept off food and fluids for 10 hours before surgery. At a higher dose, it raises blood pressure at the expense of the kidneys, Oral - by mouth Question Details D. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. - Rates if 8-15 liters The physician is responsible for instructing the patient about the test and for writing the order for the test. Rub injection site w/ alcohol swab After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Type I diabetes position head depending upon where instillation is desired ASittingBTrendelenburg CStandingDGenupectoralQuestion 18 Explanation: 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. always draw up medication with a filter needle, plastic or glass container with rubber seal, insert 5-15 degrees To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Amyotrophic lateral sclerosis (Lou Gerhigs disease) Answer Choice(s) Selected improper use. A) Instruction was done at the bedside by a physician in the U.S. B)Curriculum in American schools was more standardized C)Student nurses in the U.S. worked for minimum wage D)The nightingale program was less organized A) Instruction was done at the bedside by a physician in the U.S. 2/8 Fundamentals of Nursing Ch. Learning needs Side rails should not be used In the prone position, the patient lies on his abdomen with his face turned to the side. The act protects patients from unskilled, undereducated and unlicensed personnel. You got 50 minutes to finish the exam .Good luck! Please wait while the activity loads. An additional Vitamin C is required during all of the following periods except: displace skin over injection site before injecting 43. Environmental modifications Recumbent 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. Person, environment, health, nursing Ability to absorb, metabolize, and excrete For a rectal examination, the patient can be directed to assume which of the following positions? Genupecterol Slide patient down knee Question 19To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Text Mode Start 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. 3. 17. 3. - body has become used to CO build-up, therefore excess CO does not motivate to breathe and it increases 4% every liter, Continuous positive airway pressure shiny or dry The need to move the feet apart to maintain this stance is an abnormal finding. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. You Selected Lim begins to cry as the nurse discusses hair loss. Changes in vital signs may be cause by factors other than blood loss. prevent contamination of solution 36. C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End Collaborative care Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Start 41. The patient uses her dominant hand to insert the suppository along the posterior wall of the vaginal canal. However, the familys concerns must be addressed before members are asked to sign a consent form. Changes in vital signs may be cause by factors other than blood loss. Nursing Process: IMPLEMENTATION for patients with low oxygenation, Health Promotion: Instructing the patient about this diagnostic test If you leave this page, your progress will be lost. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. 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. (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) Discuss the problem with her supervisor Know interactions/ compatibilities STAT - give immediately Errors include Discourage the patient from walking in the hall for a few more days Question 41Certain substances increase the amount of urine produced. Malpractice A. Fluids containing caffeine have a diuretic effect. Nursing Fundamentals Final Exam; Nursing Fundamentals oxygenation; Nursing Fundamentals Quiz; Preview text. What are the most frequent route of exposure to blood-borne disease? calibrated to 1/100 mL Continue administering oxygen by high humidity face mask Document injury, Special Considerations for Administering Medications to Infants and Children, Age, weight, surface area Childhood Waiting to consult a physical therapist is unnecessary. -Must be allowed to toilet, eat. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. prevention- Hep B vaccine, cylindrical barrel Automated medication dispensing systems in the hospital - Respiratory pattern - It is thought that bipap is easier on the patient, but it is noisier. Vital signs Risk for injury Which findings should be reported? Dont worry.. offers some relief but doesnt recognize the patients feelings. Wrong 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. A. Increased work load of the left ventricle "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". Hypothermia is an abnormally low body temperature. Question 17In Maslows hierarchy of physiologic needs, the human need of greatest priority is:AOxygen BEliminationCNutritionDLoveQuestion 17 Explanation: 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. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. How do your prioritize if patient misses two doses of meds due to a long procedure? altered blood flow do not massage, used to deposit medication into the loose connective tissue underlying the dermis Administer medications following the rights - other places: lungs, kidneys, blood, and intestines Person, health, nursing, support systems The nurse contacts the prescriber and receives a STAT telephone order for a medication.
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