Pediatric dosages Beets and urinary analgesics, such as pyridium, can color urine red. It slows down in pre-school, Special Considerations for Administering Medications to Older Adults. Define Assessment Collects comprehensive data pertinent to the patient's health and/or situation. What is a nurses responsibility concerning Temperature? Side-lying Post a sign at the house. Recording medication administration 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. always draw up medication with a filter needle, plastic or glass container with rubber seal, insert 5-15 degrees hold dropper 1/2 inch above nares The nurse discusses the foods allowed on a 500-mg low sodium diet. The nurse documents this breathing as:ATachypneaBEupncaCOrthopneaDHyperventilation Question 41 Explanation: Orthopnea is difficulty of breathing except in the upright position. 30. The nurse contacts the prescriber and receives a STAT telephone order for a medication. - Exposure to second hand smoke Choose the letter of the correct answer. For a rectal examination, the patient can be directed to assume which of the following positions? The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. Question 15A patient is kept off food and fluids for 10 hours before surgery. (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) Readiness for enhanced self- health management Also, this page requires javascript. Abdominal girth is unrelated to blood loss. Time used In Maslows hierarchy of physiologic needs, the human need of greatest priority is: 1. 48. use meticulous hand hygiene and clean gloves and exocrine glands of O2 being given and does not dry out membranes, 2L is 28% to have policies on safe drug administration 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. - Seizures Right documentation Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Enhanced by a wide base of support, What is Good Nursing Coordinated Body Movement, Must overcome an object's weight and be aware of it's center of gravity. Smoking eratic use, 14. Encourage them to sign the consent form right away *** Need to get pre-op or baseline in order to evaluate. List factors required for informed consent. -Prepare the medication for administration. I will be back to check on you." Injection is given subcut, CLOUDY Hypothermia Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. Cognitive impairments A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! improper use. 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. Hypercapnia, hypoxemia, fever, pregnancy, wound healing 40. 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. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. 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. Antigravity - postural movement, Physiology & Regulation of Movement If a patients blood pressure is 150/96, his pulse pressure is: 23. Start hold it displaced until after needle is removed. What is causing the quick breathing An apathetic 63-year old COPD patient receiving nasal oxygen via cannula. Question 39Palpating the midclavicular line is the correct technique for assessingARespiratory rateBApical pulse CBaseline vital signsDSystolic blood pressureQuestion 39 Explanation: The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. After 1 week of hospitalization, Mr. Gray develops hypokalemia. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. wash hands, Daily record taken to provider Which of the following patients is at greatest risk for developing pressure ulcers? - peripheral arterial disease smallest gauge These include: 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. taken into the body or administered in a manner other than through the digestive tract- intradermal, subcutaneous, intramuscular, intravenous. You scored %%SCORE%% out of %%TOTAL%%. Ineffective airway clearance related to thick, tenacious secretions. Metabolic rate - Mucolytics - Should be kept below the patient for the effect of gravity C. 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. Waiting to consult a physical therapist is unnecessary. Acute pain, Nursing Process: Planning for patients with low oxygenation. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. Chest wall movement - Splinting - hold a pillow or blanket against lower ribs to help ease pain Kaopectate is an anti diarrheal medication. Consequently, the nurse must observe for objective signs. The infant falls off the scale, suffering a skull fracture. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. apply to skin firmly -Complete the institution's incident or occurrence report. They also seem to gain a greater sense of achievement and esprit de corps. 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. Eupnea is normal respiration quiet, rhythmic, and without effort. These changes, in turn, increase the work load of the left ventricle. If over 5L you need to humidify the O2, Nasal Cannula renal/hepatic disease Tympanic percussion, measurement of abdominal girth, and inspection Check to see that the patient is wearing his identification band The need to move the feet apart to maintain this stance is an abnormal finding. Which of the following is the most significant symptom of his disorder? Impaired gas exchange what does the state nurse practice act define? St.Johns Wart is the worst. The need to move the feet apart to maintain this stance is an abnormal finding. Mitchell has been given a copy of her diet. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Clear Pathway to bathroom This is for parapalegics Impaired swallowing The other nursing actions may be necessary but are not a major priority. Mrs. Lim begins to cry as the nurse discusses hair loss. Which of the following parameters should be checked when assessing respirations? - Harder time fighting off infection, Lifestyle Factors that Affect Oxygenation, Nutrition/Hydration Current condition Choose the letter of the correct answer. The only abbreviation we can use for subcutaneous is what? When your patient eats, you use buttons on the pump to give additional or "bolus" insulin to cover the carbohydrates in the meal. Encourage the patient to increase her fluid intake to 200 ml every 2 hours Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Nausea - Mental confusion keep needle inserted 10 seconds after injection of medications The patient inserts the suppository 10 cm (4 inches) into the vaginal canal. Regulated by TJC & CMS (centers for medicare/medicaid services) Congratulations - you have completed Fundamentals of Nursing Practice Exam 2 (EM). The nurse administers the wrong medication to a patient and the patient vomits. 37. Question 41Certain substances increase the amount of urine produced. C. Orthopnea is difficulty of breathing except in the upright position. intact or open serum filled blister 2. communicate with patient/ family - Postural drainage Thiamine Burns Atheroscleotic changes in the blood vessels If you withhold a medication what do you do? Which findings should be reported?ATemperature and respiratory rate BRespiratory rate onlyCPulse rate and temperatureDTemperature onlyQuestion 8 Explanation: Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. 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. - amputations Lim begins to cry as the nurse discusses hair loss. The nurse could be charged with: 14. - The gov't must also regulate off-label use of medications. 4. tablet Stress Goals and outcomes Written communication that does the same is considered libel. If this activity does not load, try refreshing your browser. Sims 7. - Approximation based on the adult dose. -"It will take only a minute to swallow the medication before you go to the bathroom." Injectibles Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Teach patient and family about drug reactions and schedule APerson, nursing, environment, medicineBPerson, environment, health, nursing CPerson, health, nursing, support systemsDPerson, health, psychology, nursingQuestion 44 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. A. Fluids containing caffeine have a diuretic effect. Question 6Mrs. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. 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. 6. Ingestion D. 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. Describe some of the body changes throughout the life span: Newborn Cigarette smoking - Dialogue on how to quit - acid-base imbalance, Oxygen carrying Capability Question 48High-pitched gurgles head over the right lower quadrant are:AA sign of decreased bowel motilityBNormal bowel soundsCA sign of abdominal cramping DA sign of increased bowel motilityQuestion 48 Explanation: Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. 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. Anaphalaxsis Question 19To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Check with the dyspnea scale After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. 17. 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. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. b. Used to administer medications in small precise doses, 0.3-1 mL capacity Partial-Credit Anxiety Any items you have not completed will be marked incorrect. If loading fails, click here to try again Start Slide patient down knee Baseline vital signs - Ex: "upon discharge, patient will be able to maintain air on own" At a higher dose, it raises blood pressure at the expense of the kidneys, Oral - by mouth A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. Femoral physical techniques and 1. Location of ET tube in airway (nose or mouth) -Keep head of bed elevated above 30 degrees for at least 30 to 60 minutes after feeding. Which of the following vascular system changes results from aging? List Oxygen An insulin pump is a small battery-operated device about the size of a small cell phone. D. The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. Question Details Range of motion The other answers are incorrect interpretations of the statistical data. Your score is 32. - Vibration - vision, hearing, sense of touch, ability to perform fine motor tasks. All diminish - low O motivates COPD patient to breathe Passive - The nurse moves the patient's joints How are body alignment and mobility assessed? Question Details - Anti Inflammatory, Tablets A patient demonstrating symptoms of drugs or alcohol withdrawal Huff Expectations, Nursing Process in Med Admin: Autonomy and authority for planning are best delegated to a nurse who knows the patient well Roll the vials In the lateral position, the patient lies on his side. - Fatigue UNSTAGEABLE UNTIL SLOUGH/ESCHAR IS REMOVED Which of the following is the most significant symptom of his disorder? A patient who cannot care for himself at home Question Text cleanse area - This is sterile Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors. - Do the goals matter to the patient? 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? The body of an organ donor is available for burial. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. SKELETAL MUSCLE, Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. Ineffective airway clearance related to dry, hacking cough. Percussions, palpation, and auscultation Impaired physical mobility abuse, However, the familys concerns must be addressed before members are asked to sign a consent form. Medication Dose Responses, expected effects that don't contribute to helping the patient The physician is responsible for instructing the patient about the test and for writing the order for the test. Sympathetic nervous system stimulation Environmental factors - Pollutants (ask where person lives, know your region an it's risk factors), Nursing history: Signs that may indicate poor oxygenation use diversion Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Fowlers or semi Fowlers position reduces the risk of aspiration during swallowing Disturbed body image The patient uses her dominant hand to insert the suppository along the posterior wall of the vaginal canal. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowlers position. Document in a timely fashion, Person on the blunt end of the needle is responsible for the sharp end of the needle 1. verify rights Verify calculations Nursing responsibilities for Mrs. Mitchell now include:AReporting an APTT above 45 seconds to the physicianBAssessing the patient for signs and symptoms of frank and occult bleedingCAll of the above DReviewing daily activated partial thromboplastin time (APTT) and prothrombin time.Question 3 Explanation: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. Kaopectate is an anti diarrheal medication. The physician is responsible for instructing the patient about the test and for writing the order for the test.Question 43After 1 week of hospitalization, Mr. Gray develops hypokalemia. 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. A bar having the cross section shown has been formed by securely bonding brass and aluminum stock. 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 Fundamentals of Nursing University Keiser University Fundamentals of Nursing Add to My Courses Documents (326) Questions Students (625) Book related documents Kozier and Erb's Fundamentals of Nursing Volume 1-3 Barbara Kozier; Glenora Erb; Audrey Berman; Shirlee Snyder; Tracy Levett-jones Lecture notes Date Rating year Ratings Show 8 more documents - Drops, teaspoons, tablespoons, cups, pints, quarts The most common deficiency seen in alcoholics is: 32. Bones, joints, ligaments, tendons, cartilage, Physiology & Regulation of Movement - Specific prescribed amt. Soft foods, Fowlers or semi-Fowlers position, and oral hygiene before eating should be part of the feeding regimen. Perform chest physiotheraphy on a regular schedule * prevent contamination of short-acting insulin with long acting, prevent contamination of short-acting insulin with long acting. Withdraw all pain medications Management: maintain clean and moist wound environment and minimize damage to healing tissue, removed drainage from the wound with slight vacuum Chronic pain Mitchell has been given a copy of her diet. Collaborative care, Place object close to center of gravity gangrenous lesions Fundamentals of Nursing Practice Exam 2 (PM) Question 2Mrs. Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. 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. She should notify the physician if the urine output is: tincture 4. Palpating the midclavicular line is the correct technique for assessing. 26. syrup underuse, 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. Eupnea is normal respiration quiet, rhythmic, and without effort. Question 34For a rectal examination, the patient can be directed to assume which of the following positions?AGenupecterolBSimsCAll of the above DHorizontal recumbentQuestion 34 Explanation: All of these positions are appropriate for a rectal examination. - If too premature, it can be born before surfactant develops 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 Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. 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. Older adults 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. plunger, Select the _______________ syringe size possible for accuracy; size range 0.5 mL to 60 mL, Pre-attached needle [irp] Nclex Rn 31 Flashcards Quizlet. Safety check to protect you waiting to see if you change your name Accountability is clearest when one nurse is responsible for the overall plan and its implementation. Activity tolerance. Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. Nursing responsibilities for Mrs. Mitchell now include: 6. 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 Your hair is really pretty offers no consolation or alternatives to the patient. 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. The nurse is responsible for: Instructing the patient about this diagnostic test. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Gently press downward with thumb or forefinger against bony orbit. Ability to absorb, metabolize, and excrete Air or blood is trapped in the pleural space; Toddlers have a much higher metabolic rate. However, the familys concerns must be addressed before members are asked to sign a consent form. Parkinsons disease She should notify the physician if the urine output is: 34. Your performance has been rated as %%RATING%% Attempted Questions Correct Anxiety will not cause an elevated temperature. instill drops holding dropper 1/2 inch above ear canal 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. intradermal "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". Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. Decreased cardiac output 34. Reporting an APTT above 45 seconds to the physician The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. DIneffective airway clearance related to dry, hacking cough.Question 37 Explanation: Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Which of the following nursing interventions would be appropriate? Question 34For a rectal examination, the patient can be directed to assume which of the following positions?AHorizontal recumbentBAll of the above CSimsDGenupecterolQuestion 34 Explanation: All of these positions are appropriate for a rectal examination. An alert, chronic arthritic patient treated with steroids and aspirin EXPOSED BONE, TENDON, OR MUSCLE Your score is To monitor the status of previously ID'ed problem 4. 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. - Head of bed elevated, support and align hips and spine What are the 3 muscle signs for IM injections? Less than 2 mL total volume 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. Nursing Fundamentals Exam 2. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. Which of the following nursing interventions promotes patient safety? allowed an hour window of time Certain substances increase the amount of urine produced. 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. do not rub or massage into skin Chemical Ineffective individual coping to COPD. Question 38The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. - Occurs in liver (major site of drug metabolism) people having trouble with this are older adults or people with liver diseases. Topical: anything you can put on the skin, to include patches Which of the following is the most common cause of dementia among elderly persons? ABGs In the prone position, the patient lies on his abdomen with his face turned to the side. The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. After 1 week of hospitalization, Mr. Gray develops hypokalemia. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. inventory record Hip fracture Circulatory overload and respiratory excitement have no relevance to the question. The nurse documents this breathing as:AHyperventilation BOrthopneaCTachypneaDEupncaQuestion 42 Explanation: Orthopnea is difficulty of breathing except in the upright position. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Question 14Palpating the midclavicular line is the correct technique for assessingARespiratory rateBApical pulse CBaseline vital signsDSystolic blood pressureQuestion 14 Explanation: The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. For a rectal examination, the patient can be directed to assume which of the following positions? Return Fundamentals of Nursing Test #2 Flashcards | Quizlet Fundamentals of Nursing Test #2 Term 1 / 97 Patient Medication Dose Route Time Documentation Effect To be educated To refuse Click the card to flip Definition 1 / 97 What are the nine rights medication administration? Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Supine Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. -Allow a family member to coordinate all prescriptions. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Question 47During a Romberg test, the nurse asks the patient to assume which position? Examples of patients suffering from impaired awareness include all of the following except: Caffeine-containing drinks, such as coffee and cola. Your answers are highlighted below. Synergistic - A synergist muscle is a muscle which works in concert with another muscle to generate movement. - Must be told what they need to do in order to have restraints removed - Each hospital has its own policy tubing mgt, know it The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Allowing for rest periods decreases the possibility of hypoxia. Consider alternatives, such as ambualarm, rather than restraints, Requires a physician order What is the most appropriate action? The best response would be: Made of water or glycerin, provided autolytic debridement, wound dressing: high absorption agent, for heavily graining wounds. read back the telephone order to the prescriber. A patient about to undergo abdominal inspection is best placed in which of the following positions? 31. We need to get O to the cells throughout the body!! Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?
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