CNS Damage Motor vehicle accident, Common developmental safety hazards for ADULT, Issues related to lifestyle habits 1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950End The infant falls off the scale, suffering a skull fracture. chemical name - compound that makes up the drug The nurse is responsible for giving the patient breakfast at the scheduled time. Correct dosage An Asian patient is likely to hide his pain. Question 31If a patients blood pressure is 150/96, his pulse pressure is:A54B150C246D96Question 31 Explanation: The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. very young and very old The nurse documents this breathing as:AHyperventilation BOrthopneaCTachypneaDEupncaQuestion 42 Explanation: Orthopnea is difficulty of breathing except in the upright position. - This is sterile A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors Question 31Which of the following nursing interventions promotes patient safety?ADemonstrate the signal system to the patientBAsses the patients ability to ambulate and transfer from a bed to a chairCCheck to see that the patient is wearing his identification bandD All of the above A. Stress Discourage the patient from walking in the hall for a few more days An apathetic 63-year old COPD patient receiving nasal oxygen via cannula Also, this page requires javascript. In this case, the supervisor is the resource person to approach. Evaluation, Place call light within reach An insulin pump is a small battery-operated device about the size of a small cell phone. 110 Report Document Comments Please sign inor registerto post comments. withdraw needle smoothly at same angle as insertion no sloughing/ bruising 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. What are the 5 steps in the nursing process? Beets and urinary analgesics, such as pyridium, can color urine red. - body has become used to CO build-up, therefore excess CO does not motivate to breathe Don't require refrigeration After 1 week of hospitalization, Mr. Gray develops hypokalemia. Diagnose & Plan, NANDA-I list Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. - Administer medication correctly She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. 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. Patient's tolerance of procedure, Coughing Techniques to prevent poor oxygenation, Cascade support client head with non-dominant hand 23. Circulatory overload and respiratory excitement have no relevance to the question. 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. You build on each experience by pulling . Pantothenic acid In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The brain-dead patients family needs support and reassurance in making a decision about organ donation. Collaborative care Urinary Tract Infection 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. 20. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to: Ensuring the patients safety is the most essential action at this time. If a patients blood pressure is 150/96, his pulse pressure is: What should she do? Inform the staff that they must volunteer to rotate 45. Impaired gas exchange Question Details Question 21After 1 week of hospitalization, Mr. Gray develops hypokalemia. Your answers are highlighted below. Screw on needle right drug 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. 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. Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. household system, When administering medications to older adults do what? Which nursing action has the highest priority for a patient receiving medication via a nasogastric feeding tube? Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? You have not finished your quiz. 15. Applying a hot water bottle or heating pad to a patient without a physicians order does not include the three required components. 10. Position the patient The nurse contacts the prescriber and receives a STAT telephone order for a medication. Encourage the patient to walk in the hall alone Are drugs interacting, does patient know why taking the drug? All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! Tachypnea is rapid respiration characterized by quick, shallow breaths. What is comfort level (any pain?) Swallowing - patient may not be able to swollow and patient should sit upright when taking meds Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. 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 39 Explanation: Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. improper use. - Head of bed elevated, support and align hips and spine 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. Physical Exam -"It will take only a minute to swallow the medication before you go to the bathroom." School-aged children and adolescents - Pneumothorax Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. offer tissue to blot runny nose but not blow. Circulatory overload and respiratory excitement have no relevance to the question. Two patient identifiers Age is also a factor. 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. outer aspect of upper arms 3 yrs Question Text In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. Choose the letter of the correct answer. - CDC: Annual influenza vaccines for those 6 months and those over 50 years of age Accompany the patient for his walk. 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. 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. Question 14Mrs. - Ex. Attempted Questions Wrong Attempted Questions Wrong Musculoskeletal Trauma Have client look at ceiling cleanse selected collection site A sign of abdominal cramping Immediately dispose of needle in sharps container Tachypnea is rapid respiration characterized by quick, shallow breaths. Asses the patients ability to ambulate and transfer from a bed to a chair Less than 30 ml/hour Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? Some of the pumps monitors your blood glucose level. right patient 48. Use technology Toddler 20. Impaired skin integrity 42. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: An additional Vitamin C is required during all of the following periods except: 39. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. for tuberculin and allergy skin testing Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. The nurse discusses the foods allowed on a 500-mg low sodium diet. 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. 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. What should the nurse do?AEncourage them to sign the consent form right awayBTell them the body will not be available for a wake or funeral CListen to their concerns and answer their questions honestlyDDiscourage them from making a decision until their grief has easedQuestion 29 Explanation: The brain-dead patients family needs support and reassurance in making a decision about organ donation. smallest gauge Can you document that you gave a medication before you give it to the client? Thus, a respiratory rate of 30 would be abnormal. Obstruction, decreased environmental oxygen Dont worry. 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? - Anti-anxiety drugs -To increase the number of medication orders - Chest percussion To monitor the status of previously ID'ed problem 4. RN, BSN, PHN. D. Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Expectations, Nursing Process in Med Admin: Results - other places: lungs, kidneys, blood, and intestines intact or open serum filled blister b. Prone 3. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Patient's perspectives You have not finished your quiz. A patient is kept off food and fluids for 10 hours before surgery. Air or blood is trapped in the pleural space; adapter (tip) designed to fit the hub of a needle or needless device - Drops, teaspoons, tablespoons, cups, pints, quarts Proper positioning of client CPAP & BiPAP, Invasive Maintenance and Promotion of Lung Expansion, Chest tubes 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. The nurse is responsible for: Post a sign at the house. Assess for orthostatic hypotension, Active - patient can move joints on own However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. - It is thought that bipap is easier on the patient, but it is noisier. Allergic Reactions Before rigor mortis occurs, the nurse is responsible for: 50. 29. Radial Activity tolerance. -Never use over-the-counter (OTC) drugs or herbal supplements. A prescribed amount of oxygen s needed for a patient with COPD to prevent: 40. Setting priorities 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. Question 19A patient is kept off food and fluids for 10 hours before surgery. What are the nine rights medication administration? 6. Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. 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. Person, environment, health, nursing 7. Discuss the problem with her supervisor Your score is We need to get O to the cells throughout the body!! to have the correct drug route and dose dispensed The nurse is responsible for: Instructing the patient about this diagnostic test. What is a nurses responsibility concerning Nutrition? The nurse is responsible for giving the patient breakfast at the scheduled time. Aging Question 6Mrs. 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. 11. Quiet crying After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Question 48A prescribed amount of oxygen s needed for a patient with COPD to prevent:AInhibition of the respiratory hypoxic stimulus BCirculatory overload due to hypervolemiaCRespiratory excitementDCardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)Question 48 Explanation: 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. - flow sheet must be completed on every patient in retraint Nurse is responsible for following legal provisions for administering opioids which are carefully controlled through federal and state guidelines, overuse, capsule In the lateral position, the patient lies on his side. The best response would be: Why are you crying? 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. NEVER recap needle St.Johns Wart is the worst. - Wrong medication, route, and time Ask the patient - Airway patency (stridor), Diagnostic Test that may indicate poor oxygenation, ECG - what is heart doing? 19. Chest x-ray These changes, in turn, increase the work load of the left ventricle. and exocrine glands Check to see that the patient is wearing his identification band Fever Mitchell has been given a copy of her diet. Allowing for rest periods decreases the possibility of hypoxia. 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. All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be apply gentle pressure to the injection site unless contraindicated use middle third of muscle, easily accessible Such a patient is unlikely to display emotion, such as crying. Correct Answer Question 32Which of the following is an example of nursing malpractice?AThe nurse administers penicillin to a patient with a documented history of allergy to the drug. extremes of weight Lateral You Selected hold it displaced until after needle is removed. position-supine 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. 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. If you leave this page, your progress will be lost. Assessment for distention, tenderness, and discoloration around the umbilicus. 34. These include: Caffeine-containing drinks, such as coffee and cola. Question 12The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would beAMaintain the patient on strict bed rest at all timesBMaintain the patient in an orthopneic position as neededCAdminister oxygen by Venturi mask at 24%, as neededDAllow a 1 hour rest period between activities Question 12 Explanation: When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. 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. 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. However, the familys concerns must be addressed before members are asked to sign a consent form. Infants and children Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. (med math in another set). Muscle irritability Question 44The four main concepts common to nursing that appear in each of the current conceptual models are: When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominalorgans from pressing against the diaphragm, thus improving ventilation. 48. 7. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale. What should the nurse do? Who can prescribe? A. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. A semiconscious or over fatigued patient For a rectal examination, the patient can be directed to assume which of the following positions? Sympathetic nervous system stimulation - info medical personnel can look at The patient voids before insertion. Acute pain, Nursing Process: Planning for patients with low oxygenation. Knowledge deficit Which of the following is the most common cause of dementia among elderly persons? The brain-dead patients family needs support and reassurance in making a decision about organ donation. displace skin over injection site before injecting How are body alignment and mobility assessed? 9. Checking the patients identification band verifies the patients identity and prevents identification mistakes in drug administration. -Change the feeding pump bag and tubing every 24 hours. - Pursed lip breathing to slow down breathing rate Parkinsons disease of O2 being given and does not dry out membranes, 2L is 28% Question 33The most common deficiency seen in alcoholics is:AThiamineBPantothenic acid CRiboflavinDPyridoxineQuestion 33 Explanation: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Administer medications following the rights [irp] Nclex Rn 31 Flashcards Quizlet. slough present the does not obscure depth of tissue loss Mashed potatoes and broiled chicken are low in natural sodium chloride. 2) Comprehension - The patient must understand the explanation. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. Hint What should the nurse do?ADiscourage them from making a decision until their grief has easedBTell them the body will not be available for a wake or funeral CListen to their concerns and answer their questions honestlyDEncourage them to sign the consent form right awayQuestion 13 Explanation: The brain-dead patients family needs support and reassurance in making a decision about organ donation.
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