-To decrease the number of medication orders intact or open serum filled blister people who are overly stressed may require insulin to regulate blood glucose for a short period of time. Question 42The nurse observes that Mr. Adams begins to have increased difficulty breathing. Mrs. Lim begins to cry as the nurse discusses hair loss. Reported to provider at time of test Trendelenburg Supositories You have completed Pulse rate and temperature PRN - as needed / per requested Circulatory overload and respiratory excitement have no relevance to the question. Posture 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. Tachypnea is rapid respiration characterized by quick, shallow breaths. Respondent superior - Make sure outcomes are measurable Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Prone Question 16If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:ASlanderBLibelCAssaultDRespondent superior Question 16 Explanation: Oral communication that injures an individuals reputation is considered slander. 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. Regulates movement and posture, proprioception and balance with the precentral gyrus (motor strip) in the cerebral cortex. Why is this patient getting the med? Inform the staff that they must volunteer to rotate Mashed potatoes and broiled chicken are low in natural sodium chloride. Management: maintain clean and moist wound environment and minimize damage to healing tissue, removed drainage from the wound with slight vacuum to stop, think and be vigilant when administering medications, metric system UNSTAGEABLE UNTIL SLOUGH/ESCHAR IS REMOVED Venturi Mask 21. Your performance has been rated as %%RATING%% Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. 47. The patient should always feed himself 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. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery? Illness 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. 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. ID nursing dx, collaborative problems, and wellness dx 3. Urinary analgesics O2 saturation Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Be vigilant Hypothermia is an abnormally low body temperature. They also seem to gain a greater sense of achievement and esprit de corps. Question 35A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. Temperature and respiratory rate A. Keep it simple Not Attempted Disturbed body image 4. instill prescribed number of drops BSympathetic nervous system stimulationCFeverDExerciseQuestion 4 Explanation: 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. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. The nurse could be charged with: Malpractice is defined as injurious or unprofessional actions that harm another. Acute pain If a patients blood pressure is 150/96, his pulse pressure is: 23. 38. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. 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 17 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. Ensuring that the attending physician issues the death certification Bend knees Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Quiet crying The best response would be: Why are you crying? must be derided to allow for healing The nurse could be charged with: 14. Patient's tolerance of procedure, Coughing Techniques to prevent poor oxygenation, Cascade Question 46Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?AContinuity of patient care promotes efficient, cost-effective nursing careBAutonomy and authority for planning are best delegated to a nurse who knows the patient wellCThe holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. Start Tell them the body will not be available for a wake or funeral - muscle-skeletal changes occur Fatigue Higher level on inspiration and lower level on expiration Helps balance. - Air entrapment & is more precise intravenous (IV), first time administration An appropriate nursing diagnosis would be: 37. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates: Don't do this on rib fractures, bleeding disorders, old person with osteoporosis Respiration should be between 16-20 Love Standing If nurse administers an injection to a patient who refuses that injection, she has committed: prevent contamination of solution Changes in vital signs may be cause by factors other than blood loss. Which of the following statement is incorrect about a patient with dysphagia? Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? Changes in vital signs may be cause by factors other than blood loss. -Contact the pharmacy to have the medication sent to the nursing unit STAT. Get Results Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. Dont worry.. offers some relief but doesnt recognize the patients feelings. 36. Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams), NCLEX Practice Exam for Blood Transfusion, The patient will find pureed or soft foods, such as custards, easier to swallow than water, Fowlers or semi Fowlers position reduces the risk of aspiration during swallowing. rotate sites To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool through guaiac (Hemoccult) test. Administration of Meds: do not massage, used to deposit medication into the loose connective tissue underlying the dermis After 1 week of hospitalization, Mr. Gray develops hypokalemia. SKELETAL SYSTEM, Provides attachments for muscles and ligaments and the leverage necessary for movement: Portable During the procedure, the client begins to cough and has difficulty breathing. Provide information and reassurance, How to Document for Endotracheal Intubation, Size of ET tube (width & length) The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following is the most common cause of dementia among elderly persons? 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. Question 15A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. position head depending upon where instillation is desired - Do the goals matter to the patient? Good luck! to have the correct drug route and dose dispensed 54 Guaiac test - BUT we cannot give too much O because they do not have functioning alveoli to carry out the O transport, so the O build-up causing high level of O resulting in no motivation to breathe. She should notify the physician if the urine output is: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. 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. Your hair is really pretty offers no consolation or alternatives to the patient. Complete blood count Document in a timely fashion, Person on the blunt end of the needle is responsible for the sharp end of the needle Age is also a factor. Pain. Explain the procedure to the client- allow them as much control and involvement as possible. The nurses most important legal responsibility after a patients death in a hospital is: Thus, a respiratory rate of 30 would be abnormal. minimizes pain and irritation Side rails are a deterrent that prevent a patient from falling out of bed. 42. 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 nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Nausea Answer Choice(s) Selected 22. Inform the staff that they must volunteer to rotate. Administer oxygen by Venturi mask at 24%, as needed Implementation Pathological influences on body alignment, exercise, & activity, Congenital Defects D. 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. - Airway obstruction due to swallowing small objects A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Check vitals in response to the medication 2. communicate with patient/ family Certain substances increase the amount of urine produced. 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. Accompanying him will offer moral support, enabling him to face the rest of the world. Cognitive impairments The most common deficiency seen in alcoholics is: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. often includes undermining and or tunneling Such a patient is unlikely to display emotion, such as crying. Anxiety will not cause an elevated temperature. Examples of patients suffering from impaired awareness include all of the following except: 44. Allergies, medication, diet 2. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Continuity of patient care promotes efficient, cost-effective nursing care, Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
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