Thus, a respiratory rate of 30 would be abnormal. In the lateral position, the patient lies on his side. What are the nine rights medication administration? 10. to have the correct drug route and dose dispensed -Assess and examine the patient. The nurse discusses the foods allowed on a 500-mg low sodium diet. Instructing the patient about this diagnostic test Get Results Text Mode Lungs - alcohol, nitrous oxide Metered dose Hold pen with thumb ready to depress Increased pulse rate and blood pressure 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. The correct sequence for assessing the abdomen is: Assessment for distention, tenderness, and discoloration around the umbilicus. 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. Everyone! The need to move the feet apart to maintain this stance is an abnormal finding. Which of the following patients is at greatest risk for developing pressure ulcers? Question 24Which of the following vascular system changes results from aging?AIncreased peripheral resistance of the blood vesselsBAll of the above CDecreased blood flowDIncreased work load of the left ventricleQuestion 24 Explanation: Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. Ts To Know For Nclex Flashcards Quizlet. a. Insert the tube quickly. C. A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility. Question 12If a patients blood pressure is 150/96, his pulse pressure is:A96B246C150D54Question 12 Explanation: The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. Establishing outcomes, Nursing Process in Med Admin: Recording medication administration All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation. 4. 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. Exercise 33. 3 yrs nonviable tissue, usually accompanied by purulent drainage 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. - Document! The most common injury among elderly persons is: 45. -Reporting any changes in patient's status after medication administration The other nursing actions may be necessary but are not a major priority.Question 50The most common injury among elderly persons is:AHip fracture BUrinary Tract InfectionCIncreased incidence of gallbladder diseaseDAtheroscleotic changes in the blood vesselsQuestion 50 Explanation: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. CThe nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.DThe nurse administers penicillin to a patient with a documented history of allergy to the drug. Fall Risk, Impaired sensory perception intact or open serum filled blister Maintain an erect trunk, Fowler/semi-Fowler Don't press directly on eyeball tablet 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. Answers and Rationales The only abbreviation we can use for subcutaneous is what? Certain substances increase the amount of urine produced. (Choose all that apply) These include: Caffeine-containing drinks, such as coffee and cola. ** acid--base regulation, O motivates Sitting Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Question 36Which 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 careBThe holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care. Nursing diagnosis Right time - full tissue destruction Proper positioning of client All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! Regulates movement and posture, proprioception and balance with the precentral gyrus (motor strip) in the cerebral cortex. What position should patient be in for rectal suppositories? 22. Allpatients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation. High-pitched gurgles head over the right lower quadrant are: STAT - give immediately Check to see that the patient is wearing his identification band Tachypnea is rapid respiration characterized by quick, shallow breaths. What should she do? Which of the following statement is incorrect about a patient with dysphagia? Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. What factors affect ventilation and O transport? - Some drugs can cross the placenta and should not be administered to pregnant women, Therapeutic Effects The nurse is responsible for giving the patient breakfast at the scheduled time. High- humidity air and chest physiotherapy help liquefy and mobilize secretions. oxygen therapy, In the lateral position, the patient lies on his side. Fundamentals Exam 2 Practice Test Flashcards | Quizlet minimizes pain and irritation Look at when next due dose is? Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. 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. 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. Fever, exercise, and sympathetic stimulation all increase the heart rate. **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 Have client look at ceiling 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. Most are U-100 and must be matched up with U-100 insulin medications absorbed more slowly this route than IM Use technology Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. The act protects patients from unskilled, undereducated and unlicensed personnel. 34. Absorption is the passage of medications into the blood from the site of administration bowel, Risk for injury C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Question 5To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Airway protection The other answers are incorrect interpretations of the statistical data. 16. -trauma, Developmental Factors that impair oxygenation, Premature infants Question 11If nurse administers an injection to a patient who refuses that injection, she has committed:AMalpracticeBNegligenceCAssault and batteryDNone of the above Question 11 Explanation: Assault is the unjustifiable attempt or threat to touch or injure another person. Question 23A prescribed amount of oxygen s needed for a patient with COPD to prevent:ACardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)BInhibition of the respiratory hypoxic stimulus CCirculatory overload due to hypervolemiaDRespiratory excitementQuestion 23 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. 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. 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. Polypharmacy - patient on many drugs. chemical name - compound that makes up the drug A. Draw out cloudy insulin Document in a timely fashion, Person on the blunt end of the needle is responsible for the sharp end of the needle 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. If a patients blood pressure is 150/96, his pulse pressure is: 36. Now - give it now, without breaking neck to do so -To decrease the number of medication orders Studies have shown that patients and nurses both respond well to primary nursing care units. 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. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. - Approximation based on the adult dose. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation. - slow reaction time & dull the senses Infants and children 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. 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. Use needleless systems/ avoid use of needles Right dose Complain to her fellow nurses seconds Such a patient is unlikely to display emotion, such as crying. 19. Ensure that client has taken medications before leaving the room Pulse rate and temperature Don't use expired medications Mashed potatoes and broiled chicken are low in natural sodium chloride. Reporting an APTT above 45 seconds to the physician 110 Report Document Comments Please sign inor registerto post comments. rotate sites, Position cotton ball or tissue with non-dominant hand on cheekbone just below lower lid Once you are finished, click the button below. History Respondent superior 96 In this case, the supervisor is the resource person to approach. Diabetes Nclex Questions And Rationale Rnspeak. Made of water or glycerin, provided autolytic debridement, wound dressing: high absorption agent, for heavily graining wounds. Return Respiratory rate Which of the following is the most common cause of dementia among elderly persons? Inform the staff that they must volunteer to rotate people who are overly stressed may require insulin to regulate blood glucose for a short period of time. Friction. access to download your test bank fundamentals of nursing practice test questions final exam web answered 0 of 0 questions 1 when it comes to client education . Nursing Process: IMPLEMENTATION for patients with low oxygenation, Health Promotion: research shows the least injury from injections here Please visit using a browser with javascript enabled. Correct Atheroscleotic changes in the blood vessels Changes in vital signs may be cause by factors other than blood loss. Abdominal girth is unrelated to blood loss. 1. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs.
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