B. Respondent superior The other answers are incorrect interpretations of the statistical data. 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. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. question Final Score on Quiz You can program different amounts of insulin for different times of the day and night. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?AGuaiac testBComplete blood countCVital signsDAbdominal girth Question 49 Explanation: 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. 5. Potential Nursing Diagnosis for a patient that is immobile: Activity intolerance Contraindications? What is a nurses responsibility concerning oxygen? These include: 35. ..I didnt get to the bad news yet would be inappropriate at any time. Arthritis - can patient get lid off container? 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. Completely black on CXR indicated a collapsed lung Please wait while the activity loads. Which of the following patients is at greatest risk for developing pressure ulcers? Beets and urinary analgesics, such as pyridium, can color urine red. 22. Please visit using a browser with javascript enabled. 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. Your answers are highlighted below. secure with transparent dressing or tape, remove old patch before applying a new one 1,2, and 3 Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet. Thiamine hold syringe steady while needle is in tissue - Approximation based on the adult dose. 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. She is required to bathe only soiled areas of the body since the mortician will wash the entire body. 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. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. Consider alternatives, such as ambualarm, rather than restraints, Requires a physician order Topical, - To protect our patients and each state must abide by these laws epidural Proper positioning of client 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. Soft foods, Fowlers or semi-Fowlers position, and oral hygiene before eating should be part of the feeding regimen. AC = before meals use diversion The most common deficiency seen in alcoholics is: 32. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. test: fundamentals of nursing 8th edition ch. Age is also a factor. Palpating the midclavicular line is the correct technique for assessing 1. 46. Intra arterial 246 Score Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. Which of the following vascular system changes results from aging? RN, BSN, PHN. SKELETAL SYSTEM, Provides attachments for muscles and ligaments and the leverage necessary for movement: Not Attempted The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Inhibition of the respiratory hypoxic stimulus When a patient self-administers a vaginal suppository, which behavior would require further teaching? Childhood Have client close eye gently Fundamentals of Nursing Exam 2 1) The nurse is inserting a nasogastric tube in an adult client. Amyotrophic lateral sclerosis (Lou Gerhigs disease). people who are overly stressed may require insulin to regulate blood glucose for a short period of time. Question 3The most common psychogenic disorder among elderly person is:ADecreased appetite BInability to concentrateCDepressionDSleep disturbances (such as bizarre dreams)Question 3 Explanation: Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. Get Results 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. Fever, exercise, and sympathetic stimulation all increase the heart rate. 26. If a patients blood pressure is 150/96, his pulse pressure is: B. Time used Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth. Questions Not Attempted Venturi Mask Increased pulse rate and blood pressure Simple Face Mask frequent emptying of the reserve, never remove a surgical dressing for wound inspection until you have the order Libel Your score is 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 However, the familys concerns must be addressed before members are asked to sign a consent form. 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. Most of the time it passes through the stomach and dissolves in the intestines (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) Prone The force that occurs in a direction to oppose movement. - The gov't must also regulate off-label use of medications. red- pink wound bed Consequently, the nurse must observe for objective signs. 33. 14. Route of administration (fastest I.V.) Be vigilant Machines vary from facility to facility, wash hands household system, When administering medications to older adults do what? 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. A patient is kept off food and fluids for 10 hours before surgery. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk. Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Muscle weakness NO BONE, TENDON OR MUSCLE EXPOSED A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. - Vibration Hypothermia is an abnormally low body temperature. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. The nurses most important legal responsibility after a patients death in a hospital is: Notifying the coroner or medical examiner, Ensuring that the attending physician issues the death certification. Dependent edema, Activity intolerance- quality of life? Conversions between systems Influenza and pneumococcal vaccine - anxiety attacks/pain/fear A. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. The other answers are diseases that can occur in the elderly from physiologic changes. Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. A. If heart is not working properly then we don't get perfusion 25. - Suction this first, NonInvasive Maintenance and Promotion of Lung Expansion, Positioning Membrane permeability 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. Changes in vital signs may be cause by factors other than blood loss. gangrenous lesions - Respiratory pattern Location of ET tube in airway (nose or mouth) The nurse must place a pillow under the decreased persons head and shoulders to prevent blood from settling in the face and discoloring it. 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. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. Who can prescribe? Genupectoral 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. 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. The nurse discusses the foods allowed on a 500-mg low sodium diet. - bag must be full Explain the procedure to the client- allow them as much control and involvement as possible. Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. A. Fluids containing caffeine have a diuretic effect. Ineffective individual coping to COPD. - Patient must be checked every 15 minutes 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). Pantothenic acid - Hemothorax 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. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. In the prone position, the patient lies on his abdomen with his face turned to the side. Expectations, Nursing Process in Med Admin: maintain privacy 20. Non-rebreather Mask Percussions, palpation, and auscultation -Documenting patient's response to medication Which of the following nursing interventions has the greatest potential for improving this situation? Antigravity - postural movement, Physiology & Regulation of Movement In the lateral position, the patient lies on his side. Instructing the patient about this diagnostic test 16. Consuit a physical therapist before allowing the patient to ambulate. "I will bring the medication back to your room once you return from the bathroom", The nurse is ready to administer a patient's morning medication when the patient states, "Please leave the medication on my table. -Presence of a fever 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. Question 4All of the following can cause tachycardia except:AParasympathetic nervous system stimulation Risk for infection Defamation Question 33Which of the following patients is at greatest risk for developing pressure ulcers?AAn 88-year old incontinent patient with gastric cancer who is confined to his bed at homeBAn alert, chronic arthritic patient treated with steroids and aspirinCAn apathetic 63-year old COPD patient receiving nasal oxygen via cannulaDA confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. Elevate the head of the bed Musculoskeletal Trauma The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. Congratulations - you have completed Fundamentals of Nursing Practice Exam 2 (PM). Alterations compared to surrounding tissue, softer or firmer, warmer or cooler, partial thickness loss You build on each experience by pulling . Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration. Muscle irritability Evaluation, Place call light within reach self medication, Nurse's Rights for safe medication administration, to complete and clearly written order that clearly specifies the drug, dose, route, and frequency Choose the letter of the correct answer. -Administering oral medications Draw out cloudy insulin The patient will find pureed or soft foods, such as custards, easier to swallow than water 6. - Cough 30. The nurse discusses the foods allowed on a 500-mg low sodium diet. -To decrease the number of medication orders - Face down Thus, an axillary temperature of 99.6F (37.6C) would be considered abnormal. Start C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. 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. Monitor determined by the physician as well as the frequency Parkinsons disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Return Dont worry.. offers some relief but doesnt recognize the patients feelings. 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. Oral communication that injures an individuals reputation is considered slander. Effects of medications (2) Sustained Release - a longer time to dissolve, What factors Influence Medication Distribution, Circulation Your performance has been rated as %%RATING%% In the lateral position, the patient lies on his side. She is required to bathe only soiled areas of the body since the mortician will wash the entire body. - Bronchodialators You Selected Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Trendelenburg Client fluid preference Respiratory rate Written report within 24 hours of occurrence, Comparison of medications taken at home and prescribed when in the health care setting, Change in patient's condition The best response would be:AWhy are you crying? Maintain the patient in an orthopneic position as needed Laboratory data may increase undermining and or tunneling Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. research shows the least injury from injections here The brain-dead patients family needs support and reassurance in making a decision about organ donation.
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