Correct Answer gluteus medis and minimus muscles SKELETAL MUSCLE, Movement of bone and joints involves active processes that are carefully integrated to achieve coordination. 1. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. instruct client to breathe through mouth 34. 1. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. The correct sequence for assessing the abdomen is: 18. Score An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Document in a timely fashion, Person on the blunt end of the needle is responsible for the sharp end of the needle Allow a 1 hour rest period between activities A tossed salad with oil and vinegar and olives Side rails should not be used At a higher dose, it raises blood pressure at the expense of the kidneys, Oral - by mouth C. The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen. Has a reservoir that is filled with insulin and a microcomputer that allows you to adjust how much insulin is to be delivered. Sims Please visit using a browser with javascript enabled. - Hypotension, tachycardia (may indicate tension pneumothorax). 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. Beets and urinary analgesics, such as pyridium, can color urine red. Follow the medication administration rights Fatigue - Chemical structure of medication determines where excretion occurs The correct sequence for assessing the abdomen is: remove protective covering Ensuring the patients safety is the most essential action at this time. B. Once you are finished, click the button below. anterior lateral aspect of thigh They also seem to gain a greater sense of achievement and esprit de corps. Which of the following statement is incorrect about a patient with dysphagia? Absence of the apical, radial, or femoral pulse is abnormal and should be investigated. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. Question 24Which of the following patients is at greatest risk for developing pressure ulcers?AAn apathetic 63-year old COPD patient receiving nasal oxygen via cannulaBA confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed. Higher level on inspiration and lower level on expiration -Assess and examine the patient. Exam 1 Fundamentals Of Nursing Flashcards Quizlet. as drainage is being emptied out of reservoir, compress the device until bottom and top are in contact, quickly cleanse opening Hourly Apical extremes of weight Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2) Atheroscleotic changes in the blood vessels The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.Question 18 Explanation: 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). 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. Impaired physical mobility Impaired swallowing Nursing responsibilities for Mrs. Mitchell now include: Slide patient down knee Time used Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? Pain related to immobilization of affected leg. What is the name of the compound with the formula BaCl2_22? Put air into the cloudy vial first Question 9Studies 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?ASide rails are ineffectiveBSide rails are a reminder to a patient not to get out of bed CSide rails are a deterrent that prevent a patient from falling out of bed.DSide rails should not be usedQuestion 9 Explanation: 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. Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. position-supine 21. Examples of patients suffering from impaired awareness include all of the following except: - Airway patency (stridor), Diagnostic Test that may indicate poor oxygenation, ECG - what is heart doing? Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. The nurse discusses the foods allowed on a 500-mg low sodium diet. 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. Such a patient is unlikely to display emotion, such as crying. Sometimes based on weight or body surface area. Which of the following nursing interventions would be appropriate? for tuberculin and allergy skin testing 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. date, time, and initial paper 30. A125 ml in 4 hours B64 ml in 2 hoursC90 ml in 3 hoursDLess than 30 ml/hourQuestion 19 Explanation: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract? Depression In the prone position, the patient lies on his abdomen with his face turned to the side. Ensure that client has taken medications before leaving the room Air or blood is trapped in the pleural space; Tachypnea is rapid respiration characterized by quick, shallow breaths. Conversions between systems (adult- a handbreadth above knee to a handbreadth below the greater trochanter of the femur) The other nursing actions may be necessary but are not a major priority. Single one time dose DANB RSH Domain II: Quality Assurance and Rad. Pantothenic acid cleanse area Skip to document. Portable - Wrong medication, route, and time What is comfort level (any pain?) The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. - Exposure to second hand smoke Everyone! Ts To Know For Nclex Flashcards Quizlet. Errors include Dependent edema, Activity intolerance- quality of life? Once you are finished, click the button below. 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. report all injuries immediately Providing a complete bath and dressing change She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patients death; however, she is not legally responsible for performing these functions. Draw out cloudy insulin Vital signs Look at when next due dose is? - Face down Question 2The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?AFemoral BApicalCRadialDPedalQuestion 2 Explanation: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. The need to move the feet apart to maintain this stance is an abnormal finding. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward. Question Text Reusability Your response is Vitamin C CAutonomy and authority for planning are best delegated to a nurse who knows the patient wellDAccountability is clearest when one nurse is responsible for the overall plan and its implementation.Question 36 Explanation: Studies have shown that patients and nurses both respond well to primary nursing care units. Evaluation, Place call light within reach BIneffective individual coping to COPD.CIneffective airway clearance related to dry, hacking cough.D Ineffective airway clearance related to thick, tenacious secretions.Question 22 Explanation: Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. - semiprone on right or left side with weight placed on anterior ilium, humerus, & clavicle, Patient safety - 1st priority Which of the following is the most common cause of dementia among elderly persons? It slows down in pre-school, Special Considerations for Administering Medications to Older Adults. - The gov't must also regulate off-label use of medications. The best response would be:AWhy are you crying? Question 27Which of the following vascular system changes results from aging?ADecreased blood flowBIncreased peripheral resistance of the blood vesselsCIncreased work load of the left ventricleDAll of the above Question 27 Explanation: Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. In Sims position, the patient lies on his left side with the left arm behind the body and his right leg flexed. Motor vehicle accident, Common developmental safety hazards for ADULT, Issues related to lifestyle habits 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. collect blood in test strip keep needle inserted 10 seconds after injection of medications Which of the following is an example of nursing malpractice? -Rectal bleeding What should she do? 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. 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. 28. Inability to concentrate Dosage calculations Can position patient in order to encourage drainage. The infant falls off the scale, suffering a skull fracture. Question 42The physician orders a platelet count to be performed on Mrs. Smith after breakfast. Fundamentals of Nursing Practice Exam 2 (EM) The nurse could be charged with:ADefamationBMalpractice CAssaultDBatteryQuestion 40 Explanation: Malpractice is defined as injurious or unprofessional actions that harm another. Eupnca EX: Sometimes post surgery a patient can be put on a insulin drip as a therapy to control the cortisol release from the stress-response syndrome as surgery, anesthesia, and issues that brought patient to hospital can cause a great deal of stress. 10. Use needleless systems/ avoid use of needles minimize muscle tension Decreased appetite After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. hold position for 5 minutes Question 45All of the following can cause tachycardia except:AExerciseBParasympathetic nervous system stimulation The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be, Administer oxygen by Venturi mask at 24%, as needed, Maintain the patient on strict bed rest at all times, Allow a 1 hour rest period between activities, Maintain the patient in an orthopneic position as needed. Reading - can patient read the label Two patient identifiers You have completed "activity intolerance related to COPD as evidence by dyspenia when walking to car" Noncompliance The infant falls off the scale, suffering a skull fracture. St.Johns Wart is the worst. Implementation 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. right dose, Administration of Meds: Return plan to safely handle and dispose of needles before procedure begins 29. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the torso and upper legs. Consider alternatives, such as ambualarm, rather than restraints, Requires a physician order - Pursed lip breathing to slow down breathing rate The patient should always feed himself 6. Maintain the patient on strict bed rest at all times Verify calculations -trauma, Developmental Factors that impair oxygenation, Premature infants
