Foundations final

what to do if patient says they are at a level 10 pain, but when you come back to administer meds, the patient is acting fine and laughing,etc

you still have to give patient meds if they still request it

culture imposition

expecting people to change when they move to america, should never be used

critical thinking

taking info from experiences and comparing it to new ones to predict what will happen based on previous experienes

western world

very focused on medicine and not alternative, non medicine approaches as often we need to respect patients opinion and let them use whatever helps them like herbs or tea

what happens when you experience pain

vials increase, especially HR and BP

when a person has a stroke, what might they need after

walking with a nurse to prevent falls, and assistive devices

assessment

what works to relieve a pain, when did it start, what type of pain is it and where not one and done, it is a continuation to see why changes happen

assimilation

when people who move to america take on american culture (like speak english)

modifiable factors that contribute to pain

you can change anxiety and fear - you can not change age, race, culture gender, ideas about an experience

what happens when you realize a doctor made a wrong dosage

you must contact doctor to share the mistake and correct it

informed consent

patient knows everything including all risks or benefits of procedure

what happens when your immobile

everything slows down and pneumonia, an infection, can occur or respiratory infections in general

when can patients change their mind on treatment

patients can change their mind at any time no matter what (ex about DNR order

who experiences the most grief?

people who are unprepared like in an accident

infection

- incubation; no symptoms but contagious - convalescence: no active symptoms but still healing and restoring health

oral temperature

1 degree below

axillary temperature

2 degrees cooler than core temp

vital signs for adult

Pulse: 60-100 bpm BP: 100-120/60-80 mmHg Respirations: 12-20 breaths/min Temperature: oral- 98 rectal- 98.6

vital signs for child (10 years)

Pulse: 70-100 bpm BP: 110/58 Respirations: 17-22 breaths/min Temp: oral- 98.6

vital signs for baby

Pulse: 80-180 bpm BP: 60-80/40-50 mmHg Respirations: 30-60 breaths/min Temperature: axillary - 98.2

The nurse gives a patient the wrong medication and documents that the correct medication was given. The next staff member recognizes the error and reports the nurse to the state board of nursing. Which action can the state board of nursing take against the nurse in this situation? a. Disciplinary action against the nurse's license to practice b. Employment release from the institution c. Medical malpractice lawsuit against the nurse d. Clinical misdemeanor charges against the nurse

a. Disciplinary action against the nurse's license to practice

which set of vital signs is within normal limits for a client at rest? a. adolescent: T 98.2 (oral), HR 80, RR 18, BP 120/68 b. older adult: T 98.6, HR 110, RR 28, BP 170/95 c. infant: T 98.8 (rectal), HR 160, RR 16, BP 120/54 d. adult: T 99.6 (oral), HR 48, RR 22, BP 130/ 84

a. adolescent: T 98.2 (oral), HR 80, RR 18, BP 120/68

a nurse is teaching a patient how to administer insulin, with the expected outcome that the patient will be able to self administer the insulin injection. how would this outcome be evaluated a. asking patient to demonstrate self injection of insulin b. asking the patient how comfortable he or she is with the injection c. asking the patient to verbally repeat the steps of injection d. asking the family members how much trouble the patient is having with injections

a. asking patient to demonstrate self injection of insulin

which describes the most important use of the nursing diagnosis? a. describes the client's needs for nursing care b. differentiates the nurse's role from that of the physician c. identifies a body of knowledge unique to nursing d. help nursing develop a more professional image

a. describes the client's needs for nursing care

what guidelines do nurses follow to identify the patient's healthcare needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes? a. nursing process b. ANA standards of professional performance c. evidence based practice guidelines d. nurse practice acts

a. nursing process

what do nursing codes of ethics support? a. patients have the right to dignity, privacy, and safety b. patients can receive emergency treatment regardless of their ability to pay c. nurses will educate patient's about advanced directives. d. nurses with HIV must disclose their condition to their employer

a. patients have the right to dignity, privacy, and safety

a preschool aged child is scheduled for a tonsillectomy, which strategy might help lessen the child's anxiety before surgery? a. show the child a short, animated video about the hospital visit and procedure b. provide one to one instruction about the care he will need after surgery c. give the child a tour of the hospital a week before surgery is scheduled d. allow child to use computed assisted instruction to teach him about the procedure

a. show the child a short, animated video about the hospital visit and procedure

when should you wash your hands

all of the time, before seeing a patient, during time with patient, after seeing patient - number 1 way of preventing spread of germs

another name for low blood pressure: a. hypoxia b. hypotension c. hypertension d. pyrexia

b) hypotension

the nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath, which instruction should the nurse include? a. "wash patients back, buttocks, and perineum first" b. "bathe the patient from head to toe, cleanest areas first" c. "provide the patient with warm water for washing his perineum" d. "cleanse only those areas likely to cause odor"

b. "bathe the patient from head to toe, cleanest areas first"

A patient newly diagnosed with breast cancer tells the nurse "I am worried I wont live to see my children grow up" which response by the nurse best conveys concern and active learning? a. "you're strong and have youth on your side to fight breast cancer" b. "breast cancer is a serious disease, I can understand why you are worried" c. " there have been many advances in breast cancer treatment, hope for the best" d. "I'd be worried too, I've seen a lot of patients die of breast cancer"

b. "breast cancer is a serious disease, I can understand why you are worried"

The nurser reviews an entry in a medical record before clicking the SAVE button. When preforming this review, the nurse analyzes the content for completeness, clarity, accuracy, comprehensiveness, and which other criteria? a. Character b. Chronological c. Category d. Concise

b. Chronological

Which instruction is the most important for the nurse to include when teaching a mother of a 3-year-old about protecting the child against accidental poisoning? a. Purchase medication in child-resistant containers b. Never leave the child unattended around medications or cleaning solutions c. Take medications in front of the child and explain that they are for adults only d. Store medications on counter tops out of the child's reach

b. Never leave the child unattended around medications or cleaning solutions

A confused elderly patient is continually getting out of bed and wandering the hallways of the medical surgical unit where he is a patient. The nurse understands the risks of restraints, and would like to use alternative methods to keep this patient safe. Which of the following methods would be the best way to keep this patient safe without using restraints? a. Placing the patient farther from the nurses station to decrease stimulation and allow him to sleep b. Putting an alarm on the bed so the staff will know when the patient attempts to get out of bed c. Obtain a physician's order for a sedative to administer at bedtime so the patient remains in bed d. Placing all 4 side rails up so the patient is unable to get out of bed

b. Putting an alarm on the bed so the staff will know when the patient attempts to get out of bed

when making a diagnosis using NANDA_I, which provides support for the diagnostic label chosen by the nurse? a. diagnostic label b. defining characteristics c. etiology d. related factors

b. defining characteristics

a nursing student is having difficulty understanding the role of nursing diagnosis and setting client goals. what should the instructor explain to this student? a. client goals are used to coordinate care activities b. diagnosis is the basis for planning client centered goals c. client goals ensure cost effective care is provided d. diagnosis ensures the correct treatment is prescribed for the client

b. diagnosis is the basis for planning client centered goals

the nurse plays music for a child with leukemia who is experiencing pain, which pain management technique is this a. sequential muscle relaxation b. distraction c. guided imagery d. hypnosis

b. distraction

a nurse is completing a client's history and physical examination. which of the following information should the nurse consider subjective data? a. blood pressure b. naseua c. cyanosis d. petechiae

b. naseau

which is the most commonly reported safety incident in hospitals? a. equipment malfunctions b. patient falls c. treatment delays d. laboratory specimen errors

b. patient falls

which pain management task can be safely delegated to nursing assistive personnel (NAP)? a. administering an oral dose of acetaminophen b. providing a therapeutic back massage c. evaluating the effectiveness of pain medication d. assessing the quality and intensity of patient's pain

b. providing a therapeutic back massage

a conscious and competent client who is ventilator dependent wants to be removed from the ventilator even though the nurse believes the client is committing suicide. what is the nurse demonstrating when standing at the bedside holding the client' hand? a. value set b. value neutrality c. value system d. value awareness

b. value neutrality

how to know which patient to treat first

based on priority, especially ABC's (airway, breathing, circulation) then safety - vital signs done first to get info on these

chinese culture

believe in a balance of opposites like hot and cold

orthostatic hypotension

blood pressure drops quickly when position is changed (sitting to standing to lying down) and can cause dizziness

sanguineous

blood wound

a client whose belongings were lost in a hurricane says " what is the use of starting over? It will probably happen again" which of the following is an appropriate response by the nurse? a. " I am sure everything will work out" b. " let me arrange for a chaplain to come speak with you" c. " I can see this is difficult for you, tell me more about how you're feeling" d. " we need to try to not worry about things we can't change"

c. " I can see this is difficult for you, tell me more about how you're feeling"

in which of the following situations would the SBAR technique of communication be most appropriate? a. a nurse is explaining the process of bone marrow biopsy to a patient who is schedules for the procedure b. a nurse is facilitating a family meeting in order to coordinate a patient discharge plan c. a nurse is calling a physician to report a patient's new onset of chest pain d. a nurse is teaching a patient about the benefits of smoking cessation and the risk of continuing to smoke

c. a nurse is calling a physician to report a patient's new onset of chest pain

the ethics committee is consulted because an older client asked for a do not resuscitate order, however, the family does not agree. which model will the ethics committee most likely use in the patient's case a. DNAR determination b. patient benefit c. autonomy d. social justice

c. autonomy

in order to achieve balance, body mass must be distributed around which point? a. center of body alignment b. base of support c. center of gravity d. center of balance

c. center of gravity

the nurse is teaching a client who sustained an ankle injury about cold application. which instruction should the nurse include in the teaching plan? a. keep the cold pack in place for at least 24 hours b. place the cold pack directly on the skin over the ankle c. check the skin frequently for extreme redness d. apply the cold pack to the ankle for 30 mins at a time

c. check the skin frequently for extreme redness

the nurse is reading a research article. in which section will the nurse locate information that explains the meaning of the study? a. research design b. purpose c. conclusion d. abstract

c. conclusion

a nurse writes the following nursing diagnosis for a client with alzheimer's disease: disturbed though process related to alzheimer's disease as evidenced by incoherent language. which part of the diagnosis is considered the problem stated? a. related to b. alzheimers disease c. disturbed thought process d. incoherent language

c. disturbed thought process

what is the body's first line of defense against bacteria? a. inflammatory response b. white blood cells c. intact skin d. lymph glands

c. intact skin

which is an example of cluster of related clues? a. has productive cough and states stools are loose b. has a daily bowel movement and eats high fiber diet c. reports nausea and stomach pain after eating d. respiratory rate 20 breaths/min heart rate 85 beats/min, BP 136/84

c. reports nausea and stomach pain after eating

a nurse educator is teaching new nurses about fire safety at an orientation in service. the nurse educator will teach the new nurse that which of the following should be performed first in the case of a fire emergency? a. confine the fire b. pull the fire alarm c. rescue the clients d. extinguish the fire

c. rescue the clients

a 15 year old patient complains of left ankle after being tackled while playing football. he asks the nurse what tests he needs to have to determine whether he has a strain or fracture. how should the nurse reply? a. you dont need an x-ray, i can tell by the way your ankle looks and feels whether you have a strain or fracture b. first you need to get an MRI to diagnose you injury as a fracture instead of strain or sprain c. sprains, strains, and fractures have similar symptoms at first, you will need an x-ray of the joint to be certain d. we will need to get a venous doppler study to make sure that there is not a fracture

c. sprains, strains, and fractures have similar symptoms at first, you will need an x-ray of the joint to be certain

spiritual distress

can be nursing diagnosis, at end of life, people want to make peace but may not be able to which makes them think the bad things they did will make them go to hell

what can CNA's can and cannot do

can: take vital signs, make beds, bathing, ADL's cannot: assess vital signs, give medication, use restraints

jean watson

caring

serous wound

clear fluid

epidemiology

community health nursing when monitoring statistics (ex: how many people have lice or TB)

Madeline Leininger

culture is important for caring

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I will keep the fluorescent ceiling light on in my room at night" b. "I will place an area rug at the entry of my bathroom" c. "I will keep my walker at the end of my bed" d. "I will place a bath seat in my shower to use when I bathe"

d. "I will place a bath seat in my shower to use when I bathe"

a nurse is preparing a teaching plan for a client who has just found out she has type 2 diabetes mellitus. what is the nurse's priority in preparing this plan? a. give her access to a video about diabetes b. evaluate the effectiveness of the client's teaching plan c. establish short term realistic goals for client d. determine what the client knows about managing her diabetes

d. determine what the client knows about managing her diabetes

which law does a hospital use to determine if a patient with no healthcare coverage who is seeking medical care should receive care or be transferred to another facility? a. newborns and mothers health protection act (NMHPA) b. patient self determination act (PSDA) c. health care quality improvement act (HCQIA) d. emergency medical treatment and active labor act (EMTALA)

d. emergency medical treatment and active labor act (EMTALA)

before developing a procedure, a nurse reviews all current research based literature on insertion of a NG tube. What type of nursing will be practiced based on this review? a. institutional practice b. factual based practice c. authoritative nursing d. evidence based practice

d. evidence based practice

the nurse manager suspects that a staff nurse is taking narcotics from the care area. if reported of what will this staff nurse be accused? a. battery b. misdemeanor c. libel d. felony

d. felony

what was Hildegard Peplau's major contribution to nursing? a. health promotion b. transcultural nursing c. holistic comfort d. nurse patient relationship

d. nurse patient relationship

the staff development trainer considers using a feminist theory to explain the resolutions of an ethical dilemma. what will the trainer use when implementing this theory a. risk benefit analysis b. principles c. rules d. relationships

d. relationships

which is nonverbal behavior that enhances communication? a. asking mostly open ended questions b. keeping a neutral expression on your face c. maintaining a distance of 6-12 inches d. sitting down to speak with patient

d. sitting down to speak with patient

which set of topics makes up a hand off report given in a recommended format? a. patient diagnosis medications activity b. subjective objective assessment plan c. data action response d. situation background assessment recommendations

d. situation background assessment recommendations

a nurse is observing a client's nonverbal behavior, when evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication? a. nonverbal communication conveys less truth than what the client states verbally b. nonverbal communication is a poor reflection of what the client feels c. the client enacts nonverbal communication consciously d. the client's socio-cultural background influences nonverbal communication

d. the client's socio-cultural background influences nonverbal communication

when should nurse assess pain? a. during the admission interview b. every 4 hours for the first 2 days after surgery c. only when the patient complains of pain d. whenever full set of vitals is taken

d. whenever full set of vitals is taken

fall precautions

do not have cords around, should not be barefoot, have clear pathways

rules for using heat and cold therapy

do not put it on direct skin, and intermittenly

signs of infection

elevated WBC, fever, red and hot swelling

palliative care

end of life care

how often do you reposition patient to avoid skin breakdowns

every 2 hours

what to do if patient has hearing problems

face them and speak louder and slower

what happens when patient themself can't give consent

family would be asked for consent not living will, this is about wishes

patient preferences

follow patients lead, model their behavior, ask what they want

how do you clean

from clean to dirty, head to toe, front to back

jehovah witness

generally do not allow blood transfusions

nursing license

given by state nursing board

bed baths

given completely by nurse when patient is bedridden

PPE

gloves, mask, gown and goggles to protect from body fluids - put on before entering room and taken off when exit room

grief

has no time frame, everyone responds differently - if it interferes with daily life and functioning then it mimics depression

what do you do when patient falls or faints

help them to the ground

papileau

importance of nurse patient relationship

where do dentures go

in labeled container

hospice

less than 6 months, for comfort

florence nightingale

made many advances in sanitation and cleanliness

core temperature

most accurate is rectal

hearing aids

need to be taken out and cleaned, if not cerumen (earwax) can build up and cause infections

patricia benner

novice to expert

assisted living

only for general help like some ADLs

what can nail polish effect

pulse oximeter reading which checks for oxygenation in blood and it is noninvasive procedure

purulent wound

pus, smelly, green

osteoporosis

puts people at risk for broken bones and fractures, they are very fragile

1st step in making a teaching plan

see what the patient already knows before making the plan

therapeutic communication

should be nonjudgemental and no false hope statements or false promises

eye contact

some cultures it is looked as disrespectful and uncomfortable for the patient always take the patients lead and see what they do and copy it

what do you do when patient says they are fine but has nonverbal cues of pain

the nurse can ask patient more about what they are seeing and say that it is okay to say you're in pain, we are here to help and ask questions to get more knowledge

SA node

the pacemaker of heart, electrical impulses

battery

the physical harm done to patient

which patient would be seen first? normally healthy teen with a HR of 140 or an elderly injured man that is 90

the teen because 140 is not normal

what happens to your vessels as you age

they become less elastic so BP will increase

assault

threatening to hurt

what happens if you have the wrong blood pressure cuff

too big= falsely too low BP, too small = falsely high

skilled nursing

total care, like meds administered, treatment done by nurse

how to stop biases

understand ourself and our beliefs 1st and don't let them influence our work, and have value neutrality

when do you start to plan discharge

upon admission

SBAR

used for the healthcare team for hand offs or reports, not to patient

uniform determination act

used to determine if someone is dead or not (brain dead) with no body function and brain stem is dead

evidence based practice

using clinical experience, patient perspective and research for treating and caring for patients