FUNDS Exam 2

to prevent excessive bruising when administering subcutaneous heparin, which technique will the nurse employ? a. administer the injection via the z track technique b. avoid massaging the injection site after the injection c. use 2 ml of sterile normal saline to dilute the heparin d. inject the medication into the vastus lateralis muscle in the thigh

b

what is a critical step prior to administering PRN pain medications? a. assessing fiber intake to prevent constipation b. identifying time of last dose given c. validating pain d. teach about dependence and tolerance

b

what is the best goal for sleep deprivation? a. patient will sleep for at least 8 hours b. patient will state they feel rested in morning c. patient will be in bed and rest for duration of night shift d. patient will not require sleep aide medication

b

what would be the most appropriate careplan for a patient with diabetic neuropathy? a. noncompliance related to nurse patient relationship b. risk for injury related to decreased sensation c. risk for falls decrease due to changes in lower extremity strength d. risk for neurovascular dysfunction related to neuropathy

b

which finding in a client with pulmonary edema requires the most rapid action by the nurse? a. weak, rapid pulse b. o2 82% c. bp 99/54 d. crackles throughout both lungs

b

who is most at risk of sensory deprivation? a. icu patient on constant monitoring b. patient on airbone isolation c. hearing loss patient d. patient with chronic pain

b

what is true about managing pain? a. focuses on promoting sleep b. promotes non pharmacological treatments only c. focuses on promoting optimal functioning d. focuses on using a few pain med as possible

c

the nurse notices that a diabetic client is consuming chocolate brought by a family member. which action would the nurse perform to adhere to the principle of autonomy? a. ask if the client has a weakness for sweets b. request that the client refrain from eating chocolates c. explain the consequences of eating chocolates to the client d. collaborate with a dietitian to obtain a special diet chart for the client

d

What is restless leg syndrome?

Cannot lie still, unpleasant creeping, crawling or tingling sensations in the legs

What are psychological signs of sleep disturbance? a. changes in emotional state b. changes in temperature c. blurred vision d. changes in appetite

a

What can your teaching change about the patient's pain? a. misconceptions about pain meds b. pain tolerance c. prior experiences with pain d. contributing factors like gender, age, race

a

patient teaching does all except what? a. begins once discharge orders are obtained b. promotes improved continuity of care c. begins on admission d. promotes informed decisions

a

the nurse is formulating a teaching plan for a client recently diagnosed with type 3 diabetes. which interventions would the nurse include to decrease the risk of complications? SATA a. examine feet daily b. wear well fitting shoes c. perform regular exercise d. powder the feet after showering e. visit the primary health care provider weekly f. test bathwater with the toes before bathing

a,b,c

Which nursing interventions would the nurse implement to promote sleep for a client in a health care setting? SATA a. restrict visitors b. reduce lighting c. provide activities during the day d. decrease sound of infusion alarms e. increase the dosage of pain prescriptions at night

b,c

for which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? a. weight loss b. unusual fatigue c. dependent edema d. nocturnal dyspnea e. increased urinary output

b,c,d

which would the nurse do to understand the nature of a client's pain?SATA a. cover area of discomfort b. observe where the client locates the pain c. refarin from touching the area of tenderness d. note whether the pain radiates to any other part of the body e. instruct the client not to moves so as not to increase the pain

b,d

which are the best ways for the nurse to be protected legally? SATA a. ensure that a therapeutic relationship with all clients has been established b. provide care within the parameters of the standards for nursing practice set by the state or province c. carry at least $100,000 worth of liability insurance d. document consistently and objectively e. clearly document a client's nonadherence to the medical regimen

b,d,e

which interventions would the nurse include in the plan of care for a client after total hip replacement?SATA a. maintain the affected hip in adduction postion when moving the client b. pain control should include regularly scheduled analgesics and as needed medications c. the client should sit in a chair at the height to encourage flexion of the hip joint d. frequent neurovascular assessment should be done and compared with the unaffected side e. when turning, the client should be log rolled to prevent the leg from falling forward or backward

b,d,e

a client who receives morphine by patient controlled analgesia has a respiratory rate of 6 breaths/minute. which intervention is needed? a. nasotracheal suction b. mechanical ventilation c. naloxone administration d. cardiopulmonary resuscitation

c

an adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How would the nurse respond to complaints of pain? a. by withholding the medication to help prevent addiction b. by stating that the limb has been removed and that the pain is psychological c. by acknowledging that the pain is real and administering medication to relieve it d. by explaining that the phantom limb sensation will subside within a few more days

c

expressive aphasia is a. difficulty understanding spoken word b. difficulty understanding written word c. difficulty expressing oneself verbally d. difficulty with writing out communication

c

left sided heart failure leads to a. bloody sputum b. peripheral edema c. crackles in lungs d. increased cardiac input

c

right sided heart failure leads to a. cough b. shortness of breath c. edema in legs d. confusion

c

sensory deficit is a. .too much stimuli b. too little stimuli c. alteration in ability to sense a. all of the above

c

the nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess? a. proteinemia b. contractures c. tissue ischemia d. thrombus formation

c

which element would the nurse focus on when teaching crutch walking to a client who has a casted leg fracture? a. establish a schedule for pain medication b. maintaining a fixed schedule of daily activities c. modifiying the home environment to prevent accidents d. understanding that a more sedentary lifestyle is necessary

c

Which statements made by the client indicate effective learning about management of low back pain? SATA a. i should sleep in a prone position b. i should sleep with my legs out straight c. i should keep a check on my body weight d. i should stop exercising if the pain becomes severe e. i should exercise by leaning forward without bending the knees

c,d

which strategies would the nurse teach a client who says ' i have been having trouble sleeping and feel wide awake as soon as i get into bed'? SATA a. eating a heavy snack near bedtime b. reading in bed before shutting out the light c. leaving the bedroom when unable to sleep d. drinking a cup of warm coffee with milk at bedtime e. exercising in the afternoon rather than in the evening f. drinking at least 1 glass of wine or other alcoholic beverage at bedtime

c,e

a client who has received tap water enemas until clear is at risk for developing which complication? a. hypercalcemia b. hypocalcemia c. hyperkalemia d. hypokalemia

d

What are the three types of aphasia?

expressive, receptive, global

what are signs of acute pain?

increased BP, RR, HR dilated pupils diaphoresis

diffusion (breathing)

movement of O2 and CO2 between alveoli and capillaries

ventilation (airway)

movement of air in and out of the lungs

what can obstruct diffusion?

pneumonia, asthma mucus, COPD, bronchitis, emphysema, anemia

What are the 3 types of sensory deprivation?

reduced sensory input or meaningful input (visual or hearing loss), elimination of patterns or meaning from input (strange environments), restrictive environments (bed rest and isolation precautions)

what is proprioception?

sense of body position and movement

What is somnambulism?

sleep walking

which is the primary focus of the when providing evidence- based care to the client? a. practice trends b. research studies c. clinical experience d. problem solving approach

d

what is true about pain in elderly patients? a. it decreases with age b. confused patients do not feel pain c. it requires more medications to treat d. it can be more difficult to care for

d

the nurse is caring for a client whose forehead feels warm to the touch. the nurse uses a thermometer and obtains the client's temperature. which step is the nurse doing? a. validation b. assessment c. interpretation d. documentation

a

which question asked by the nurse is most appropriate to assess the nature of the client's pain? a. can you describe your pain to me? b. is your pain associated with movement? c. can you rate your pain on a scale of 0 to 10 d. do you notice your pain worsening with any activity

a

which written statement made by the nurse while documenting factual records indicates a need for additional training? a. the client seems restless b. the client states 'i am worried' c. the client pulse rate is 90 beats/min d. the client has a body temperature of 39 degrees

a

which action is the nurse's responsibility when administering prescribed opioid analgesics? a. count the client's respirations b. document the intensity of the client's pain c. withhold the medication if the client reports pruritus d. verify the number of doses in the locked cabinet before administering the prescribed dose e. discard the medication in the client

a,b,d

which methods qualify as alternative therapies for pain? a. prayer b. hypnosis c. medication d. aromatherapy e. guided imagery

a,b,d,e

the nurse is taking care of a client who has chronic back pain. which nursing considerations would be made when determining the client's plan of care? a. ask the client about the acceptable level of pain b. eliminate all activities that precipitate the pain c. administer the pain medications regularly around the clock d. use a different pain scale each time to promote patient education e. assess the client's pain every 15 minutes

a,c

a client is receiving patient PCA after surgery. which benefit would this type of therapy provide? SATA a. client is able to self-administer pain meds as needed b. amount of medication received is determined entirely by the client c. decreases client dependency d. relieves the nurse of monitoring the client e. increases client sense of autonomy

a,c,e

which information would the registered nurse provide to a student nurse about the importance of nursing documentation for risk management? a. a nurse documentation is the evidence of care that a client receives b. nurses notes would not be given to attorneys in the event of a lawsuit c. the nurse would note assessments and significant changes in the clients health d. in case an occurrence report is filed, nurses would enter the information the clients charts e. nurses would always document the primary health care providers responses whenever they are contracted

a,c,e

perfusion (circulation)

adequate blood flow to alveoli to transport oxygen

what can obstruct perfusion?

afib, CHF, altered mobility

What can obstruct ventilation?

asthma, dysphagia/aspiration, barrel chest due to COPD

a client who had an above the knee amputation of the left leg plans to use crutches until the prosthesis is fitted. which action would the nurse take first? a. demonstrate the swing through crutch walking gait b. determine whether the client has used crutches c. introduce the client to another client who is using crutches d. provide a pamphlet that has information about using crutches

b

a pain scale of 1 to 10 is used by the nurse to assess a client's degree of pain. the client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. which conclusion would the nurse make regarding the client's response to pain medication? a. the client has a low pain tolerance b. the medication is not adequately effective c. the medication has sufficiently decreased the pain level d. the client needs more education about the use of the pain scale

b

after surgery, an adolescent has a patient-controlled analgesia pump that is set to allow morphine delivery every 6 minutes. which statement indicates to the nurse that the family understand instructions about the pca pump? a. i'll make sure that she pushes the pca every 6 minutes b. she needs to push the pca button whenever she needs pain medication c. i'll have to wake her up on a regular basis so she can push the pca button d. i'll press the pca button every 6 minutes so she gets enough pain medication while shes sleeping

b

heart failure leads to a. increased cardiac output b. decreased cardiac output c. increased renal perfusion d. decreased heart rate

b

what documentation should you utilize? a. appears to be resting b. lower right leg 2+ edema c. drank adequate amount of fluids d. medication error form completed

b

why does treating pain in the elderly become complication? a. they have a higher tolerance to pain b. they are more likely to be dependent on pain meds c. determining reason or exact location of pain is difficult d. dosing must be higher than young and middle aged adults

c

which finding would the nurse expect when caring for a client with right-sided heart failure? a. oliguria b. pallor c. cool extremities d. distended neck veins

d

an abscess develops in an obese adult after abdominal surgery. the wound is healing by second intention. which diet would the nurse expect the health care provider to prescribe to meet this client's immediate nutritional needs? a. low in fat and vitamin d b. high in calories and fiber c. low in residue and bland d. high in protein and vitamin c

d

nursing documentation should include all except what? a. subjective and objective data b. demonstration of nursing process c. proof of effectiveness of nursing care d. point out negligence and malpractice from health care team

d

sensory deprivation is a. too much stimuli b. too little stimuli c. alteration in ability to sense d. too little but can include alteration in sense

d

sensory overload can come from a. environment b. stressors c. acute and chronic health issues d. all of the above

d

sleep apnea presents an issue primarily with a. diffusion b. perfusion c. oxygen-carrying capacity d. ventilation

d