nur 107 - Final Exam

Infuse 0.62 L over the next 10.4 hr by infusion pump. What is the IV flow rate in mL/hr? Round to the nearest whole number. Answers: 26ml/hr 45ml/hr 60ml/hr 90ml/hr

60ml/hr

The nursing care plan is? Answers: -A written guideline for implementation and evaluation -Documentation of client care. -A projection of potential alterations in client behaviors -A tool to set goals and project outcomes.

A written guideline for implementation and evaluation

Doctor's order: Potassium Chloride 0.02 kg. Available: Potassium Chloride 20,000 mg per tablet. How many tablets would the nurse administer? Answers: 1 tablet 4 tablets 0.5 tablets 3 tablets

1 tablet

A nurse is providing discharge education for a postoperative patient who will be leaving the hospital with a urinary catheter. What statement reflects appropriate environmental safety education for this patient? Answers: -"Be aware that you are at risk for falling because the catheter tubing hangs by your feet and can be a tripping hazard" -"Your pain medication may cause side effects including drowsiness, so be sure not to drivewhile you are taking them" -"Because of your incision, you should be careful to not lift anything heavier than 10 lbs" -"Change positions slowly to avoid dizziness"

"Be aware that you are at risk for falling because the catheter tubing hangs by your feet and can be a tripping hazard"

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? Answers: -"I need to drink one and a half to 2 quarts of liquid each day." -"I need to take a laxative such as milk of magnesia if I don't have a BM every day." -"If my bowel pattern changes on its own, I should call you." -"Eating my meals at regular times is likely to result in regular bowel movements."

"I need to take a laxative such as milk of magnesia if I don't have a BM every day."

***A nurse is finished changing a wound dressing for a patient on contact precautions for C-Diff. Which of the following would be appropriate hand hygiene? Answers: -Before and after dressing change -Using soap and water after removing gloves -Before medication administration -Using alcohol based gel when leaving room

-Before and after dressing change -Using soap and water after removing gloves -Before medication administration

Doctor's Order: Lasix 0.007 kg IV push now. Available: 8 g in 17 ml. How many ml's will the nurse draw up? Round to the nearest whole number. Answers: 4ml 9ml 13ml 15ml

15ml

Doctor's order: 14,000,000 mcg of Ampicillin. Available Ampicillin 0.007 kg tablets. How many tablets should the nurse administer? Answers: 1 tablet 2 tablets 4 tablets 6 tablets

2 tablets

Ordered 0.88 L NS IV to infuse in 21.6 hr by infusion pump. What is the IV flow rate in mL/hr? Round to the nearest whole number. Answers: 10ml/hr 17ml/hr 33ml/hr 41 ml/hr

41 ml/hr

A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation? Answers: -Incontinence -Arrhythmias -Fecal impaction -Rectal hemorrhoids

Arrhythmias

Which activity should the nurse implement to decrease shearing force on the patient with a stage II pressure ulcer? Answers: -Lubricate the area with baby oil -Pull patient up under the arms -Avoid sliding the patient in bed -Maintain good hydration

Avoid sliding the patient in bed

The patient will have reconstructive breast surgery in an outpatient surgery center. She has not had surgery before and is asking questions of the nurses. The patient tells the nurse she would like to know more about what to expect. The nurse identifies the nursing diagnosis of readiness for enhanced knowledge related to planned surgery. An example of an outcome for this diagnosis is? Answers: -Provide instruction on routine postoperative monitoring -Perform VS measurements every hour following surgery -Patient identifies reason for VS monitoring following surgery -By the day of surgery, patient understands the routine monitoring protocol following surgery

By the day of surgery, patient understands the routine monitoring protocol following surgery

A patient's record can be more accurate if the nurse? Answers: -Charts in a timely fashion -Uses white out when making mistakes to ensure a clean legible note -Summarizes patient care at the end of the shift -Delegates charting to appropriate personnel

Charts in a timely fashion

Your nurse manager informs you that he is using the "Ask Why 5 time" tool to investigate a medication error in which you were involved. What is the nurse manager doing? Answers: -Conducting a root cause analysis -Applying the concepts of a "just culture" -Using care bundles -Ensuring "never events" do not occur

Conducting a root cause analysis

A nurse is caring for a patient with anorexia. Which of the following would be an example of interpersonal nursing interventions? Answers: -Provide basic dental care -Educate on minimal dietary requirements -Supervise patient's oral intake -Provide opportunity to examine feelings

Provide opportunity to examine feelings

After the nurse has formulated expected outcomes, the next step of the nursing process is to? Answers: -Outline evaluation strategies -Prepare an oral report -Document the rationale -Create the plan of care

Create the plan of care

The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process, willingness to look at each unique patient situation and determine which identified assumptions are true and relevant is? Answers: -Caring -Reflection -Critical thinking -Assessment

Critical thinking

The nurse is using the nursing process to care for a patient who is suicidal. Which of the following nursing steps is a part of the diagnosis step of the nursing process? Answers: -Identifies the patient's problem as risk for suicide -Notes that the patient's family reports recent suicide attempt -Prioritizes the necessity for maintaining a safe environment for the patient -Obtains a short-term contract from the patient to seek out staff if feeling suicidal

Identifies the patient's problem as risk for suicide

A patient who has bleeding tendencies has a deficiency in which vitamin? Answers: Vitamin A Vitamin B Vitamin C Vitamin K

Vitamin K

A nurse is preparing to teach a patient with poor health literacy about a new medication. What does the nurse do first? Answers: -Schedules frequent teaching sessions -Establishes a therapeutic relationship with the patient -Asks the patient to explain what was taught and provide a return demonstration of skills learned -Includes the most important information about the medication at the beginning of the teaching session

Establishes a therapeutic relationship with the patient

When assessing a client for obstructive sleep apnea (OSA), the nurse understands the most common symptom is? Answers: -Headache -Early awakening -Impaired reasoning -Excessive daytime sleepiness

Excessive daytime sleepiness

Nurse Deanna is reviewing a patient's fluid intake and output record. Fluid intake and urine output should relate in which way? Answers: -Fluid intake should be double the urine output. -Fluid intake should be approximately equal to the urine output. -Fluid intake should be half the urine output. -Fluid intake should be inversely proportional to the urine output.

Fluid intake should be approximately equal to the urine output.

During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound? Answers: -Area is red and does not blanch. -Full-thickness tissue loss to dermis and subcutaneous tissues. -Partial thickness of dermis with shallow open ulcer. -Full thickness with bone and tendon visible.

Full-thickness tissue loss to dermis and subcutaneous tissues.

Which assistive device will you use to assist a patient with mild right sided weakness as he moves from the bed to the wheelchair? Answers: -Gait belt -Slide sheet -Transfer board -Slide board

Gait belt

What must the nurse do to identify actual or potential health problems? Answers: -Evaluate care implemented -Meet with significant others -Call the physician -Gather data from sources

Gather data from sources

A patient has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing? Answers: -Carbohydrates -Protein -Fats -Vitamins

Protein

The most important reason that all nurses should have self-awareness is because it helps the nurse to? Answers: -Identify personal biases that may affect his thinking and actions -Identify the most effective interventions for a patient -Communicate more efficiently -Learn and remember new procedures and techniques

Identify personal biases that may affect his thinking and actions

A nurse is assessing a patient's pain. The nurse notes which physiological finding that is indicative of acute pain? Answers: -Pupil constriction -Decreased pulse rate -Increased blood pressure -Decreased respiratory rate

Increased blood pressure

The family of a confused ambulatory patient insists that all four side rails be up when the patient is alone. The best way to handle this situation is to? Answers: -Thank them for being conscientious -Restrict their visiting privileges -Report them to the charge nurse -Inform them of the risks associated with side rail use

Inform them of the risks associated with side rail use

The patient has a pressure ulcer resulting from urine incontinence and sustained pressure over her coccyx. The nursing care plan includes a goal of "Pressure ulcer will heal in 3 weeks". Which of the following is an evaluative measure for this goal? Answers: -Turn the patient every 90 minutes -Measure the diameter of the ulcer -Measure the color of the patient's urine -Determine the patient's report of discomfort during turning

Measure the diameter of the ulcer

The six-step clinical decision-making approach to diagnose and treat human responses to actual or potential health problems is? Answers: Problem solving Evidence-based knowledge Nursing process Diagnostic reasoning

Nursing process

Upon a peer review of a fellow nurse's charting there was comprehensive charting noted about a patient with labored breathing. Which documentation reflects subjective data? Answers: -Patient's respirations are 34 breaths per minute -Patient appears worried and anxious -Patient's family is present in the room -Patient reports that he is coughing a lot.

Patient reports that he is coughing a lot.

A patient has just received a cancer diagnosis after being hospitalized for fatigue and anemia. The nurse has information about how to improve red blood cell counts through appropriate nutrition. What is the most important thing that the nurse should know prior to conducting this education? Answers: -Patient's current level of fatigue -Patient's age -Patient's cognitive status -Patient's emotional state

Patient's emotional state

When a person selects, organizes, and interprets sensory stimuli, the process is termed? Answers: -Adaptation -Perception -Stimulation -Preoccupation

Perception

After exposure to a patient in contact isolation, visitors are encouraged to? Answers: -Wear gloves before eating or handling food -Leave the facility to prevent contamination -Perform hand hygiene upon leaving patient's room -Report to the lab for a stat blood test

Perform hand hygiene upon leaving patient's room

Which of the following is part of the implementation phase of the nursing process? Answers: -Analyzing data clustering related information and identifying problem areas -Recording data accurately -Performing nursing actions -Determining specific desired outcomes for each nursing diagnosis

Performing nursing actions

What is the priority concern when providing oral hygiene for the unconscious patient? Answers: -Thoroughly brushing all tooth and oral surfaces -Preventing aspiration -Controlling mouth odor -Applying local anesthetic

Preventing aspiration\

The nurse understands that the most vivid dreaming occurs during? Answers: -REM sleep -Stage N1 -Stage N3 -Transition period from NREM to REM sleep

REM sleep

Which of the following statements is an accurate nursing diagnosis? Answers: -Poor Parenting Abilities related to lack of sleep -Disturbed Body Image, possibly related to recent childbirth -Risk for Ineffective Breastfeeding related to poor infant latch -Sleep Deprivation, Potential related to frequent infant feeding schedule

Risk for Ineffective Breastfeeding related to poor infant latch

A patient has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the patient. When the physician leaves the room, the patient asks the nurse, "What did he just say?" The nurse understands that the patient is experiencing? Answers: -Sensory overload -Sensory deprivation -Sensoristasis -Sensory perception

Sensory overload

***Calcium assists in the contraction of a muscle. In which area of the heart is the impulse to contract stimulated? Answers: -Sinoatrial Node -Tricuspid Valve -Atrioventricular Node -Mitral Valve

Sinoatrial Node

A nurse is providing passive range of motion to a patient's left lower extremity when he encounters resistance in the ankle. What should the nurse do first? Answers: -Continue ROM to gently increase mobility -Stop movement to prevent injury -Assess ankle for swelling -Call Physical Therapist for a consult

Stop movement to prevent injury

Cardiac output is a function of the heart rate and? Answers: -Sinoatrial Node -Electrical Impulses -Autonomic Nervous System -Stroke Volume

Stroke Volume

What is the micturition reflex? Answers: -The process of filtration beginning with the glomerulus -The act of bladder contraction and perceived need to void -The reabsorption of the substances the body wants to retain -The secretion of electrolytes that are harmful to the body

The act of bladder contraction and perceived need to void

The primary purpose for evaluating data about a client's care is to determine if? Answers: -It meets accreditation standards -The medical orders were carried out -There is a need for health care consultations -The nursing care plan needs to be revised

The nursing care plan needs to be revised

***How will the nurse know if the patient education about the use of the incentive spirometer was effective? Answers: -The patient will blow into the spirometer 10 times per hour -The patient will verbalize that the spirometer will help prevent blood clots in their lungs -The patient will change the settings on the spirometer to a lower number each day -The patient will inhale deeply to raise the indicator to the goal marker on the spirometer

The patient will inhale deeply to raise the indicator to the goal marker on the spirometer

In order to provide effective nursing care, the nurse should engage in what type of communication with the patient and his/her family? Answers: -Purposive communication -Intra-personal communication -Meta-communication -Therapeutic Communication

Therapeutic Communication

***What is the purpose of the client outcome? Answers: -To evaluate the plan of care developed -To coordinate the nursing intervention -To promote patient participation -To provide a basis for the scientific rational

To promote patient participation

Ventilation, perfusion and exchange of gases are the major purposes of respiration? Answers: True False

True

***A nursing student completes an assessment of a patient. The patient's blood pressure is 92/70mm Hg and the patient reports feeling dizzy. The student goes to the medical record to learn what the patient's blood pressure and symptoms were before the diagnostic test. The nursing student's review of the medical record for data is an example of? Answers: -Validation -Data analysis -Consultation -Outcome measurement

Validation