Fundamentals Mid-Term

A nurse caring for a patient who is experiencing excruciating pain and requires frequent administration of analgesic. What statement would be an example of the nurse demonstrating aggressive communication?

"I will only medicate you every 4 hours."

the nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task?

-position patient to far side of the bed -place bath blanket over patient on top sheet -remove spread and blanket separately

the physician orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately?

-weigh patient at the same time each day -calibrate by setting scale at zero after each weight -ensure same amount of clothing is worn by patient -schedule weighing immediately after breakfast

Convert 35% to a decimal. Round to two decimal places, as indicated.

0.35

To reassure a patient who is concerned about receiving addictive drugs, the nurse states that research has shown that the percentage of patients who become addicted is less than:

1%

the nurse carefully measures drainage during the first 24hrs after surgery on a patient with a Jackson-Pratt drain. What is the max amount of drainage considered normal?

100mL

One hundred forty-five micrograms

145 mcg

The nurse prioritizes the care of four patient. Which patient has a systemic infection?

14yr old with acute appendicitis

International time, 4:08PM is

1608 hr

change the following roman numeral: XXV

25

The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?

3 seconds

684-321=

363

Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per minute?

4/32

When the nurse is preparing a tepid bath for a patient, the water temperature should be:

98.6 F

Upon admission, the nurse notes that a patient has a billfold with cash. Because there is no family member present the nurse suggest that the money be:

?

The puerperal fever described by Dr. Semmelweis is best described as:

A localized infection

How should the nurse assist the patient with moving when pain is anticipated?

Administer medication before ambulation

What is required by the health care team to identify the needs of a patient and to design care to meet those needs?

An individualized care plan

What is a nursing program considered when certified by a state agency?

Approved

What is the term for when members of a particular ethnic group believe that their beliefs and practices are the best?

Bias

A nurse must violate the personal space of a patient to perform an invasive procedure. How can the nurse reduce the discomfort of the patient?

By approaching the interaction in a professional manner

More than 99% of which cation is stored in the bones and teeth?

Calcium

The nurse carefully assessed a patient receiving opioid narcotic for the common side effect of:

Constipation

A resident in a long term care facility reports difficulty swallowing enteric coated aspirin:

Crush the tablet and mix with applesauce

Which of the following best describes a cell that is necrotic?

Dead

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?

Dehiscence

One of these techniques is percussion. What is percussion used to determine?

Density of underlying tissue

When a patient demands to be discharged without a physician order and is leaving the unit with his belongings, the nurse should ask the patient to sign a:

Discharge against medical advice form

To test for Homans' sign, the nurse would:

Dorsiflex the clients foot while the knee is slightly bent

A term that means vomiting is:

Emesis

What is an important consideration when developing the care plan?

Ensure the patient is involved in the process

When admitting a patient to the hospital, the nurse notes that the patient has mild sunburn. How should the nurse document this finding?

Erythema

What does therapeutic communication...

Facilitates the formation of positive nurse-patient relationship

The LPN/LVN assists a patient into the semi-Fowler position per physician order. What would indicate that this patient is in the correct position?

Head of bed is at a 30 degree angle

A fomite is a:

Host

What part of the body maintains a balance between heat production and heat loss, regulating the body?

Hypothalamus

The nurse assesses a red blister over the right superior iliac area of the patient. What stage is this decubitus ulcer?

II

Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part?

Implementation

Who is the legal owner of the patients medical record?

Institution

Sodium is the most abundant electrolyte in the body. The location of electrolytes is important for maintaining homeostasis. Sodium is the major electrolyte in which fluid compartment?

Intracellular

Where did Florence Nightingale original nursing education take place?

Kaiserswerth School

Term for white blood cells is:

Leukocyte

The establishment of priorities of care during the planning phase of the nursing process often uses the framework of:

Maslow hierarchy of needs

a nurse tells a patient, "This PM you are going for abdominal A&P, an H&H, as well as an IV pyelogram? Please sign these consent forms." What may this use of medical jargon cause?

Misinterpretation

Which of the following is considered the control center of the cell?

Nucleus

What should a nurse do when encountering a mercury spill?

Open any outside windows

Hyperkalemia refers to an increase in the blood levels of which ion?

Potassium

The nurse discovers a reddened area over a patients hip. What should be the nurses first intervention?

Press the area gently to assess for blanching

What is the purpose of licensing laws for LPN/LVNs?

Prevention of malpractice

The nurse is delivering a meal tray to a female Muslim patient. What intervention is most appropriate for this patient?

Providing her with a female nurse

A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the different between these two rates?

Pulse deficit

A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sure for:

Punitive damages

Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?

RN

A nurse if administering a medication at the bedside. Which of the following actions should be the first priority?

Recheck the medication label

What fundamental principle must the nurse first observe when confronted with an ethical decision?

Respect for people

A physician has diagnosed a patient as having an enlarged liver. According to the patients chart, his liver is measured as being two fingers below the costal margin of the rib cage. Where was the physician palpating to get this measurement?

Right Upper Quadrant

What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting?

Risk of infection is reduced

Where should a nurse performing a back rub begin?

Sacral area

The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?

Sanguineous

Which type of membrane lines the central body cavities that are not open to the exterior of the body?

Serous membrane

The patient tells the nurse that he gets a headache after taking an antihypertensive. The nurse explains that this is a (n)

Side effect

The head is located _____ to the chest

Superior

Why is documentation especially significant in managed care?

The hospital needs to show that employees care for patients

A patient with pulmonary edema is receiving furosemide(lasix), a kaliuretic diuretic. He has lost 6.6lb over a 48hr period. Which statement is true?

The loss of 6.6lb causes "tenting"

Which of the following must the nurse recognize regarding the health care delivery system?

The major goal is to achieve optimal levels of health care.

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

The patient complains of nausea.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

The patient is jaundiced

Before the actual discharge occurs, what must the nurse ensure?

The patient understands the discharge instructions

What is the wellness/illness continuum defined as?

The range of a persons total health

The nurse writes two nursing diagnosis: (1) inadequate nutritional intake related to vomiting as manifested by 3 pound weight loss (2) risk for impaired skin integrity related to inadequate nutrition. the major difference between the two diagnoses is that the second diagnosis:

The second diagnosis reflects a problem that does not yet exist

A nurse assesses a patients dorsal pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding?

Thready pulse

The correct abbreviation for teaspoon is:

Tsp.

How may a newly licensed LPN/LVN practice?

Under the supervision of a physician or RN

What is a fixed concept of how all members of an ethnic group act or think?

Variations within a cultural group

What role is the nurse who diligently works for the protection of the patients interests playing?

advocate

Which condition is caused by vomiting stomach contents?

alkalosis

How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter?

at least twice a day

Cocci, bacilli, and curved rods are classified as:

bacteria

You are working with a patient in the intensive care unit. Her heart rate is 40 beats per minute. This is documented as:

bradycardia

when discussing diabetes with a patient, the nurse describes this disease as falling into which group of terms for duration?

chronic

the physician has not ordered a dressing change for a drainage wound on a patient in acute care setting. How should the nurse assess the amount of drainage?

circle and date the outline of the exudate on the dressing

What is the pulse—the expansion and contraction of an artery— produced by?

contraction of the left ventricle

An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?

dehydration

During a physical assessment, the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing?

diaphoresis

the foot is located ___ to the leg.

distal

Glands that are not ducted, but release their products directly into tissue fluid and blood, are called:

endocrine

which term means a red blood cell?

erythrocyte

Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes?

from the inner towards the outer canthus

which type of solution causes crenation or shrinkage of submerged red blood cells?

hypertonic

The nurse is pouring a sterile solution from a bottle. What direction should the label on the bottle be in for appropriate technique?

in the palm of the hand

A disaster situation occurs and involves an explosion in the hospital laundry. What would this be classified as?

internal

A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of:

malpractice

What should the nurse begin by assessing when performing a head-to-toe assessment?

neurologic status

The number of abdominal regions is:

nine

The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim?

poison control center

What type of organism causes Malaria?

protozoan

a nurse frequently looks at her watch when giving a patient a bed bath. What message is most likely conveyed to the patient from the nurse?

she is feeling hurried

What is the term for a generalization about a form of behavior, an individual or a group?

stereotype

what does the nurse recognize as the initial step in conducting an assessment of a patient?

the nursing health history

during an admissions assessment, the nurse collects objective and subjective data. What is an example of objective data?

the patient is pacing back and forth

the proper abbreviation for "right eye" is:

there isn't one. It should be written out completely

The lungs are located in the:

thoracic cavity

the nurse is caring for a patient with a DNR order. Although the nurse may disagree with the order, what is his/her legal order?

to follow the order.

When must the nurse remember to use an electric razor when shaving a patient?

when a bleeding tendency is present