Exam 2: Pharmacology, Health Assessment, Fundamentals
The nurse is going to administer an intermittent tube feeding. Since the patient's feeding tube has been in place for 3 days, which action is best for the nurse to take at this time?
Aspirate gastric contents and test on a pH strip.
Which of the following accurately describes the greatest risk related to having a feeding tube?
Aspiration
Acceptable Ranges for Adults Blood Pressure:
Average: ≤ 120/80 mm Hg Pulse pressure: 30 to 50 mm Hg
plantar flexion
bending the toes and the foot downward
The student nurse is preparing to administer medication through a feeding tube. Which of the following statements if made by the student nurse indicates correct understanding?
"I will flush with 10 mL of tap water after each medicine and with 30-60 mL of water after the last medication."
For semi-Fowler's position...
, the head of the bed is elevated 30 degrees. This position is useful for patients who have cardiac, respiratory, or neurological problems and is often optimal for patients who have a nasogastric tube in place.
In the prone position..
, the patient lies on the abdomen with the head turned to one side. The hips are not flexed. Sometimes, one or both arms are flexed on each side of the patient's head. Because this position can cause hyperextension of the lower back, difficulty breathing due to pressure on the chest, and foot drop, it is not a position you'll use often. If a patient does lie prone, place a pillow under the patient's head and a small pillow or towel roll under the abdomen just below the diaphragm. Also, place a pillow under the lower legs to keep the toes from touching the bed.
Electronic thermometer
-A rechargeable battery-powered display unit with a thin wire cord and a temperature-processing probe covered by a disposable cover. -Within 1 minute after placement, the thermometer displays a digital temperature reading. -Separate probes are available for oral and axillary temperature measurement (blue tip) and rectal temperature measurement (red tip).
Temporal Artery Thermometer
-An infrared scanner is swept across the forehead. If the patient is diaphoretic, also scan just behind the ear. -Within seconds after scanning, a digital reading appears on the display unit.
Factors that influence the character of respirations:
-Exercise -Anxiety -Acute pain -Smoking -Medications -Body position -Neurologic injury
Risk Factors for Respiratory Alterations
-Fever -Pain and anxiety -Diseases of chest wall or muscles -Constrictive chest or abdominal dressings -Presence of abdominal incisions -Gastric distention -Chronic pulmonary disease -Traumatic injury to the chest wall with or without collapse of underlying lung tissue -Presence of a chest tube -Respiratory infection -Pulmonary edema and emboli -Head injury with damage to brain stem -Anemia
Vital signs are generally taken...
-On admission to a health care facility -When assessing the patient during home care visits -Before, during, and after a surgical or invasive diagnostic procedure, the administration of medications or application of therapies, a transfusion of any type of blood products, nursing interventions influencing a vital sign (e.g., before and after a patient previously on bed rest ambulates, before and after the patient performs range-of-motion exercises) -When the patient reports specific symptoms of physical distress (e.g., feeling "funny" or "different") -When the patient's general physical condition changes -Upon nursing judgment when there is reason to believe the patient's condition is changing
Signs and Symptoms of Respiratory Alterations
-Restlessness, irritability, confusion, reduced level of consciousness -Labored or difficult breathing -Use of accessory muscles -Adventitious breath sounds -Orthopnea -Inability to breathe spontaneously -Thick, frothy, blood-tinged, or copious sputum production -Pain during inspiration -Bluish or cyanotic appearance of nail beds, lips, mucous membranes, and skin
Normal vital signs for 10 yo child
10/65, 98.8ºF, 90, 24, 100%
Tympanic Thermometer
-The probe consists of an otoscope-like speculum with an infrared sensor tip that detects heat radiated from the tympanic membrane of the ear. -Within seconds after placement in the ear canal and depressing the scan button, a digital reading appears on the display unit. A sound signals when the peak temperature has been measured.
Chemical Dot Single-Use or Reusable Thermometer
-Thin strips of plastic with a temperature sensor at one end and chemically impregnated dots formulated to change color at different temperatures. - Chemical dots on the thermometer change color to reflect temperature reading, usually within 60 seconds. -Useful for screening temperatures, especially in infants, during invasive procedures, for a patient on protective isolation and in orally intubated critical care patients. -Not appropriate for monitoring fever in acutely ill patients or monitoring temperature therapies. -Can be used at axillary or rectal site if covered by a plastic sheath with a placement time of 3 minutes
A Pt is about to receive 30 mg of ketoralac (Toradol) IM/6 hr for 48hr. The medication is available in a 60mg/2mL vial. How many mL should the nurse administer for each dose?
1 mL 30mg / 60mg = 0.5 x 2mL = 1mL
You are preparing to take a patient's temperature. Which of the following factors may affect the patient's oral temperature reading? (Select all that apply.) 1. If the patient has recently consumed a hot or cold beverage 2. Warmth of the room 3. If the patient took an anti-hypertensive medication 30 minutes ago 4. If the patient has recently exercised 5. If the patient has recently smoked 6. If the patient is to be discharged soon
1, 2, 4, 5
1 mg= ?mcg
1,000 mcg
1 g= ?mcg
1,000,000 mcg
Instructions: Match the pH test result to the likely source. 1. Patient with continuous tube feeding 2. Stomach of fasting patient 3. Pleural fluid from tracheobronchial tree 4. Intestine of fasting patient
1. 5 or higher 2. 1 to 5 3. 5 or higher 4. Greater than 6
Match the medication form with the method of preparation for administration through a feeding tube. 1. Gelatin capsule 2. Capsule 3. Pill
1. Aspirate with a syringe, or dissolve in warm water over several minutes. After capsule dissolves, remove its gelatin outer layer. 2. Open and dissolve the powder in 15 to 30 mL warm water. 3. Crush and then dissolve the powder in 15 to 30 mL warm water.
Match the rationale to the step performed during insertion of an NG feeding tube. 1. Inject 10 mL of water from 30-mL or larger syringe into the feeding tube 2. Dip tube with surface lubricant into a glass of water 3. Measure distance from tip of nose to earlobe to xyphoid process of sternum and mark tube with tape or indelible ink 4. Have patient flex head toward chest after tube has passed through nasopharynx 5. Have patient mouth breathe and swallow. Give small sips of water or ice chips when possible. Advance tube as patient swallows. Rotate tube 180 degrees while inserting
1. Ensures tube patency and aids in guide wire or stylet insertion. 2. Activates lubricant to facilitate passage of tube into GI tract. 3. Determines approximate depth of insertion. 4. Closes off glottis and reduces risk of tube entering trachea. 5. Facilitates passage of tube past oropharynx; rotation decreases friction.
Match the correct image of the type of feeding tube to the patient situation 1. jejunostomy tube - 2. gastrostomy tube - 3. Nasogastric tube -
1. High risk of aspiration because of a neuromuscular disorder 2. Long-term therapy because of cerebral vascular accident and impaired swallowing 3. Short-term management of an acute illness (e.g., sepsis)
Sequence the procedure for verifying feeding tube placement.
1. Perform hand hygiene. Apply clean gloves. Draw up 30 mL of air into syringe, then attach to end of feeding tube. Flush tube with 30 mL of air. 2. Draw back on syringe and obtain 5 to 10 mL of gastric aspirate. Observe appearance of aspirate. 3. Measure pH of aspirate. Compare the color of the strip with the color on the chart provided by the manufacturer. 4. Discard used supplies, remove gloves and discard, and perform hand hygiene.
The use of proper body mechanics involves....
1. bending at the knees instead of the waist to pick items up off of the floor 2. using the large muscles of the legs instead of the back to lift 2. keeping the patient close to your body and the bed at a comfortable working height to avoid leaning or stretching while caring for the patient 3. keeping your center of gravity over a wide base of support (your feet) during strenuous activities 4. when turning, avoid twisting and instead move your entire body in the direction you wish to face
Falling can be done safely...
1. by placing your arms underneath the patient's axillae and then 2. placing one leg forward and allowing her to use it for support as you ease her to the floor. 3. bending at the knees as you help the patient to the floor.
When performing passive range-of-motion exercises...
1. cradle the patient's joint to support it both above and below. 2. put each joint being exercised through as full a range of motion as possible, starting with the neck and moving down to the lower extremities 3. if the patient reports pain or discomfort at any time, stop the exercise.
When patients are immobile because of surgery, injury, or illness, all of these systems are affected, putting them at risk for developing complications, such as:
1. decreased muscle strength 2. deep vein thrombosis, and 3. paralytic ileus.
Begin the ambulation process by...
1. having patients sit up in bed for a few minutes. 2. if they tolerate sitting up, have them dangle their legs at the side of the bed. 3. if they tolerate dangling, help them to a standing position at the side of the bed 4. if they tolerate standing, the next step is ambulation.
Passive range-of-motion exercises involve what? On who are these exercises performed?
1. moving each joint through its complete range of motion. 2. these exercises are performed so that patients who are completely immobilized can retain as much joint range of motion as possible. Because muscles do not contract during passive range-of-motion exercises, muscle strength is neither maintained nor increased.
To move the patient up in bed...
1. place a draw sheet under the patient, extending from the shoulders to the thighs. 2. place a pillow between the patient's head and the top of the bed to keep the patient's head from hitting the bed's headboard. 3. roll the draw sheet close to the patient and then grasp the sheet at the shoulders and hips (with one person at each side of the bed). 4.using appropriate body mechanics, move the patient up in bed.
When educating patient's on how to wear stockings:
1. tell them not to roll the top of the stockings down or to pull the toe openings back over the foot since either can impede circulation. 2. make sure they avoid placing the SCD's tubing and connection sites underneath the leg, since this can increase the risk of pressure ulcers and of device malfunction.
For elastic stockings and sequential compression devices to be effective, they must fit properly. If they are too large, ___(1)____. If they are too small, ___(2)__.
1. the patient's lower extremities will not be supported properly and too little compression will be applied 2. they can impair circulation in the lower extremities, resulting in injur
The proper needle length when giving an intramuscular injection in the ventrogluteal area to an average-sized adult is ... ?
1.5 inches in ventrogluteal area
Normal vital signs for 20 yo adult
118/76, 97.4ºF, 60, 14, 99%
Acceptable Ranges for Adults Respirations:
12 to 20 breaths per minute
A patient has an irregular, thready pulse. You decide to have a nursing assistant help you obtain the pulse deficit. You auscultate the apical pulse while the NAP measures the radial pulse simultaneously. The results are: apical pulse 88, radial pulse 74. The pulse deficit is...
14
A pt. is to receive 12.5 mg of prednisone (Deltasone) by mouth daily. The medication is available in 5 mg tablets. How many tablets should the nurse administer for each dose?
2.5 tablets 12.5 mg/5 mg=2.5
A patient drinks 8oz of water. Which of the following is a correct conversion of the patient's intake?
240 ml
Acceptable Ranges for Adults Pulse:
60 to 100 beats per minute
For patients who wear elastic stockings or sequential compression devices, it is important to remove them at least every ____, or according to your facility's policy, and to assess skin condition and circulatory status.
8 hours
Hypotension occurs when the systolic BP falls to
90 mm Hg or below
Normal vital signs for 1 yo infant
95/65, 98.6ºF, 120, 30, 99%
A 15-year-old male patient is hypothermic. Which temperature reflects hypothermia?
95° F (35°C)
A patient was brought to the emergency department following a motor vehicle accident. He appears drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg. What would the nurse expect his vital signs to be?
97.8°F (36.5°C), 110, 24, 80/40
The nurses are discussing feeding tube migration and prevention. Which of the following statements indicates correct understanding?
A feeding tube can enter the airway without causing obvious respiratory symptoms.
Which of he following patients is exhibiting drug tolerance?
A patient requires an increased dose of a medication to achieve continued therapeutic benefit.
Which of the following patients may benefit from enteral nutrition? (Select all that apply.)
A patient who has a brain injury A patient with oral cancer A patient with burns of the lower extremities
The mother of a 10-year-old child calls the doctor's office stating that she just administered ear drops to her child and the child is crying, stating that the ear hurts worse than it did before the ear drops were applied. What should you tell the mother? A. "Bring your child to the doctor's office. It is possible the eardrum may have ruptured." B. "The eardrum is very sensitive; I'm sure the pain will go away once the drops have been absorbed." C. "This is an expected response after the instillation of ear drops. Place some cotton in the ear for comfort." D. "You may give your child some tylenol for the pain. The ear drops were probably too cold."
A) "Bring your child to the doctor's office. It is possible the eardrum may have ruptured."
The nurse is instructing the patient on how to insert a vaginal suppository. Which of the following statements if made by the patient indicate further instruction is needed? (Select all that apply.) A. "I should warm the suppository to body temperature by putting it under warm running water while it is still in the wrapper." B. "I should insert the rounded end of the suppository along the side wall of the vagina approximately 1" or 2.5 cm (approximately to the first knuckle of the index finger)." C. "I should lying down on my back for at least 10 minutes after instillation" D. "I may have a small amount of discharge that is the color of the medication from my vagina" E. "I can wear a perineal pad after administration"
A) "I should warm the suppository to body temperature by putting it under warm running water while it is still in the wrapper." B) "I should insert the rounded end of the suppository along the side wall of the vagina approximately 1" or 2.5 cm (approximately to the first knuckle of the index finger)."
A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? A) "I will turn the continuous pulse oximetry alarms off at night so you can sleep without interruption." B) "I can give you a back massage to help you relax." C) "What kind of nighttime ritual helps you go to sleep?" D) "If the finger clip is bothering you, I can attach a probe to your ear." E) "I will notify the nurse and the two of you can determine whether you need your sleeping medication."
A) "I will turn the continuous pulse oximetry alarms off at night so you can sleep without interruption." The oximeter alarms should remain on for continuous pulse oximetry. Further inquiry may assist the staff in meeting the patient's need for sleep.
A patient has been taking Vancomycin HCl (vancomycin) for an infection. The health care provider has ordered a peak and trough level to be drawn. When should the nurse expect the phlebotomist to draw the patient's blood for the trough level? A) 30 minutes prior to administering the Vancomycin B) 30 minutes after administering the Vancomycin C) 2 hours after administering the Vancomycin D) Exactly half way in-between doses
A) 30 minutes prior to administering the Vancomycin
Which of the following patients is at least risk for a systemic effect of an agent applied topically? A. A patient who is very mobile and receiving a drug in low concentration. B. Had radiation and is receiving topical ointment for the skin burn C. Has ointment reapplied frequently for a skin graft D. Is taking a medication to reduce itching both topically and orally
A) A patient who is very mobile and receiving a drug in low concentration.
Which patient is at high risk for for the pulse oximetry alarm to sound? A) A patient with a continuous pulse oximetry reading of 84%. Correct B) A patient who is receiving oxygen via face mask. C) A patient who has an intermittent pulse oximetry reading of 95% D) A patient with a HR of 64 beats per minute
A) A patient with a continuous pulse oximetry reading of 84%. Correct Continuous pulse oximetry alarms activate if oxygen saturation falls below 85% and/or the probe falls off.
A physician has ordered Morphine (an opioid) and Vistaril (antianxiety medication) to be administered together to produce pain relief for a patient. When smaller doses of each are administered together, the effect is greater than if they were given separately. This effect is an example of: A) A synergistic effect B) Drug tolerance C) Drug Dependence D) An idiosyncratic effect
A) A synergistic effect
You are administering a subcutaneous injection of enoxaprin (Lovenox). Which of the following actions would minimize pain and discomfort for the patient? (Select all that apply.) A. Asking the patient to relax the site chosen for injection. B. Inserting the needle quickly. C. Injecting the medication quickly D. Cleaning the site with an alcohol swab E. Aspirating the syringe prior to medication administration
A) Asking the patient to relax the site chosen for injection. B) Inserting the needle quickly.
The nurse finished administering medications to a patient when she realized she gave the medications to the wrong patient. What should the nurse do first? A. Assess the patient's condition. B. Notify the health care provider C. Report the incident to the supervisor D. File an incident report
A) Assess the patient's condition.
At what temperature should the solution be when ear drops are instilled? A. Body temperature B. Refrigerated C. Very warm (105 F, 40.6 C) D. Any temperature (the ear tolerates temperature variances well)
A) Body temperature
How can you determine a patient's history of allergies? (Select all that apply.) A) By looking at the patient's allergy bracelet B) By looking at the MAR C) By asking the patient D) By looking at the front of the chart E) By administering a dose and monitoring the patient's response
A) By looking at the patient's allergy bracelet B) By looking at the MAR C) By asking the patient D) By looking at the front of the chart
Which of the following are symptoms of the overuse of MDIs? (Select all that apply.) A. Cardiac dysrhythmias B. Itching C. Drowsiness D. Tachycardia E. Restlessness F. Gagging sensation
A) Cardiac dysrhythmias D) Tachycardia E) Restlessness
You have the medication administration record, the ampule of medication, alcohol swabs, and a medication label. Identify the remaining equipment needed to deliver 0.6 mL of medication IM from an ampule: (Select all that apply.) A. Filter needle B. Diluent C. 25-27- gauge needle D. Disposable gloves E. 21- to 25-gauge needle F. 5/8-1" length needle G. 1 - 1.5" length needle H. 1-mL syringe
A) Filter needle D) Disposable gloves E) 21- to 25-gauge needle G) 1 - 1.5" length needle H) 1-mL syringe
The nurse is caring for a 76-year-old patient being treated for depression, elevated cholesterol levels, and renal failure. She is placed on a new medication to lower her cholesterol as well as a low-fat diet. She takes nine different medications in the morning, and she complains that it ruins her appetite. Her personal habits include taking over-the-counter sleep aids, taking herbal remedies, and smoking a pack of cigarettes per day. Which eight of the following are factors that place this patient at an increased risk for experiencing an adverse drug reaction? (Select all that apply.) A) Her gender B) Her age C) Having a diagnosis of depression D) Being on a low fat diet E) Having a diagnosis of renal failure F) The number of medications she takes G) Her poor appetite H) Taking over-the-counter medications and herbal remedies I) Her smoking habit J) Taking a new medication K) Having a High Cholesterol level
A) Her gender B) Her age C) Having a diagnosis of depression E) Having a diagnosis of renal failure F) The number of medications she takes H) Taking over-the-counter medications and herbal remedies I) Her smoking habit J) Taking a new medication
When withdrawing medication from a vial, why is it important to first inject air into the vial? A. It prevents the buildup of negative pressure in the vial. B. It prevents the buildup of positive pressure in the vial C. It prevents the accumulation of air bubble D. It prevents contamination of the medication
A) It prevents the buildup of negative pressure in the vial.
You have the medication administration record, the vial of dry medication, alcohol swabs, and a medication label. Identify the remaining equipment needed to administer intramuscularly to an average-size adult 1 mL of medication from a vial that requires reconstitution: (Select all that apply.) A. Needle for withdrawing B) Diluent C. 50-or 100-unit syringe D. 1- to 3-mL syringe E. Disposable gloves F. 25- to 27 gauge needle G. 21- to 25-gauge needle H. 3/8" length needle I. 5/8" length needle J. 1 - 1.5" length needle
A) Needle for withdrawing B) Diluent D) 1- to 3-mL syringe E) Disposable gloves G) 21- to 25-gauge needle J) 1 - 1.5" length needle
You have the medication administration record, the vials of medication, alcohol swabs, and a medication label. Identify the remaining equipment needed to deliver a total volume of 1.4 mL IM injection to an average-size adult from two vials: (Select all that apply.) A. Needle for withdrawing B. 50- or 100 unit syringe C. 3-mL syringe D. 25- to 27- gauge needle E. Disposable gloves F. 21- to 25-gauge needle G. 5/8" length needle H. 1 - 1.5" length needle I. 1-3" length needle J. 1-mL syringe
A) Needle for withdrawing C) 3-mL syringe E) Disposable gloves F) 21- to 25-gauge needle H) 1 - 1.5" length needle
You have the medication administration record, the vial of medication, alcohol swabs, and a medication label. Identify the remaining equipment needed to deliver 0.5 mL of medication subcutaneously from a liquid vial: (Select all that apply.) A. Needle for withdrawing B. Diluent C. 50- or 100- unit syringe D. 25- to 27-gauge needle E. Disposable gloves F. 21- to 25- gauge needle G. 3/8" length needle H. 3/8 - 5/8" length needle I. 1-1.5" length needle J. 1-mL syringe
A) Needle for withdrawing D) 25- to 27-gauge needle E) Disposable gloves H) 3/8 - 5/8" length needle J) 1-mL syringe
The nurse is inserting an NG feeding tube. Which step in the procedure is inaccurate, indicating further instruction is needed?
A) Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water.
You are to administer a tablet from a stock bottle. How should you get the tablet from the bottle into the cup? A) Pour the required number into the bottle cap and transfer them to the medication cup. B) Pour the required number into a gloved hand and transfer them to the medication cup. C) Pour the required number into the medication cup with the other medications. D) Shake the tablets toward the top of the bottle and reach in and obtain the required number. Place them in the medication cup. E) Pour the required number with the label against the palm of the hand into the medication cup.
A) Pour the required number into the bottle cap and transfer them to the medication cup.
You are planning to teach a patient about using an MDI without a spacer device. What are some points you should include in the teaching plan? (Select all that apply.) A) Show the patient how the canister fits into the inhaler. B) Warn the patient about overuse of the inhaler, including drug side effects. C) Instruct the patient to wait 1 minute between puffs. D) Instruct the patient how to time inhalation with the depression of the medication canister. E) Instruct the patient to inhale through pursed lips. F) Instruct the patient to shake the canister before administration. G) Instruct the patient to clean the canister daily in warm water.
A) Show the patient how the canister fits into the inhaler. B) Warn the patient about overuse of the inhaler, including drug side effects. D) Instruct the patient how to time inhalation with the depression of the medication canister. F) Instruct the patient to shake the canister before administration.
Which of the following actions by the nurse help reduce the risk of aspiration?
A) The nurse elevates the head of the bed
When should the patient depress the canister when using an MDI? A. The patient should depress the canister simultaneously with slow inhalation. B. The patient should exhale, depress the canister, and then inhale. C. The patient should inhale, then depress the canister, and hold the breath for 10 seconds. D. The patient should hold the breath to maximize lung expansion, exhale, depress the canister, and then inhale.
A) The patient should depress the canister simultaneously with slow inhalation.
Which of the following are situations that may contraindicate medication administration by the oral route? (Select all that apply.) A) The patient who is confused and unwilling to cooperate B) The patient that has taste alteration C) The patient who has a nasogastric tube connected to wall suction D) The patient who is NPO E) The patient who is unable to sit upright F) An unconscious patient
A) The patient who is confused and unwilling to cooperate C) The patient who has a nasogastric tube connected to wall suction D) The patient who is NPO F) An unconscious patient
You are going to instill ear drops in a 7-year-old child. In which direction should you pull the pinna of the ear? A. Up and back B. Down and back C. Up and forward D. Down and forward
A) Up and back
The correct dosage is measured on a syringe: A. Where the head of the plunger touches the sides of the barrel of the syringe B. Where the medication touches the point of the plunger C. Where the bottom end of the head of the plunger attaches to the remained of the plunger D. Anywhere on the head of the plunger
A) Where the head of the plunger touches the sides of the barrel of the syringe
You don clean gloves and measure the antianginal ointment onto dosage paper according to physician's orders. You rub the ointment off the paper directly onto the female patient's skin of the anterior chest and cover the area of ointment with plastic wrap and tape. You discard the gloves and perform hand hygiene. Which steps of the procedure were incorrect and/or missing? (Select all that apply.) A. You did not remove the previous dosage paper. B. You rubbed the ointment off the paper. C. You did not write the date, time, and initials on the paper wrapper. D. You wore nonsterile gloves. E. You applied the ointment to the anterior chest wall
A) You did not remove the previous dosage paper. B) You rubbed the ointment off the paper. C) You did not write the date, time, and initials on the paper wrapper.
Which of the following pH test results on the aspirate of a patient who receives intermittent feedings indicates that the feeding tube is in the stomach?
A) pH of 1 to 4
When should placement of a feeding tube be verified? (Select all that apply.)
A, B, C, D
Which of the following are accurate statements related to the use of water and administering medication through a feeding tube? (Select all that apply.)
A, C, E, F
The nurse administers a sublingual tablet and instructs the patient to avoid swallowing the tablet but, rather, allow it to dissolve. The patient asks why. The nurse's best response is: A. "It is designed to be absorbed through the vessels of the undersurface of the tongue, and if it is swallowed, the medication will be destroyed by the gastric juices." B. "It will work quicker this way than waiting until it is digested." C. "It is a safer method of taking the medication because it dissolves rapidly under your tongue and bypasses the liver so the drug won't become toxic." D. "It will cause gastric irritation and may upset your stomach if it is swallowed."
A. "It is designed to be absorbed through the vessels of the undersurface of the tongue, and if it is swallowed, the medication will be destroyed by the gastric juices.
Which of the following patients are at risk for developing drug toxicity? (Select all that apply) A. 65-year-old male, who has been on high doses of antibiotics for 3 weeks B. 75-year-old female, who swallowed caladryl lotion C. 82-year-old male, who has renal disease D. 16-year-old female, who has had vomiting and diarrhea E. 43-year-old male, who has live failure.
A. 65-year-old male, who has been on high doses of antibiotics for 3 weeks B. 75-year-old female, who swallowed caladryl lotion C. 82-year-old male, who has renal disease E. 43-year-old male, who has live failure.
What is the best way for nurses to prevent medication errors? A. Adhere to the 6 rights of medication administration B. Avoid distractions and take time to prepare medications C. Only give medications to patients who are alert and oriented D. Use an automated medication dispensing system
A. Adhere to the 6 rights of medication administration
Which medication administration activity can be delegated to nursing assistive personnel (NAP)? A. Application of a skin barrier cream to the perineal area B. Application of a transdermal patch C. Instillation of eye drops D. Instillation of ear drops E. Use of MDIs F. Inserting vaginal medications G. Inserting rectal medications
A. Application of a skin barrier cream to the perineal area
If the patient refuses a medication, what should the nurse do? (Select all that apply) A. Document the reason for refusal in the nurses' notes. B. Notify the health care provider within 24 hours C. Determine the reason for refusal D. Wait and administer dose at time next dose is due. E. Hide it in their food
A. Document the reason for refusal in the nurses' notes. B. Notify the health care provider within 24 hours C. Determine the reason for refusal
What is the primary danger associated with occluding the ear canal with the ear dropper during the administration of ear drops? A. It can create too much pressure within the canal with subsequent injury to the eardrum B. It will break the sterility of the medicine dropper C. It will impair the patient's ability to hear D. The nurse will not be able to accurately determine the number of drops that are being administered.
A. It can create too much pressure within the canal with subsequent injury to the eardrum
The health care provider has ordered milk of magnesia 30 ml PO now, How many ounces would this be? A. One ounce B. Six ounces C. Three ounces D. Half an ounce
A. One ounce
Which are correct regarding administration of a rectal suppository for relief of constipation? A. Place patient in left Sims' position. B. Place patient in right Sims' position. C. Insert the blunt end first. D. Insert the rounded end first. E. Avoid using water soluble lubricant. F. Insert the suppository past the internal sphincter.
A. Place patient in left Sims' position. D. Insert the rounded end first. F. Insert the suppository past the internal sphincter.
The patient is to receive 120 mg of IV lasix (furosemide) . You calculate that this will be 12 ml (10 mg/ml). The drug book states that the usual dosage is 20 to 40 mg. What steps should the nurse take to avoid medication errors in this situation? (Select all that apply) A. Question unusually large or small doses B. Be sure to read labels at least two times to make sure the medication is correct C. Double-check all calculations. D. Use at least two patient identifiers whenever administering a medication E. Only administer 4 ml (40 mg)
A. Question unusually large or small doses C. Double-check all calculations.
What position should the patient assume for insertion of a rectal suppository? A. Sims' B. Dorsal Recumbent C. Left side-lying with head flat D. Right side-lying with head flat
A. Sims' -The patient should be assisted to a left side-lying Sims' position with the upper leg flexed upward. This position exposes the anus and helps the patient to relax the external anal sphincter. The left side lessens the likelihood of the suppository and/or feces being expelled.
Why is it important to hold a transdermal patch by the edge after it is removed from its protective covering? (Select all that apply.) A. So the medication dosage will remain unchanged B. So you do not absorb the medication into your system C. So the patch will adhere well to the patient's skin D. To activate the medication for a therapeutic effect E. So the patch will remain sterile.
A. So the medication dosage will remain unchanged C. So the patch will adhere well to the patient's skin
The NAP reports the patient is complaining of dizziness and nausea after the administration of ear drops. What is the most likely cause of the dizziness? A. The medication was too cold B. Cerumen or drainage is occluding the ear canal. C. Too much pressure was applied during instillation with subsequent injury to the eardrum. D. The patient failed to remain in the side-lying position long enough.
A. The medication was too cold when it was administered.
The nurse is going to administer eye ointment in the newborn's eyes. Which action by the nurse is the correct procedure? A. The nurse applies a ribbon of ointment along the lower eyelid on the conjunctiva from inner to outer canthus. B. The nurse applies the ointment using a sterile cotton-tipped applicator to the lower conjunctival sac. C. The nurse applies gentle pressure to the nasolacrimal duct after administering the ointment D. The nurse applies a ribbon of ointment to the lower eyelid and then stimulates the baby to open its eyes.
A. The nurse applies a ribbon of ointment along the lower eyelid on the conjunctiva from inner to outer canthus.
The nurse is administering eye drops. The nurse: Performs hand hygiene applies the 6 rights of medication administration uses two identifiers to check the patient's identification asks the patient to lie supine with the neck slightly hyperextended applies clean gloves holds a clean tissue in the nondominant hand on the patient's cheekbone just below the lower eyelid and gently presses downward with the forefinger against the bony orbit, exposing the conjunctival sac asks the patient to look at the ceiling resting the dominant hand gently on the patient's forehead, the nurse holds the filled medication eye dropper approximately 1 to 2 cm (one half to three quarters of an inch) above the conjunctival sac administers the prescribed number of medication drops into the conjunctival sac gently applies pressure to the patient's nasolacrimal duct with a cotton ball or tissue for 30 to 60 seconds asks the patient to close the eyes gently discards the gloves, performs hand hygiene and documents the procedure. Which actions, if any, require further teaching? A. The nurse performed the procedure correctly. B. Positioning of the patient. C. Resting the dominant hand on the patient's forehead. D. The type of gloves the nurse used.
A. The nurse performed the procedure correctly.
Which are typical symptoms of a vaginal yeast (Candida) infection? A. Thick, white, curdlike discharge B. Bright pink and/or inflamed vaginal walls C. Abdominal discomfort D. Fever E. Nausea
A. Thick, white, curdlike discharge B. Bright pink and/or inflamed vaginal walls
Which would be a contraindication for inserting a rectal suppository? A. rectal bleeding B. hemorrhoids C. diarrhea D. constipation E. recent rectal surgery
A. rectal bleeding C. diarrhea E. recent rectal surgery
Active range-of-motion exercises involve what? Who performs these?
Active range-of-motion exercises are those the patient performs, with a nurse or a physical therapist supervising to ensure that the patient is doing them correctly. They involve moving each joint through its complete range of motion. These exercises maintain and increase muscle strength and help keep joint problems and contractures from developing.
Which of the following demonstrates the correct use of one of the six rights of medication administration?
Administering a patient's medication by the route the provider has prescribed
Which of the following should the nurse report to the healthcare provider?
Adult pt with a HR of 55
The nurse observes a confused patient pulling at her NG feeding tube. As the nurse retapes the tube to the bridge of the patient's nose, the nurse notices that the mark on the tube has moved away from the naris. What action should the nurse take?
Advance the tube until the mark is even with the naris and verify correct tube placement.
The nurse is reading the health care provider's orders to increase the rate of the patient's NG feeding. Which of the following orders should the nurse question?
Advance tube feeding rate by 100 mL/hr every 8 to 12 hours to target rate of 250 mL/hr over 12 hours.
Factor that may affect vital signs: postural changes
Affects: pulse, blood pressure, oxygen saturation
Factor that may affect vital signs: emotions
Affects: pulse, respiration, blood pressure
Factor that may affect vital signs: acute pain
Affects: pulse, respiration, blood pressure, oxygen saturation
Factor that may affect vital signs: odors
Affects: pulse, respiration, oxygen saturation
Factor that may affect vital signs: time of day
Affects: temperature, blood pressure
Factor that may affect vital signs: food/liquid consumption
Affects: temperature, pulse
Factor that may affect vital signs: temperature alterations/weather conditions
Affects: temperature, pulse, respiration and oxygen saturation
Factor that may affect vital signs: Stress (emotional and physical)
Affects: temperature, pulse, respiration, blood pressure, oxygen saturation
Factor that may affect vital signs: disease/injury status
Affects: temperature, pulse, respiration, blood pressure, oxygen saturation
Factor that may affect vital signs: exercise/activity
Affects: temperature, pulse, respiration, blood pressure, oxygen saturation
Factor that may affect vital signs: fluid and electrolyte status
Affects: temperature, pulse, respiration, blood pressure, oxygen saturation
Factor that may affect vital signs: medication
Affects: temperature, pulse, respiration, blood pressure, oxygen saturation
Factor that may affect vital signs: smoking
Affects: temperature, pulse, respiration, blood pressure, oxygen saturation
Factors that influence pulse rate and rhythm
Age Exercise Fluid balance Medications Temperature Sympathetic stimulation
Pulse site: carotid
Along medial edge of sternocleidomastoid muscle in neck -Easily accessible site used during physiologic shock or cardiac arrest when other sites are not palpable
Pulse site: dorsalis pedis
Along top of foot between extension tendons of great and first toe -Site used to assess status of circulation to foot
Why is ambulation important?
Ambulation not only maintains muscle tone, muscle strength, and joint flexibility, but it also stimulates the respiratory, circulatory, and gastrointestinal systems to help each one function properly.
Which of the following represents the correct administration of the prescribed medication?
Amoxicillin 1g PO; two 500mg tabs given
Who would the nurse expect to have the highest body temperature reading?
An adult female who is walking.
An uncommon, unexpected, or individual drug response thought to result from a genetic predisposition is called
An idiosyncratic effect
The patient is concerned that he may have systemic effects from a medication given by the non-parenteral route. Which of the following statements would be the best response by the nurse? A. "You should't worry; the health care provider wouldn't prescribe it if it wasn't safe. I will monitor you closely for any possible adverse effects." B. "Even though medications are absorbed more slowly through the skin, it is possible to have systemic effects if the drug concentrations are high." C. "As long as we give the medication in the form of eye drops, you will not have an systemic effects." D. "It really doesn't matter which route the medication is given; all medications have the same systemic effect, just at varying rates."
B) "Even though medications are absorbed more slowly through the skin, it is possible to have systemic effects if the drug concentrations are high."
At what angle should a subcutaneous injection be delivered in a normal-size adult? A. 45 degree B. 45- to 90- degrees C. 15 degree
B) 45- to 90- degrees
Which of the following may be delegated to NAP?
B) Administering a tube feeding
A patient has an order to receive nystatin oral suspension PC. When will you administer this medication? A) Before meals B) After meals C) At bedtime D) As requested by the patient
B) After meals
An alert patient has refused to take her prescribed medications, stating, "The medication isn't doing me any good!" What should you do? A) Crush the patient's medications and disguise them in some of the patient's food B) Assess further as to why the patient feels this way and notify the physician of the patient's refusal. C. Instruct the patient that the health care provider may refuse to treat her if she is noncompliant D. Leave the medications at the patient's bedside in case she changes her mind
B) Assess further as to why the patient feels this way and notify the physician of the patient's refusal.
A patient has a nasogastric feeding tube. The nurse is aware of the need to monitor the patient for potential complications. Which of the following symptoms, if demonstrated by the patient, would potentially indicate the greatest risk related to tube feedings?
B) Dyspnea
When should you document medication administration? A. When the medication is in the medication cup B. Immediately after the medication is given C. Before the next scheduled dose D. Before the end of the shift
B) Immediately after the medication is given
Why do you use a filter needle to withdraw medication from an ampule? A. It maintains sterility of the needle B. It prevents entry of glass into the syringe. C. It prevents dueling of the needle D. It maintains the safety of the needle
B) It prevents entry of glass into the syringe.
You have the medication administration record, the vial of medication, and alcohol swabs. Identify the remaining equipment needed to deliver 0.3 mL of medication subcutaneously from a liquid vial to an average-size adult: (Select all that apply.) A. Filter needle B. Needle for withdrawing C. 50- or100- unit syringe D. 25- to 27-gauge needle E. Disposable gloves F. 3 mL syringe G. 21- to 25- gauge needle H. 3/8 inch needle I. 5/8 inch needle J. 1 to 1.5 inch needle K. 1-mL syringe
B) Needle for withdrawing D) 25- to 27-gauge needle E) Disposable gloves I) 5/8 inch needle K) 1-mL syringe
You have just completed giving a patient her injection and are turning to deposit the syringe and uncovered needle into the sharps container. Suddenly her daughter runs between you and the sharps container. You stick the child with the needle. What should you do? A. Tell the mother and child it is okay and continue disposing of thee syringe B. Notify your supervisor, who will be responsible for walking the mother and child through your clinic's needle-stick procedure. C. Direct the mother and child local county health department D. Cover the needle-stick site with a band-aid to calm the child and do nothing further since this is the patient's blood relative
B) Notify your supervisor, who will be responsible for walking the mother and child through your clinic's needle-stick procedure.
The NAP tells you that the patient's pulse oximetry is 85% on room air. What nursing action(s) should you take? (Select all that apply.) A) Start oxygen at 2 liters per minute by nasal cannula B) Reassess pulse oximetry C) Place the patient in the high-Fowler's position D) Have the NAP take the patient's vital signs E) Assess the patient's respiratory and cardiac status
B) Reassess pulse oximetry C) Place the patient in the high-Fowler's position E) Assess the patient's respiratory and cardiac status The first action you should take is to reassess the patient's pulse oximetry, making sure the probe is intact and correctly positioned. You may place the patient in the high-Fowler's position to promote optimal ventilation. Observe the patient for signs of decreased oxygenation such as anxiety, restlessness, tachycardia, etc. Assess the patient's complete respiratory status (i.e., auscultate lung sounds). Assess the patient for signs of altered cardiac output (cool skin, decreased blood pressure, etc.). If the patient is unstable, you should assess the patient's vital signs rather than delegating this task to NAP. You may prepare to initiate oxygen therapy, but a physician's order is required for implementation. If the patient's pulse oximetry remains below acceptable parameters, obtain additional assessment data (i.e., vital signs, cardiopulmonary assessment) and notify the physician. The physician will determine whether arterial blood gases are necessary.
The following medications are to be administered. Which patient receives medication the most often? A) Receives a sedative at bedtime B) Receives antibiotics q4h. C) Receives an iron supplement AC. D) Receives an antihypertensive bid. E) Receives cardiac medication qid.
B) Receives antibiotics q4h.
You attempt to aspirate gastric contents from an established NG feeding tube and get zero return. What should you do next?
B) Reposition the patient
A nurse is administering daily medications when a patient states, "I never took a little yellow pill before." What is the nurse's best action? A) Inform the patient that it is probably because the facility uses a different brand of medication than what he takes at home B) Stop and recheck the medication that is correct according to the health care provider's order C) Reassure the patient that these are the medications his health care provider prescribed D) Return the unopened unit dose and document that the patient refused the medication
B) Stop and recheck the medication that is correct according to the health care provider's order
______________ pressure is the peak pressure that occurs during contraction of the heart's ventricles.
Systolic
Which of the following patients should you observe the closest for a toxic effect? A) The patient who has a history of urticaria, pruritus and wheezing after taking an antibiotic B) The patient who has liver and kidney problems and takes high doses of aspirin to relieve her pain C) The patient that appears more agitated after receiving a sleep aid D) The patient that experiences constipation and nausea while taking pain medication
B) The patient who has liver and kidney problems and takes high doses of aspirin to relieve her pain
After giving a subcutaneous injection, you refrain from massaging the site so as to prevent: A. Seepage of medication into subcutaneous tissue B. Tissue damage C. Nerve injury D. Bleb formation
B) Tissue damage
The physician has ordered an antibiotic to be given three times in a 24-hour period. Which would be the best dosing schedule for this medication in order to maintain a therapeutic blood level? A) tid B) q8h C) ac D) qid
B) q8h
The nurse is inserting an NG feeding tube. Which of the following supplies will the nurse need to perform the procedure? (Select all that apply.)
B, C, D, E, F, H
A patient is on a fluid restriction. When giving oral medications, which of the following considerations are needed? A. Use a commercial liquid thickener. B. Allow the patient to take medications with a small amount of water and document the amount on the patient's record. C. Allow the patient to take medications with water. The amount consumed does not affect fluid restriction D. Avoid giving the patient any liquid. Crush the medications and offer them in applesauce.
B. Allow the patient to take medications with a small amount of water and document the amount on the patient's record.
What can you do to help the patient relax the anal sphincter before administering a rectal suppository? A. Instruct the patient to perform pursed-lip breathing B. Ask the patient to take slow, deep breaths through the mouth. C. Have the patient alternately contract and relax the abdominal muscles D. Instruct the patient to perform the Valsalva maneuver
B. Ask the patient to take slow, deep breaths through the mouth.
What should the nurse do to maximize the effectiveness of medicated lotions and/or ointment? A. Apply a thick, even layer B. First wash area with nondrying soap and water C. Apply the dose paper over a non-hairy area of the lower arm D. Massage the ointment into the skin
B. First wash area with nondrying soap and water
Which of the following are contraindications to oral medication administration? A. confusion B. Inability to swallow C. Nausea and vomiting D. Postop for gastrointestinal surgery E. Continuous gastric suction F. Fluid restriction
B. Inability to swallow C. Nausea and vomiting D. Postop for gastrointestinal surgery E. Continuous gastric suction
The patient is to receive Nitrodisc (nitroglycerin) 0.4 mg/h topically. The nurse has been teaching the patient about the medication. Which is accurate information to review with the patient? A. To obtain a therapeutic level nitroglycerin is usually administered simultaneously in oral form and topically. B. It is recommended that nitroglycerin transdermal patches be removed after 10 to 12 hours to allow for a nitrate-free interval. C. There is little risk of overdose with nitroglycerin as the medication's effect expires as it is absorbed into the body. D. It is important to keep the Nitrodisc (nitroglycerine) in the same area of the chest; remove the old patch and place the new patch in the same place.
B. It is recommended that nitroglycerin transdermal patches be removed after 10 to 12 hours to allow for a nitrate-free interval.
A patient is being admitted to the hospital to receive Intravenous (IV) antibiotics. What type of medication administration is an IV antibiotic? A. Enteral B. Parenteral C. Nonparenteral D. Topical
B. Parenteral
How far should you insert a rectal suppository in an adult? (Select all that apply.) A. Just past the external anal sphincter B. Past the internal anal sphincter C. Approximately 4 inches D. Approximately 7.5 cm (3 inches) E. Approximately 3.75 cm to 5 cm (1.5 to 2 inches).
B. Past the internal anal sphincter C. Approximately 4 inches
Instructions: Match the unexpected outcome with the related intervention. A. Hold feeding, notify physician, maintain patient in semi-Fowler's position, and recheck in 1 hour. B. Turn off tube feeding, place in Fowler's position, suction, and notify physician. C. Reposition patient, attempt to flush with large-bore syringe and warm water; if able to flush and absence of residual, determine the patient's risk of dislodgment—if risk is low and the tube has remained taped in original position, start next feeding. D. Notify physician and confer with dietitian to determine need to modify type of formula, concentration, or rate of infusion. E. Withhold tube feeding and notify physician. Be sure tubing is patent; aspirate for residual.
B. Patient aspirates formula. C. Unable to aspirate gastric contents D. Patient develops diarrhea. A. Gastric residual exceeds 200 mL. E. Patient develops nausea and vomiting.
Match the type of feeding with the patient condition: A. Parenteral nutrition B. PEG tube C. NG feeding tube
B. Patient with difficulty swallowing after having a CVA and will need long-term nutritional support. C. Patient with difficulty swallowing after having a CVA and will need long-term nutritional support. A. Patient with malabsorption syndrome.
VS for 84-year-old female
T-96.8° F, (36°C), P-98, R-12, BP 120/80
The hospice nurse comes to the home of a patient with terminal cancer. She discovers several fentanyl (duragesic) pain patches on the patient's body. What should the nurse do first? A. Notify the health care provider the patient is not getting sufficient pain relief. B. Remove the patches except for the most recent and provide patient teaching C. Have the patient remove one pain patch every hour until they are all removed D. Assess the patient's level of pain and skin for any irritation
B. Remove the patches except for the most recent and provide patient teaching
You are instilling eye drops into a patient's eye. You check the patient's identification. You perform hand hygiene and apply gloves. You follow the 6 rights of medication administration. You ask the patient to tilt the head back and look up. You hold the patient's eye open by pushing up on the skin of the upper orbit, and with your free hand, instill the drops of medication onto the patient's cornea at a distance of 1 to 2 inches. You apply gentle pressure to the lacrimal duct and ask the patient to close the eyes gently. You discard the gloves and perform hand hygiene, and you then document the procedure. What actions by you, if any, were incorrect? (Select all that apply.) A. The nurse performed the procedure correctly B. The method you used to hold the patient's eye open. C. You used your free hand to instill the drops at a distance of 1 to 2 inches. D. You applied the eye drops onto the patient's cornea. E. Applying pressure to the lacrimal duct F. The nurse asked the patient to close the eyes gently
B. The method you used to hold the patient's eye open. C. You used your free hand to instill the drops at a distance of 1 to 2 inches. D. You applied the eye drops onto the patient's cornea.
If a health care provider's handwriting is difficult to read and as a result the nurse administers a wrong medication or incorrect dosage, who is legally responsible for the error? A. The health care provider B. The nurse who gave the medication C. The pharmacist who filled the medication order D. The hospital
B. The nurse who gave the medication
The nurse is administering eye medication. Which nursing action requires further intervention by the nurse? (Select all that apply) A. The nurse cleans the eye from inner to outer canthus with warm water and a clean wash cloth B. The patient blinks and the eye drop falls on the outer lid after instillation C. The nurse applies gentle pressure to the patient's nasolacrimal duct for 30-60 seconds D. The nurse rests the dominant hand on the patient's forehead and uses this hand to administer the eye drops E. The nurse applies the ointment alone the inner edge of the lower eyelid from the outer to inner canthus
B. The patient blinks and the eye drop falls on the outer lid after instillation E. The nurse applies the ointment alone the inner edge of the lower eyelid from the outer to inner canthus
The patient's wife is watching as the nurse prepares to insert a small bore feeding tube. She asks the nurse, "What is the purpose of the guide wire?" The nurse correctly responds:
Because feeding tubes are flexible, a guide wire or stylet is used to provide rigidity that facilitates positioning.
Identify the appropriate times to verify enteral tube placement by pH testing. (Select all that apply.)
Before each intermittent feeding At least once every 6 hours during continuous feedings Before administration of medications through the tube
Pulse site: popliteal
Behind knee in popliteal fossa -Site used to auscultate lower extremity BP -Site used to assess status of circulation to lower leg
Pulse site: femoral
Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine -Site used to assess pulse during physiologic shock/cardiac arrest when other pulses are not palpable -Used to assess status of circulation to leg
The nurse decides to collect the patient's temperature orally using an electronic thermometer. Choose the equipment to be used.
Blue probe electronic thermometer, thermometer cover, pt's data recording sheet and a pen
__________ __________ is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment.
Body temperature
VS for 1-day-old newborn
T-97.4° F, (36.3°C), P-144, R-58, BP 40
A nursing instructor is reviewing with you measures used to prevent medication errors. Which of the following statements indicate a correct understanding of steps used to prevent medication errors? A. "I will check the label once against the eMAR as I remove the medication from the container." B. "I will ask the patient if he or she has the name that I will read off of the eMAR." C. "I will shut the door of the medication room when I am preparing medications." D. "I will have the pharmacist calculate all drug dosages." E. "I will do my best to interpret illegible handwriting to administer the medication on time and then clarify the order the next time the health care provider makes rounds."
C) "I will shut the door of the medication room when I am preparing medications."
A 65-year-old, 61-kg patient, is ready for her annual flu vaccine that is delivered intramuscularly. What size needle would you use to administer this IM injection in the deltoid muscle of this patient? A. 25- gauge 3/8 inch needle B. 25- gauge 5/8 inch needle C. 25-gauge 1" needle
C) 25-gauge 1" needle
For which of the following patients would a transdermal patch be the preferred type of medication administration? A. A patient who requires a reliable absorption rate so that lower drug dosages can be used. B. A patient who has multiple allergies, including latex and adhesives. C. A patient with liver disease. D. A patient who cannot tolerate any type of systemic effect of the drug.
C) A patient with liver disease.
The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best nursing action at this time? A) Request the NAP obtain the patient's pulse oximetry and report the reading to the nurse. B) Ask the NAP to obtain a full set of vital signs C) Assess the patient yourself, including the pulse oximetry reading D) Notify the health care provider
C) Assess the patient yourself, including the pulse oximetry reading The nurse should assess the patient. NAP can obtain a pulse oximetry reading if the patient is stable and after the NAP's skill with the oximeter is validated.
You are preparing an IM injection from a liquid vial. You have selected a 25-gauge, 1.5-inch needle, but you are experiencing great difficulty withdrawing the fluid from the vial. You notice as you tip the vial up that the solution is very thick. What should you do? A. Add diluent to the vial so the solution is easier to withdraw C. Change needles and use a 21-gauge, 1.5-inch needle. B. Add more air to the vial D. Change needles and use a 27-gauge, 1.5-inch needle
C) Change needles and use a 21-gauge, 1.5-inch needle.
You prepare to administer a subcutaneous injection to a normal-size adult on the upper left arm. You choose a needle: A. 7/8 inch in length B. 5/8 inch in length to insert at a 90- degree angle C. Half of the width of the skin fold D. 1 to 1.5 inches in length
C) Half of the width of the skin fold
The patient complains of burning after the administration of a non-parenteral medication. By which route would you most likely expect this response? A. Vaginal route B. Rectal route C. Instillation onto the eye. D. Transdermal patch
C) Instillation onto the eye
You are going to administer eye drops into the eye of a confused elderly patient. What safety precautions should you take? A. Apply restraints while instilling the eye drops B. Wait and administer the eye drops in the corner of the patient's eye when the patient is asleep and then awaken the patient to open their eye C. Rest hand holding the eye dropper on the patient's forehead and hold the eye dropper 1 to 2 cm above the conjunctival sac. D. Apply an eye patch and instruct the patient to avoid rubbing the eye and causing further irritation
C) Rest hand holding the eye dropper on the patient's forehead and hold the eye dropper 1 to 2 cm above the conjunctival sac.
You are reviewing a patient's prescribed medications. The patient states that she quit taking her blood pressure medication because it made her "too weak and tired." What type of medication action was the patient most likely experiencing? A) Idiosyncratic reaction B) Synergistic effect C) Side effect D) Drup dependence
C) Side effect
A nurse understands the importance of providing culturally competent care. Which of the following fails to take possible cultural differences into consideration? A. The nurse asks the African patient for permission before instilling ear drops B. The nurse obtains an orange casing for the inhaler of a latino patient C. When admitting a patient, the nurse asks only about prescribed medications. D. The nurse emphasizes the importance of completing a prescribed regimen
C) When admitting a patient, the nurse asks only about prescribed medications.
You just inserted an NG feeding tube. The physician's order states to administer all meds per tube and a continuous feeding of Isocal at 30 mL per hour. The order also states to check the patient's blood glucose every 6 hours. When can you begin to instill feedings, water, or medications through the feeding tube?
C) When tube placement has been verified by x-ray film
The nurse is teaching the patient how to use an MDI with a spacer device. Which statement, if made by the patient, indicates further teaching is required? A. "I should remove the mouthpiece cover from the inhaler and spacer, insert the MDI into the end of the spacer, and shake the inhaler well for 2 to 5 seconds." B. "I should close my mouth around the mouthpiece of the spacer, depress the medication canister and breathe in slowly and fully for 5 seconds, then hold my breath for approximately 10 seconds." C. "I should wait 20 to 30 seconds between puffs and 2 to 5 minutes between inhalations of different medications. I should administer the inhaled steroids first followed by the bronchodilator." D. "I should rinse my mouth with warm water, then spit the water out after each use of the MDI."
C. "I should wait 20 to 30 seconds between puffs and 2 to 5 minutes between inhalations of different medications. I should administer the inhaled steroids first followed by the bronchodilator."
You have a handwritten medication order that is difficult to read. Which of the following is the most appropriate action to take to avoid an error in medication administration?
Call the medical provider for clarification of the order
VS for 18-year-old female
T-98.6° F, (37°C), P-60, R-16, BP 116/74
A patient states that she has difficulty swallowing pills and asks the nurse to crush them. Which of the following medications would it be okay to crush? A. Enteric coated aspirin B. Cardizem CD (diltiazem) C. A scored tablet of Lanoxin (digoxin) D. Entex LA (guaifenesin)
C. A scored tablet of Lanoxin (digoxin)
The ear canal should be straightened when instilling ear drops to provide direct access to deeper ear structures. In what direction should the auricle be pulled in an infant to straighten the ear canal? A. Upward and outward B. Upward and back C. Downward and back D. Downward and inward
C. Downward and back
What is the purpose of massaging the tragus of the ear after ear drop instillation? A. It keeps the ear from tickling. B. It reduces the perception of pain. C. It helps move the medication inward. D. It prevents escape of the medication when the patient sits or stands.
C. It helps move the medication inward.
The nurse brings the patient's medications but the patient refuses to take them, stating, "I'll take them later. right now my stomach feels a little upset. Could you bring me some crackers?" What is the best action the nurse should take? (Select all that apply) A. Leave the medications at the patient's bedside and check on him later. B. Document the patient is noncompliant in following the medication regimen C. Lock the patient's medications up temporarily and document the incident D. Offer the patient some crackers and see if the patient has any medications that could help relieve the nausea. E. Have the patient take the medications at this scheduled time with a small sip of water.
C. Lock the patient's medications up temporarily and document the incident D. Offer the patient some crackers and see if the patient has any medications that could help relieve the nausea.
The nurse is going to prepare a liquid medication for a patient. Which of the following actions, if made by the nurse, indicates that further instruction is needed in performing this procedure? A. The nurse mixes the liquid B. The nurse discards a medication that has changed color or become cloudy C. The nurse removes the bottle cap and places the cap facing down D. The nurse holds the bottle with the label away from the nurse's hand while pouring E. The nurse places the cup at eye level and fills to the desired level. F. The nurse wipes the lip of the bottle with a paper towel and replaces the cap
C. The nurse removes the bottle cap and places the cap facing down. D. The nurse holds the bottle with the label away from the nurse's hand while pouring.
A patient has been prescribed eye drops for the treatment of glaucoma. The nurse is observing the patient self-administer the eye drops. Which action by the patient requires further teaching? A. The patient cleans the eye from the inner to the outer canthus. B. The patient looks upward toward the ceiling and administers the eye drops in the conjunctival sac. C. The patient touches the conjunctival sac with the eyedropper to make sure she is in the correct location. D. While administering the eye drops, a drop lands on the patient's outer lid so the patient administers another drop.
C. The patient touches the conjunctival sac with the eyedropper to make sure she is in the correct location.
You are going to insert a rectal suppository. You provide privacy, perform hand hygiene, don gloves, place the patient in the Sims' position, drape the patient appropriately, and remove the suppository from its wrapper. You tell the patient to take a few slow, deep breaths, and you insert the blunt end into the patient's rectum until it is unable to be seen. You remove the gloves, perform hand hygiene, and assist the patient onto the back with the head elevated to the level of comfort. What steps, if any, are missing and/or did you perform incorrectly? (Select all that apply.) A. The nurse performed the procedure correctly B. The patient was placed in the Sims' position. C. You inserted the suppository without additional lubricant. D. You inserted the blunt end of the suppository into the patient's rectum. E. You inserted the suppository into the patientt's rectum until it was unable to be visualized. F. You assisted the patient onto the back with the head elevated.
C. You inserted the suppository without additional lubricant. D. You inserted the blunt end of the suppository into the patient's rectum. E. You inserted the suppository into the patientt's rectum until it was unable to be visualized. F. You assisted the patient onto the back with the head elevated.
A patient had an NG feeding tube inserted 1 week ago. You notice that the patient's nasal mucosa is inflamed, and the patient complains of pain at the site of insertion. The other naris appears patent with intact skin. What is the best action to take at this time?
Call the health care provider; get an order to remove the feeding tube and insert a new feeding tube in the opposite naris.
Why is it important to have the tube feeding at room temperature?
Cold formula can cause gastric cramping.
Enteral feedings may be administered by: (Select all that apply.)
Continuous feeding pump Intermittent gravity drip Large-bore syringe (bolus)
Identify signs and symptoms of accidental respiratory migration of a feeding tube
Coughing Choking Decreased pulse oximetry
The patient asks why the nurse applies the drops in the conjunctival sac. The nurse's best response is: A. "The conjunctival sac can normally hold 3 drops of medication." B. "There is less chance of the medication getting into the lacrimal duct." C. "It prevents the blink response which occurs when medication is applied to the cornea." D. "Applying drops to the conjunctival sac provides even distribution of medication across the eye."
D) "Applying drops to the conjunctival sac provides even distribution of medication across the eye."
As you are preparing a subcutaneous injection, you accidentally touch the tip of the syringe with your hand as you are attaching the needle. What should you do? A. Nothing, because the nurse will apply disposable clean gloves when administering the injection B. Nothing, because this is a part of the syringe that the nurse can touch C. Wipe the tip of the syringe off with an alcohol swab and attach the needle D. Get a new sterile syringe.
D) Get a new sterile syringe.
A patient has been hospitalized for several days after a motor vehicle accident. The patient has several fractured bones and has cuts and scratches across the chest area. Where should you apply the Duragesic patch to treat the patient's pain? A. Over one of the cuts and/or scratches so it is absorbed more quickly B. Over a previous scar to cause less pain C. On the patient's non-dominant forearm. D. On the upper back in an area that is free of hair
D) On the upper back in an area that is free of hair
Mrs. Star in room 129-1 requests a prn pain medication. The nurse administered Mrs. Star's pain medication to Mrs. Start in room 138-2. After The nurse assesses Mrs. Start and reports the incident to the physician, The nurse reviews the patients' MARs and determines that both Mrs. Star and Mrs. Start had orders for the same prn pain medication. Fortunately, Mrs. Start's order stated she could receive pain medication every 4 hours, and 5 hours had elapsed since her last dose. Since neither patient was harmed by the error, why should the nurse complete an incident report? A. In this case, it would be unnecessary to complete an incident report. B. The nurse should complete the report so the facility can keep track of which nurses are making the most errors C. The nurse should do so to provide documentation should legal action be taken D. The nurse should do so to determine why the mistake occurred and what can be done to avoid similar errors in the future.
D) The nurse should do so to determine why the mistake occurred and what can be done to avoid similar errors in the future.
The nurse verified feeding tube placement by pH testing and administered the regularly scheduled medications at 10 a.m. The nurse flushed the feeding tube with 10 mL of water between medications and with 30 mL of water after the last medication. It is now 10:45 a.m. and the patient is requesting pain medication. The only pain medication ordered is to be administered per feeding tube. What action should the nurse take at this time?
D) The nurse should verify placement with a pH strip, administer dissolved medication, and flush with 30 mL of water.
What additional instruction should you include for the patient who is receiving steroids via an MDI? A. May have a gagging sensation in the throat B. Should always use a spacer device C. Should avoid scheduled inhalation if the respiratory rate is less than 20. D. The patient should rinse the mouth after use of the MDI.
D) The patient should rinse the mouth after use of the MDI.
A patient is demonstrating the use of an MDI (without a spacer device). The patient removes the mouthpiece cover and shakes the inhaler. The patient takes a deep breath and exhales, places the mouthpiece of the inhaler in the mouth, and depresses the canister while inhaling. The patient holds the breath for approximately 10 seconds and exhales with canister in mouth. The patient shakes the canister again and repeats the procedure in approximately 10 seconds. The patient replaces the mouthpiece cover when finished administering puffs. What steps did the patient miss and/or perform incorrectly? (Select all that apply.) A. Shook the inhaler B. Depressed the canister during inhalation C. Held the breath for 10 seconds D. The patient used the wrong method of exhalation after using the MDI. E. The patient repeated the procedure in 10 seconds. F. The patient replaced the mouthpiece cover when finished administering puffs.
D) The patient used the wrong method of exhalation after using the MDI. E) The patient repeated the procedure in 10 seconds. F) The patient replaced the mouthpiece cover when finished administering puffs.
You have finished administering medications at 1030 when you realize that you gave a patient all of his medications at 1000, including some medications that should have been administered at 1200 and some at 1400. Which of the 6 rights of medication administration did you overlook? A. The right route B. The right dose C. The right patient D. The right time E. The right documentation F. The right medication
D) The right time
You are administering a flu vaccine to a patient. You perform hand hygiene, locate your site and swab with alcohol. You allow the alcohol to dry, uncap the needle and administer the injection. You dispose of the syringe and needle in the sharps container. Which of the following actions increased the risk for infection? A. Failed to cap the needle after the injection B. Allowed the alcohol to dry before administrating the injection C. Failed to assess the patient's temperature D. You failed to apply clean gloves after performing hand hygiene.
D) You failed to apply clean gloves after performing hand hygiene.
You select a medication according to the MAR for the correct name, dosage, and route. You go to the patient's room and compare the date of birth on the patient's ID bracelet to that information on the MAR. You administer the medication orally because it is a pill, and then you return the MAR and document the medication administration. Which of the following 6 rights did you overlook? A) The nurse followed all of the 6 rights of medication administration B) The right medication C) The right dose D) The right time E) The right patient F) The right route G) The right documentation
D) You overlooked the right time.
The nurse is administering medication to a patient when the patient accidentally drops the tablet on the floor. What should the nurse do? A. Allow the patient to take the tablet if it appears clean B. Quickly remove the tablet from the floor and wipe off the tablet with a gloved hand. Administer the tablet because medications are costly C. Ask the patient whether he would like for the nurse to obtain a new tablet or take the one that fell on the floor. D. Discard the tablet and get another one.
D. Discard the tablet and get another one
A medication label states, "For Parenteral Use Only." What is the correct interpretation of this statement? A. The medication should be given orally so it is absorbed through the GI tract. B. The medication should only be used in adults. C. The medication should be administered topically. D. The medication should be administered by injection.
D. The medication should be administered by injection.
The nurse administered a routine scheduled medication of Prozac (fluoxetine hydrochloride), An antidepressant, 20 mg PO to a patient. The nurse checked the medication label against the MAR when getting it out of the automatic dispensing system, again when placing the medication in a cup, and once more at the patient's bedside prior to administration. The label reads 20 mg and contained a single capsule. The nurse asked the patient to state her name and administered the medication, offering the patient a drink of water. The nurse documented the administration of the medication. Which of the six rights of medication administration did the nurse violate? A. The nurse administered the medication correctly B. The nurse did not have a second nurse verify the dose C. The nurse did not make the appropriate number of checks for the right drug. D. The nurse did not use two patient identifiers
D. The nurse did not use two patient identifiers
The patient is presently receiving intermittent tube feedings of 120 mL every 6 hours. The health care provider's orders state: Jevity formula feeding 240 mL every 6 hours per feeding tube, increase per patient tolerance. Which of the following assessment data indicate patient intolerance of the tube feeding and therefore inability of the rate to be increased? (Select all that apply.)
Diarrhea Abdominal distention and discomfort Nausea Residual volume greater than 250 mL
As the ventricles of the heart relax and fill, arterial pressure begins to decrease.
Diastolic
______________ pressure is the minimal pressure exerted against the arterial wall at all times.
Diastolic
The patient's BP reading is 150/50. For this patient, 50 is representative of:
Diastolic pressure and ventricles during relaxation
movement of O2 and CO2 between the alveoli and the red blood cells.
Diffusion
You are reading the physician's orders and note date and time of the prescriptions, as well as the physician's signature. Which of the following prescriptions is complete?
Digoxin (Lanoxin) 1.25 mg PO daily
To straighten the ear canal: Which way do you pull the auricle for children 3 and younger?
Down and back
The nurse suspects the patient's feeding tube has migrated. Which of the following would indicate the greatest risk related to tube migration?
Dyspnea and decreased oxygen saturation
The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. True. False.
False. For routine auscultation of the apical pulse, you should rely on the diaphragm side of the chest piece because it is designed to pick up higher-pitched heart sounds like that of the apical pulse.The bell side of the stethoscope should be used to assess heart sounds to identify murmurs.
The nurse is attempting to administer medication through a feeding tube but is unable to do so because of a blockage in the tube. What action(s) should the nurse take? (Select all that apply.)
For a newly inserted tube, notify health care provider and obtain x-ray confirmation of positioning. For an established tube, attempt to flush tube with large-bore syringe and warm water. If unable to flush, contact health care provider for replacement of tube and potential need to reroute medication.
Pulse site: apical
Fourth to fifth intercostal space (ICS) at left midclavicular line -Site used to auscultate for apical pulse at point of maximal impulse (PMI)
The health care provider just left the patient s room after explaining the options of NG or NI feeding tube placement. A student asks a nurse about the differences between nasogastric and nasointestinal feedings. Which of the following are accurate statements made by the nurse? (Select all that apply.)
Gastric aspirate is expected to have a lower pH than intestinal aspirate. The advantage to an NI tube is that there is less risk for aspiration Both NG and NI tubes are usually used for less than 30 days.
The patient is receiving a continuous enteral feeding. Which of the following assessment findings would require follow-up?
Gastric residual of 275 m
Pulse site: brachial
Groove between biceps and triceps muscles at antecubital fossa -Site used to assess status of circulation to lower arm -Site used to auscultate blood pressure
is the carrier for respiratory gases.
Hemoglobin
VS for 3-year-old child
T-98.9° F, (37.1°C), P-110, R-28, BP 100/65
A 15-year-old male has come to the health care provider's office because he does not feel well after football practice. He looks sheepish when you ask him about drug and alcohol use but is unwilling to explain why. His temperature is 102°F (38.9°C). This is a:
High temp for a person his age.
When taking your patient's pulse, you want to pay attention to...
How fast or slow it is (rate). How regular or irregular it is (rhythm or cadence). How strong or weak it is (amplitude).
With which route of drug administration are there no barriers to absorption?
IV
A nurse is administering a subcutaneous injection to a patient. What data should the nurse recognize as the highest priority to prevent potential complications?
Identify if the Pt has allergies to the medication
Which of the following is your highest priority action for ensuring overall safety during medication administration?
Identify the patient by two acceptable methods
The nurse aspirates stomach contents from a newly inserted feeding tube. The nurse is aware the patient has been on the proton-pump inhibitor omeprazole (Pepcid). The pH strip reads "3." Where should the nurse expect the x-ray to determine placement of the feeding tube?
In the stomach
Pulse site: posterior tibial
Inner side of ankle below medial malleolus -Site used to assess status of circulation to foot
continuous passive range of motion (CPM) device
It is used to restore range of motion in a variety of joints, including the ankle, knee, shoulder, and wrist. It is most commonly used after knee surgery; the provider usually prescribes it on the day of surgery or on the first postoperative day. To keep the patient's skin from rubbing on the frame and becoming irritated, sheepskin is usually used to pad the cradle and any other hard surfaces that might touch the leg.
Which of the following is an appropriate nursing action to prevent a complication of NG tube feedings?
Keep the head of the patient's bed elevated at least 30 degrees
You are instructing the patient about self-administration of insulin. What site would you suggest?
Lower abdomen (at least 2 in from umbilicus, should be recommended for self-administration of insulin)
Match with correct type of inhaler A) DPI B) MDI _ Do not shake _It requires coordination with inhalation. _It requires less manual dexterity. _It does not require a spacer. _A spacer may be necessary.
Match with correct type of inhaler A) DPI B) MDI A) Do not shake B) It requires coordination with inhalation. A) It requires less manual dexterity. A) It does not require a spacer. B) A spacer may be necessary.
Pt asks why insulin is injected subcutaneously. Why?
Medication absorption is slower b/c it has a relatively poor vascular system, an important factor in the effectiveness of insulin therapy. (It is the abundance of the vascular supply that is the primary factor in the speed with which meds enter into the bloodstream
For intestinal placement of a feeding tube, in what position should the nurse place the patient while waiting for radiological confirmation of correct placement?
On the patient's right side
A patient has been given an opioid analgesic (e.g., morphine) for pain relief. Why does the nurse assess the patient's respiratory rate before administering the next dose?
Opioid analgesics may depress rate and depth of respirations, although this is a rare adverse event.
Electronic thermometers are color coded for intended use. Oral: Rectal: Axillary:
Oral: blue probe. Rectal: red probe. Axillary: blue probe.
Pulse site: temporal
Over temporal bone of head above and lateral to eye -Easily accessible site
What is a term that indications a medication given by injection?
Parenteral
A group of nursing students are studying together. They are discussing the differences between parenteral and enteral nutrition. Which statement, if made by one of the students, indicates further instruction is needed?
Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube."
distribution of red blood cells to and from the pulmonary capillaries.
Perfusion
For safe administration of oral medications through a feeding tube, specific attention must be paid to: (Select all that apply.)
Proper placement of the tube Whether the medication can be crushed for administration through the tube
The patient begins to cough and choke as the nurse is inserting the NG tube. What is the best action for the nurse to take at this time?
Pull the tube back and attempt to reinsert.
You are taking a patient's BP by using the one-step method. Which of the following is an incorrect step in the sequence for performing this procedure?
Pump the cuff to 20 mm Hg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mm Hg
Pulse site: radial
Radial or thumb side of forearm at wrist -Common site used to assess character of peripheral pulse and assess status of circulation to the hand
The nurse is having great difficulty hearing any sound when taking a patient's BP. What can the nurse do to increase the ability to auscultate the reading?
Reduce environmental noise, make sure stethoscope does not touch pt's clothing or BP cuff, keep stethoscope tubing still to avoid extraneous sound, ensure chest piece is on diaphragm side, ensure the bladder of the cuff is centered 1 in above the brachial artery.
You have inserted an NG feeding tube. The patient vomited during insertion and continues to gag. What action(s) should you take? (Select all that apply.)
Suction airway as needed Remove feeding tube Position patient on side Contact health care provider for possible chest x-ray.
The nurse is going to irrigate the patient's established feeding tube with 30 mL of tap water before instilling the tube feeding. The nurse attempts to do so without success. What should action should the nurse take?
Reposition the patient.
the exchange of oxygen (O2) and carbon dioxide (CO2) between cells of the body and the atmosphere.
Respiration
The nurse is going to administer a bolus enteral tube feeding of 240 mL. The nurse has obtained a pH of 4 and 50 mL of gastric aspirate. Based on these findings, what action should the nurse take?
Return the aspirate to the patient's stomach and administer the feeding.
6 rights of medication administration:
Right dose Right route Right patient Right time Right medication Right documentation
A nurse is preparing to administer an insulin injection to a patient. What is appropriate?
Rotate injection sites to avoid tissue injury
Generally with a subcutaneous injection, medication absorption is_____ than that of an IM injection.
Slower
Acceptable Ranges for Adults Pulse Oximetry:
SpO2 ≥95%
If the nurse suspects the NG feeding tube has migrated, the nurse should:
Stop any enteral feedings and obtain an order for a chest x-ray to determine placement.
Which of the following medications should never be given through a feeding tube? (Select all that apply.)
Sublingual tablets Enteric-coated (EC) Sustained release (SR) Extended release (XR) Long acting (LA)
The force exerted against the wall of the artery when the ventricles contract.
Systolic
The NAP reports to the nurse that the patient's pulse oximetry is 88%. What action(s) should the nurse take?
Take the pulse oximetry his/herself, assist patient to high-Fowler's position, be prepared to administer oxygen, perform a cardiopulmonary assessment, notify physician.
A healthy 30-year-old male arrives at the clinic for a physical because he will be living in a third-world country for the next 2 to 5 years, and he wants to make sure he is healthy. The nurse is responsible for collecting his vital signs. Which of these can be delegated to NAP?
Temp, pulse, resp., BP, O2 sat
Which of the following VS are expected for the adult pt who is experiencing cyanosis?
Temp- 98.6 F (37 C), P-102 R-28 BP-98/50, O2 sat- 85%
Acceptable Ranges for Adults Temperature Range: Average oral/tympanic: Average rectal: Average axillary:
Temperature Range: 36° to 38° C (96.8° to 100.4° F) Average oral/tympanic: 37° C (98.6° F) Average rectal: 37.5° C (99.5° F) Average axillary: 36.5° C (97.7° F)
Identify why a child's respirations might be shallow.
The child is in acute pain.
The reverse Trendelenburg's position is the opposite of Trendelenburg's position:
The head of the bed is elevated with the foot of the bed down. This is often a position of comfort for patients with gastrointestinal problems, and it can help prevent or minimize esophageal reflux.
The nurse is inserting an NG feeding tube for the first time. Which action, if made by the nurse, indicates further instruction is needed?
The nurse has the patient flex the head as the tube is inserted into the naris.**
Which of the following is the most appropriate documentation of a patient's response to a pain medication?
The patient reports pain decreased to 3/10, 30 min after medication administration
A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle. What should the nurse do to locate the appropriate site?
With the heel of the hand on the greater trochanter, point the index finger up toward the anterior superior iliac spine, extending the other fingers back along the iliac crest.
The health care provider has ordered an enteral feeding tube for an elderly patient. Which statement if made by the patient s family member indicates further instruction is needed?
The tube feedings are used to improve digestion.
A patient with lung cancer has a feeding tube to help meet nutritional needs because of difficulty swallowing since radiation treatments. The patient requests some pain medication. The patient has an order for morphine, 5 mg IV push, every 2 hours as needed, or MS Contin (extended-release morphine tablet) PO 30 mg every 8 hours as needed. The nurse returns with the injectable form to be administered IV. The patient seems upset by this, stating, "I take a morphine pill for pain; why are you bringing me a shot?" What is the nurse's best response?
This is the same medication only in a form that I can administer through your IV line. The pill form you took at home should never be crushed, so I am unable to administer it through your feeding tube."
In what direction should the nurse pull the pinna of the adult when taking a tympanic temperature? a. Backward, down and out b. Backward, up and out
b. Backward, up and out
A patient is receiving a continuous enteral feeding by infusion pump. The nurse enters the patient's room to verify tube placement and measure residual. The nurse notices the patient's respirations are shallow and rapid and that the patient's color is ashen. The nurse notes rhonchi upon auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should the nurse take? (Select all that apply.)
Turn off the tube feeding. Position the patient in Fowler's position and suction the patient. Notify the health care provider. Prepare for chest x-ray examination.
Pulse site: ulnar
Ulnar side of forearm at wrist -Site used to assess status of circulation to the ulnar side of the hand -Site used to perform Allen's test
To straighten the ear canal: Which way do you pull the auricle for children and adults ages 3 and older?
Up and out (back)
Nurse is preparing to administer an intradermal injection. What should the nurse do to ensure proper technique?
Use a tuberculin syringe w/ a 3/8- to 5/8-inch, 25- to 27-gauge needle
mechanical movement of gases into and out of the lungs.
Ventilation
Which of the following, if exhibited by the patient, may increase the risk for spontaneous enteral tube dislocation? (Select all that apply.)
Vomiting Frequent nasotracheal suctioning Severe bouts of coughing
A nurse is performing a physical assessment on a patient and instructs the pt to stat with his feet together and arms at his sides. The purpose of positioning the pt in this manner is to test which of the following?
balance
transferring
When patients are able to get out of bed, sit in a chair, or leave the room, their physical and psychological well-being improves. When patients are unable to do these things on their own, it becomes your responsibility to help them with these tasks.
contracture
a deformity that results from abnormal shortening of muscle tissue, making the muscle highly resistant to stretching
gait belt
a device, usually a strap of cotton webbing with a buckle, designed to be placed around a patient's waist to assist with transferring and ambulating the patient
footboard
a flat panel composed of either wood or plastic, to help prevent footdrop, place it at the foot of the bed to keep the patient's feet dorsiflexed.
A transfer sheet is...
a heavy half sheet or a top sheet that is folded in half and placed underneath the patient. You then use the sheet to help position the patient in bed. You can also use it with a transfer board.
Hoyer lift
a piece of equipment designed to raise a patient slowly above a surface to assist in transferring the patient to another surface
log rolling
a procedure for turning a patient as one stable unit, with hands crossed on the chest, in a smooth continuous motion
For which of the following inhalation medication delivery methods is it important for the nurse to assess the pt's ability to inale deeply before administering the medication? a) Dry powder inhalation (DPI) b) Nasal spray c) Metered dose inhaler (MDI) with attached spacer d) Use of a nebulizer via a mask
a) Dry powder inhalation (DPI) This method has no propellant and requires a deep inhalation to trigger the release of medication
A pt is to receive his daily isoniazid (INH) dosage for tuberculosis. He states he is feeling nauseated with this medication and refuses to take it. the nurse knows that the correct way to indicate this refusal is to... a) document the reason for refusal along with the date and time in the pt's medical record b) circle the scheduled time of medication administration on the medication record c) initial the scheduled time of medication administration on the medication record d) notify the PCP that the pt refused to take the medication
a) document the refusal with date and time in pt medical record Pt has the right to refuse medication. it must be documented in the pt's record with date, time, and reason for refusal
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? a. "Ask the patient not to eat, drink, or smoke for 15 minutes and then assess the patient's oral temperature." b. "Since the soup was not hot, go ahead and take the patient's temperature." c. "Change to the red thermometer probe and take the patient's temperature rectally." d. "Take the patient's temperature using the axillary route and when you record the reading, add 1°F."
a. "Ask the patient not to eat, drink, or smoke for 15 minutes and then assess the patient's oral temperature." The temperature of food or liquid could impair the accuracy of the reading. The NAP should ask the patient not to eat, drink, or smoke for 15 minutes and then assess the oral temperature. Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient. Although the axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an axillary temperature reading, the site is documented, but the reading itself is unchanged.
How far should a rectal thermometer be inserted in an adult? a. 1.5 in (3.8 cm) b. 3.5 in (8.9 cm) c. 0.5-1 in (1.3-2.5 cm) d. 2 in (5 cm)
a. 1.5 in (3.8 cm)
Which of the following patients would need frequent assessment of their temperature? (Select all that apply.) a. A patient receiving a blood transfusion for chronic anemia. b. An elderly patient who needs assistance with feeding and dressing. c. A 43-year-old female who has undergone a hysterectomy. d. A child who is small for his age. e. A 19-year-old with a white blood count of 15,000/mm3.
a. A patient receiving a blood transfusion for chronic anemia. c. A 43-year-old female who has undergone a hysterectomy. e. A 19-year-old with a white blood count of 15,000/mm3. Certain conditions place patients at risk for temperature alterations and may require more frequent assessment. Patients at risk may include those receiving a blood product infusion, those who are of a postoperative status, and those with a white blood cell count below 5,000 or above 12,000/mm3.
Which of the following patients may require more frequent temperature measurement and nursing assessment because they are at risk for an alteration in temperature? (Select all that apply.) a. A patient who is in the recovery room after having his gallbladder removed b. A patient with pneumonia c. A patient receiving a blood transfusion d. A patient who is receiving physical therapy e. A patient with cancer whose white blood cell count is 2500 per mm^3
a. A patient who is in the recovery room after having his gallbladder removed b. A patient with pneumonia c. A patient receiving a blood transfusion e. A patient with cancer whose white blood cell count is 2500 per mm^3
Which of the following is likely to result in a higher temperature reading? (Select all that apply) a. A temperature taken in the evening b. The temperature of a college student taking an exam c. The temperature of a healthy elderly adult d. A temperature taken in the morning e. The temperature of a teenager who just ran a mile
a. A temperature taken in the evening b. The temperature of a college student taking an exam e. The temperature of a teenager who just ran a mile
What is the nursing intervention if your patient is taking more than 20 breaths per minute? (Select all that apply.) a. Count again for a full 60 seconds (1 minute). b. Tell the patient that you are counting breaths so the patient will slow the rate of breathing. c. Assess physiologic factors that may be causing the patient to breathe so fast. d. Administer a bronchodilator that will decrease the respiratory rate.
a. Count again for a full 60 seconds (1 minute). c. Assess physiologic factors that may be causing the patient to breathe so fast. If the patient has a respiratory rate greater than 20 breaths per minute, you should count the respiratory rate again over a full minute and assess for factors causing the patient's elevated respiratory rate. Administering a bronchodilator would require a physician's order and may not treat the cause (e.g., pain could be the cause of the increased rate). You should attempt to assess the patient's respiratory rate inconspicuously to prevent the patient from altering the rate of breathing.
Identify the factors that may have an effect on an 82-year-old patient's temperature: (Select all that apply.) a. Drinking a cold glass of water. b. Participation in strenuous physical therapy exercises. c. Infection. d. Room temperature. e. Patient's height.
a. Drinking a cold glass of water. b. Participation in strenuous physical therapy exercises. c. Infection. d. Room temperature. The average body temperature of older adults is lower (96.8 °F). Cold water and a cool room temperature would lower temperature. A warm room would raise temperature. Exercise and an infection would raise temperature. Height is not a factor that would affect body temperature.
Tim Rogers is a 22-year-old who has come to the outpatient clinic with an injured right leg. You need to collect Tim's vital signs. You are to give Tim morphine to treat his pain. The drug book says to assess respirations before administration. Why is this necessary? a. Opioid analgesics in high doses may decrease the rate and depth of respirations. b. Acute pain may increase the rate and depth of respirations. c. It's necessary to make sure the patient is not allergic to morphine. d. The anxiety of receiving an injection will increase the patient's rate and depth of respiration.
a. Opioid analgesics in high doses may decrease the rate and depth of respirations.
The students locate the point of maximal impulse and reassess the patient's apical pulse prior to administering a cardiac medication. They agree the patient's pulse is irregular. How should the apical pulse be measured? a. Take the patient's apical pulse for a full minute. b. Take the patient's apical pulse for 30 seconds and multiply by 2. c. Take the patient's apical pulse for 15 seconds and multiply by 4. d. A Doppler should be used to obtain the apical pulse.
a. Take the patient's apical pulse for a full minute Because the apical pulse is irregular and because a cardiac medication is to be administered, the apical pulse should be assessed for a full minute
Vital signs reveal __________ changes in a patient's condition, as well as changes that occur __________.
sudden; progressively
Your newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? a. Temporal artery b. Tympanic c. Chemical dot d. Rectal electronic
a. Temporal artery The temporal artery thermometer reflects rapid change in core temperature and can be used on newborns. The tympanic membrane sensor is unable to accurately measure core temperature changes during and after exercise. Chemical dot thermometers are inappropriate for use when there is a sudden and/or variable rise in temperature. It would be unnecessary to use a rectal thermometer and could cause bowel perforation if inserted too far on a newborn.
Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) a. The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. b. The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. c. The NAP waits until a tone sounds to read the tympanic thermometer. d. The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. e. The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer.
a. The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. b. The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. The electronic thermometers are differentiated by the probe cover tips: blue for oral or axillary, red for rectal. Even though a probe cover is applied, a red-tipped probe should not be placed into a patient's mouth. The single-use chemical dot thermometer is plastic and can only be used once. All electronic thermometers (oral, axillary, rectal) and the tympanic thermometer have a tone that sounds when the measurement is complete. Pull the pinna up, back, and out in an adult when inserting the tympanic thermometer.
The student nurse caring for an elderly patient with congestive heart failure determines the patient's pulse is irregular. The student asks a peer to help determine whether there is a pulse deficit. The student who took the apical pulse obtained a rate of 56 and irregular. The student who took the radial pulse obtained a rate of 72 and irregular. How could this best be explained? a. There was an error made in obtaining the pulse rates. b. The patient's pulse deficit is 16. c. The patient has ineffective cardiac contractions. d. The patient's dosage of cardiac medication needs adjustment.
a. There was an error made in obtaining the pulse rates. When a pulse deficit exists, the apical pulse rate is greater than the radial pulse rate because the heart is not contracting effectively enough to perfuse out to the extremity where it can be felt. It would be impossible to have a faster rate at the radial site than at the apical site; therefore, an error must have occurred.
Which of the following situations may affect a patient's vital signs? (Select all that apply.) a. Time of day. b. Occupation. c. Moving from lying to standing position. d. Pain rated as a 7 on 0-10 pain scale. e. Isolation precautions.
a. Time of day. c. Moving from lying to standing position. d. Pain rated as a 7 on 0-10 pain scale. Factors that may alter vital signs include time of day, stress (emotional and physical), temperature alterations/weather conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status, noise, food/liquid consumption, and odors. The person's occupation and isolation precautions do not alter vital signs. If a person's job requires an activity that increases exertion or stress, the activity affects vital signs, not the occupation.
Having hypertension can increase a person's chance of dying from heart attack or stroke. a. True b. False
a. True
Hypertension is having a BP of greater than 140/90 mm Hg on two separate occasions. a. True b. False
a. True
Respirations should be assessed at rest to allow for objective comparison of values. a. True b. False
a. True
The normal respiratory rate for an adult is 12 to 20 breaths per minute. a. True b. False
a. True
The nursing student administered morphine 5 mg IV at 1330 for pain to a postoperative knee replacement patient. The nursing student returned to the patient's room in 30 minutes to determine whether the medication was effective. The nursing student noticed that the patient's respirations were regular at 8 per minute. The student nurse should take the patient's respiratory rate prior to administering the morphine, as well as after administration. a. True b. False
a. True Any time a patient is to receive a medication which can affect respiratory status, such as an opioid analgesic, the nurse should assess the respiratory status prior to medication administration as well as following up afterward. Although an opioid analgesic rarely depresses rate and depth of respirations, the student should assess a patient's condition to determine whether it is safe to give, or should be held.
The nursing student administered morphine 5 mg IV at 1330 for pain to a postoperative knee replacement patient. The nursing student returned to the patient's room in 30 minutes to determine whether the medication was effective. The nursing student noticed that the patient's respirations were regular at 8 per minute. The student nurse should assist the patient to a high-Fowler's position. a. True b. False
a. True Assist the patient to a supported sitting position (semi- or high-Fowler's) for maximum ventilatory movement.
Which of the following may increase both rate and depth of respiration? (Select all that apply.) a. Walking 1 mile briskly. b. Having a pain level rating at 7 on a scale of 0-10. c. Feeling anxious when taking a test. d. Smoking a cigarette. e. Taking an opioid to relieve pain. f. Having an addiction problem with amphetamines/cocaine. g. Using a bronchodilator h. Incurring a head injury from a motor vehicle accident.
a. Walking 1 mile briskly. c. Feeling anxious when taking a test. f. Having an addiction problem with amphetamines/cocaine. Exercise, anxiety, and amphetamines/cocaine increase both respiratory rate and depth. Respiratory rate may increase when the patient is in pain, but breathing becomes shallow. Smoking also increases the respiratory rate, but depth is unaffected. Opioids may depress both respiratory rate and depth. It is clinically significant when both rate and depth are affected. Bronchodilators decrease the respiratory rate. Damage to the brain stem impairs the respiratory center and slows the rate and rhythm.
To assess activity tolerance, a patient's vital signs may be taken __________ and __________ ambulating a patient for the first time following prolonged bedrest.
before; after
lateral flexion
the act of bending to one side
The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? a. When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. b. When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. c. When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. d. After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing.
a. When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. Respiratory rate is equivalent to the number of respiratory cycles (one inspiration and one expiration) per minute. The NAP should assess the patient's respiratory rate for 1 full minute if the patient's respiratory rhythm is irregular, less than 12, or greater than 20.
You just bought a new stethoscope. During practice in the skills lab, you try to auscultate your partner's apical pulse with the bell of the stethoscope but are unable to hear any sound. What is the most logical reason for this? a. You need to turn the chest piece so sound may be heard from the diaphragm side. b. The ear pieces are occluding your ear canals and you have the binaurals angled so the ear tips are pointing toward your face. c. You bought a stethoscope with tubing that is too long. d. You should be using the bell side to auscultate the apical pulse.
a. You need to turn the chest piece so sound may be heard from the diaphragm side.
Pete is a 62-year-old man admitted to the hospital with prostate cancer. You are assessing Pete for signs and symptoms of decreased cardiac output. Which of the following indicate abnormal cardiac function? (Select all that apply.) a. chest pain b. flat jugular veins c. dyspnea d. cyanosis e. increased urine output f. edema
a. chest pain c. dyspnea d. cyanosis f. edema
Which of the following thermometers (an corresponding route) would be most accurate for monitoring rapid changes in core body temperature? a. temporal artery thermometer b. rectal electronic thermometer c. oral electronic thermometer d. tympanic thermometer e. electronic thermometer used axillary f. chemical thermometer (oral/skin)
a. temporal artery thermometer c. oral electronic thermometer
hypotension
abnormal lowering of blood pressure that is inadequate for normal profusing and oxygenation of tissue
orthostatic hypotension
abnormally low blood pressure occurring when someone stands up
tachypnea
abnormally rapid rate of breathing
bradypnea
abnormally slow rate of breathing
It is generally __________ to assess a patient's vital signs if the patient complains of feeling "funny".
accepted
Expiration is an __________ __________ only during exercise, voluntary hyperventilation, and certain disease states.
active process
Inspiration is an __________ __________.
active process
A nurse is able to transfer to a chair a patient who has a weak left leg...
aligning the nurse's knees w/the pt's knees just before transfer
assistive device
an object or piece of equipment designed to help a patient with activities of daily living, such as a cane, eyeglasses, or a hearing aid
Elastic stockings are also called what?
antiembolic or thromboembolic device (TED) hose
Because of the force of the blood exiting the heart, __________ __________ aortic distention creates a pulse wave that travels rapidly toward the extremities.
aortic distention
The NAP reports to the nurse a 65-year-old patient's blood pressure is 160/98. The initial response of the nurse is to: a. Ask the NAP if the patient received their anti-hypertensive medication this a.m. b .Assess the patient's blood pressure. c. Instruct the NAP to obtain a full set of vital signs. d. Document this as a normal finding in an elderly adult.
b .Assess the patient's blood pressure. This is out of normal range. If there is a question regarding a patient's vital signs or a suspected change in the patient's condition that may require further assessment, the nurse should take the patient's vital signs rather than delegating the task.
weight bearing
being able to support some percentage of the body's weight (mass, load), as in full weight bearing (able to support 100% of the body's weight)
partial weight bearing
being able to support some percentage of the body's weight (mass, load), such as 30% to 50%
A nurse will be administering several medications to a pt who is receiving enteral feedings through a small bore nasogastric tube. The nurse administers the medications correctly by... a) Adding crushed medications to the enteral tube feedings and infusing via an electronic pump b) infusing each medication by gravity and flushing with water before and after instillation c) Administering medications through a large bulb syringe d) Lowering the syringe to promote instillation of medication
b) infusing each med by gravity and flushing with water before and after instillation Medications should be instilled via gravity, flushing before and after with water
A nurse is preparing to instill antibiotic ear drops into a toddler's ear. Which of the following techniques should the nurse use when administering ear drops to this pt.? a) Have the pt maintain side-lying position for 30 min after administration of ear drops b) Pull the pt's auricle down and back to open the canal when administering ear drops c) The nurse should don sterile gloves prior to administration of ear drops d) Insert the tip the dropper into the ear canal when administering it
b) pull the pt auricle down and back
If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? a. 37-39 °C (98.6-102.2 °F) b. 96.8-100.4 °F (36-38 °C) c. 35-36 °C (95-96.8 °F) d. 96.8-98.6 °F (36-37 °C)
b. 96.8-100.4 °F (36-38 °C) The normal temperature range for an adult is 96.8° F to 100.4° F or 36° C to 38° C. The normal temperature range for a newborn is 95.9° F to 99.5° F. Nursing judgment should be used to determine whether further assessment is indicated regarding an individual patient's temperature, even if it is within the identified range of normal for most people. For example, a patient recovering from a stroke with a feeding tube and a temperature of 99.0° should be assessed further as this may be an initial indication of aspiration.
You check the patient's baseline temperature reading and note that it was recorded as 98.6° F (37 °C). What would you expect the temperature reading to be if it was obtained using the rectal route? a. 98.6° F (37 °C) b. 99.5° F (37.5 °C) c. 97.7° F (36.5 °C) d. 99.1° F (37.3 °C)
b. 99.5° F (37.5 °C)
In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) a. A newborn. b. A patient returning from OR after having a hip replacement. c. A patient who received morphine for severe cancer pain. d. A student who is getting ready to take a final exam. e. A patient who had a bleeding episode.
b. A patient returning from OR after having a hip replacement. c. A patient who received morphine for severe cancer pain. Having general anesthesia or receiving an opioid analgesic may decrease the pulse rate. A newborn has a higher pulse rate than an adult. Sympathetic stimulation such as anxiety will increase the pulse rate. Having a decreased fluid volume will increase the pulse rate as the heart attempts to compensate to maintain cardiac output.
Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) a. a 76-year-old with Type 1 diabetes who is otherwise healthy. b. A patient who was just informed of a diagnosis of cancer. c. A patient with peripheral vascular disease. d. A patient who is receiving bolus IV fluids. e. A patient with Alzheimer's disease.
b. A patient who was just informed of a diagnosis of cancer. c. A patient with peripheral vascular disease. d. A patient who is receiving bolus IV fluids. Certain conditions place patients at risk for pulse alterations. This may include a person with cardiovascular disease, a patient who is experiencing anxiety, and a patient who received a sudden infusion of IV fluids. Uncomplicated diabetes and Alzheimer's disease fail to directly relate to pulse alteration.
The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) a. An apical pulse of a patient who is going to receive digoxin (Lanoxin). b. A radial pulse on a patient with a 1200 mL fluid restriction. c. A radial pulse of a patient in the emergency room with chest pain. d. A femoral pulse following a lower leg amputation. e. The temporal pulse of a child.
b. A radial pulse on a patient with a 1200 mL fluid restriction. e. The temporal pulse of a child. The skill of pulse measurement can be delegated to NAP unless the patient is considered unstable or you are evaluating a response to a treatment or medication. The pulse of a patient on a fluid restriction may be delegated to NAP, as well as the temporal pulse of a child, provided the NAP knows how to locate this pulse site
Who would you expect to have the lowest body temperature? a. A 16-year-old who ran 1 mile. b. An 80-year-old who walked half a mile. d. A child playing softball
b. An 80-year-old who walked half a mile. The 80-year-old would have a lower starting temperature and therefore, would most likely have the lowest body temperature although it may take longer to return to baseline after exercise. To be febrile means to have a fever. The toddler would fail to have the lowest body temperature. A 16-year-old will have a higher starting body temperature, and exercise will increase the body temperature further. A child will have a higher starting temperature and exercise will increase the body temperature further.
Mary Helen, a 23-year-old patient, has been admitted to the hospital with a fever of unknown origin. Intravenous (IV) fluids have been started, and Mary Helen is feeling much better. You are going to take Mary Helen's temperature. Which of the following would be the best thermometer selection? a. An electronic thermometer with a red probe end b. An electronic thermometer with a blue probe end c. A chemical thermometer (skin sensor)
b. An electronic thermometer with a blue probe end
Pete is a 62-year-old man admitted to the hospital with prostate cancer. Pete's radial pulse is 56 and irregular. What action should you take next? a. Notify the health care provider. b. Auscultate the apical pulse. c. Ask another nurse to take Pete's radial pulse. d. Obtain an electrocardiogram.
b. Auscultate the apical pulse.
Tim Rogers is a 22-year-old who has come to the outpatient clinic with an injured right leg. You need to collect Tim's vital signs. The best way to count a respiratory rate is: a. Count from the end of expiration through the beginning of inspiration. b. Count from the beginning of inspiration to the end of expiration. c. Count from the beginning of inspiration to the end of inspiration. d. Count from the beginning of expiration to the end of expiration.
b. Count from the beginning of inspiration to the end of expiration. A full breath cycle begins with the onset of inspiration and ends with the end of expiration.
A diagnosis of hypertension can be made on one reading if the BP is significantly elevated above 140/90. a. True b. False
b. False
Hypotension is generally considered present when the SBP falls to 100 mm Hg or below. a. True b. False
b. False
Orthostatic changes in vital signs are good indicators of blood volume expansion. a. True b. False
b. False
The terms hypotension and orthostatic hypotension mean the same and can be used interchangeably. a. True b. False
b. False
The nursing student administered morphine 5 mg IV at 1330 for pain to a postoperative knee replacement patient. The nursing student returned to the patient's room in 30 minutes to determine whether the medication was effective. The nursing student noticed that the patient's respirations were regular at 8 per minute. Because the patient's respirations are regular, the student nurse may count the number of respirations in 30 seconds and multiply by 2. a. True b. False
b. False Because the patient's respirations fall below the normal range for an adult (below 12 breaths per minute) the student nurse should assess the respiratory rate for a full minute.
Assess respirations before pulse measurement in the adult. a. True b. False
b. False Respirations should be assessed immediately after pulse measurement. Inconspicuous assessment prevents the patient from consciously or unintentionally altering the rate and depth of breathing.
Which of the following actions could lead to an inaccurate temperature reading when using a temporal artery thermometer? a. Wiping the forehead with a towel prior to assessing the temperature. b. Releasing the scan button before putting the sensor behind the patient's ear. c. Keeping the probe flush on patient's skin while sliding the probe across forehead. d. Pressing the scan button with your thumb.
b. Releasing the scan button before putting the sensor behind the patient's ear.
Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? a. Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. b. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. c. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. d. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%.
b. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, average BP less than 120 over 80, and pulse oximetry 95% to 100%. A BP greater than 140 over 90 may be an indication of hypertension.
A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which information should be provided to the NAP delegated to take her temperature? (Select all that apply.) a. The patient's age. b. The type of temperature required. c. The patient's diagnosis d. The frequency for taking or monitoring the temperature. e. What changes to report immediately to the nurse.
b. The type of temperature required. d. The frequency for taking or monitoring the temperature. e. What changes to report immediately to the nurse. It is more important that the temperature be done on time by the correct route, with the correct equipment, and that identified changes be reported as requested.
You take a patient's vital signs on admission to the hospital. Why is it important to take vital signs at this time? a. To complete the routine paperwork of the admission process b. To obtain a baseline measurement for comparison with subsequent vital sign measurements c. To determine how the experience of being hospitalized is affecting the patient d. To provide accuracy in measurement before the task is delegated to NAP for future assessment
b. To obtain a baseline measurement for comparison with subsequent vital sign measurements You should always obtain a baseline measurement of vital signs on first contact with a patient to provide a means for comparison with subsequent vital sign measurements.
You are supposed to take your patient's vital signs preoperatively and record them on the patient's record as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) a. To see if the patient is "feeling funny." b. To provide a set of vital signs to use for comparison during and after surgery. c. To make sure the patient is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention at this time. d. To provide the patient with reassurance that he or she is being cared for by a competent staff.
b. To provide a set of vital signs to use for comparison during and after surgery. c. To make sure the patient is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention at this time. The patient who is going to surgery is going to experience a change in condition and an invasive procedure. Vital signs are necessary so that the operative team has a baseline for comparison as well as to rule out any complications before the beginning of the surgical event. Providing reassurance to the patient can be done verbally.
Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should consider: a. Checking the carotid pulse. b. Using a stethoscope and assessing the quality of the apical pulse as well as the rate. c. Counting the pulse again for 30 seconds and multiplying the results by two. d. Checking the radial pulse on the opposite side.
b. Using a stethoscope and assessing the quality of the apical pulse as well as the rate. The nurse should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy. The pulse on the opposite side should also be assessed to see if the alteration is happening bilaterally, in addition to assessing the apical pulse.
Pete is a 62-year-old man admitted to the hospital with prostate cancer. Pete is to have his vital signs taken before going to surgery. Which of the following, if present, may increase Pete's pulse rate? (Select all that apply.) a. elevated BP b. fever c. acute pain d. large dose of an opioid analgesic e. Pete's age f. anxiety
b. fever c. acute pain f. anxiety
Which of the following should a nurse assess before administering medications through a nasogastric tube? a) Correct tube placement by inserting air into tube while auscultating at gastric fundus b) Areas of tympany and dullness by percussing abdomen c) amount of residual volume left in stomach d) ability of pt to cooperate with instructions
c) amount of residual volume Checking residual volume prevents putting medications into an already full stomach
A nurse is admininstering aspirin 81 mg PO daily as prescribed. The medication is scheduled for 0800 hours. Which of the following demonstrates proper use of one of the six rights of medication administration? a) the nurse performs the first check of the correct dosage at the pt's bedside b) The nurse identifies the pt by stating the pt's name as written on the medication administration record c) The nurse documents that the aspirin was given at 0825 d) The nurse opens the 82 mg aspirin unit dose package prior to entering the pt's room
c) documents that aspirin was given at 0825 All routinely ordered medications should be given within 60 min of the time ordered (30 min before/after the prescribed time)
What is the normal pulse range for an adult? a. 120 to 160 beats per minute. b. 90 to 140 beats per minute. c. 60 to 100 beats per minute. d. 50 to 80 beats per minute.
c. 60 to 100 beats per minute. The normal pulse range for an adult is 60 to 100 beats per minute. The the pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute.
Mary Helen's temperature is 102.2 ºF (39 ºC). What action should you take? a. None, because this is an acceptable temperature for a young adult. b. None, because her temperature is too low to institute measures to lower her body temperature. c. Administer an antipyretic as ordered. d. Apply a hyperthermia blanket as ordered.
c. Administer an antipyretic as ordered.
Which of the following patients is exhibiting abnormal vital sign values for their age? a. Newborn: Temperature 98.6º F, pulse 130, respiration 35, mean BP 40, pulse oximetry 99% b. Adolescent: Temperature 37º C, pulse 84, respiration 16, BP 120/75, pulse oximetry 100% c. Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84% d. Older adult: Temperature 96.8º F, pulse 98, respiration 12, BP 116/76, pulse oximetry 95%
c. Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84%
Which of the following patients would require follow-up? a. A child with a respiratory rate of 24 breaths per minute. b. An adolescent with a respiratory rate of 16 breaths per minute. c. An adult with a respiratory rate of 10 breaths per minute. d. A newborn with a respiratory rate of 40 breaths per minute.
c. An adult with a respiratory rate of 10 breaths per minute. The normal respiratory rate for a newborn is 35 to 40 breaths per minute. The normal respiratory rate of a child is 20 to 30 breaths per minute. The normal respiratory rate for a teenager is 16 to 20 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up.
Which patient would it be appropriate for the nurse to delegate vital signs? a. New admission to the hospital. b. Patient transferred from ICU. c. Elderly nursing home resident. d. Patient with recent complaint of headache.
c. Elderly nursing home resident. The nurse may delegate routine vital signs of stable patients. Obtaining a baseline upon admission or transfer patient should be completed by the nurse. If a patient has a change in condition, such as a headache which could be reflective of hypertension, the nurse should assess the patient's vital signs.
At the end of the clinical day, the nursing instructor notices that a student nurse has documented a resident having a temperature of 99.8° F (37.7 °C) and that the student administered a flu shot. What should the student nurse have done? a. Notified the doctor of this change in patient condition. b. Administered an antipyretic along with the flu vaccine. c. Held the flu vaccine; notify supervisor or instructor of increase in temperature. d. Administered the flu vaccine and increased the resident's fluid intake.
c. Held the flu vaccine; notify supervisor or instructor of increase in temperature.
A nurse ambulates an unsteady patient, the pt becomes light-headed and begins to fall. Which of the following interventions by the nurse is appropriate in this situation?
extend one leg and allow the pt to slide down it
crutch gait
method of walking with crutches (artificial supports made of wood or metal and used to assist with walking) that involves alternately bearing weight on one or both legs and on the crutches
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) a. Place the patient's feet in a tub of cool water with ice. b. Apply a hyperthermia blanket as ordered c. Remove the patient's blankets. d. Limit the patient's fluid intake. e. Administer an antipyretic to the patient as ordered.
c. Remove the patient's blankets. e. Administer an antipyretic to the patient as ordered. Although the task of temperature assessment may be delegated, it is the nurse's responsibility to determine the accuracy of the measurement and to assess for further indication of infection. Fluids should be increased to 3 L daily (unless contraindicated). The nurse should administer an antipyretic as ordered and reassess the temperature in 30 minutes and every 4 hours until the temperature has stabilized within normal limits. A cool wet wash cloth may be provided, but the patient should not be excessively chilled, such as with ice. Cooling the temperature in the room will aid in reducing the temperature, and reducing the amount of external covering will promote heat loss. A hyperthermia blanket is used to raise body temperature.
Which of the following charting entries depicts the most complete assessment of the vital sign respiration? a. The respiratory rate is 16 with a regular rhythm. b. Deep respirations are noted at a rate of 12 per minute. c. Respirations are nonlabored and regular at a rate of 20 per minute with normal depth. d. Respirations are shallow at a rate of 25 per minute. The patient complains of pain in the left lower leg, rated at a "7" on the pain scale.
c. Respirations are nonlabored and regular at a rate of 20 per minute with normal depth.
Blood pressure =
cardiac output x peripheral vascular resistance
apnea
cessation of airflow through the nose and mouth
circumduction
circular movement of a limb or of the eye
Temperature of deep body tissue
core temperature
A nurse is teaching the daughter of an older adult pt how to instill eye drops in the pt's right eye. Which of the following statements indicates that the daughter has understood the directions a) "I will have my mother look down while dropping the medication into her eye" b) " I will instruct my mother to tightly close her eye for 30-60 seconds after medications have been given" c) I should apply the medication using a thin stream from the inner canthus to the outer canthus" d) I will pull down her lower eyelid and drop the medication inside"
d) i will pull down her lower eyelid This method will allow the medication to be distributed evenly across the eye with less discomfort
A nurse is caring for a pt. who has been prescribed a fluticasone propinate (Flovent HFA) inhaler with a spacer. The pt asks the nurse why a spacer is needed with the inhaler. Which of the following responses by the nurse is correct? a) "By using a spacer, you can take the medication correctly without any spills" b) "You can inhale five or more puffs in 1 min when using a spacer" c) " By using a spacer, you eliminate the need for mouth rinsing after administration" d) "More medication is delivered to the lungs when you use a spacer"
d) more medication is delivered A spacer slows down and breaks up the medication, allowing the pt to better control the flow of medication. This, in turn, decreases the amount of medication deposited in the oropharynx
You check the patient's temperature using the axillary route, and the thermometer reads 97.9° F (36.6 °C). Which of the following would be the most accurate documentation of the reading? a. 97.9° F (36.6 °C) b. 98.8° F (37.1 °C) c. 97.0° F (36.1 °C) Ax. d. 97.9° F (36.6 °C) Ax.
d. 97.9° F (36.6 °C) Ax.
For which patient would a tympanic thermometer be the preferred thermometer to use? a. A marathon runner who developed weakness during the race. b. A newborn in the intensive care unit that requires continuous temperature monitoring. c. A child who had tubes surgically placed in the ears. d. A tachypneic patient who is receiving oxygen by nasal cannula.
d. A tachypneic patient who is receiving oxygen by nasal cannula. An advantage to the tympanic thermometer is that it can be used for tachypneic patients. The tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic membrane and does not accurately measure core temperature after exercise. A continuous measurement cannot be obtained with the tympanic thermometer.
The nursing student administered morphine 5 mg IV at 1330 for pain to a postoperative knee replacement patient. The nursing student returned to the patient's room in 30 minutes to determine whether the medication was effective. The nursing student noticed that the patient's respirations were regular at 8 per minute. What would this breathing pattern be called? a. Tachypnea b. Cheyne-Stokes respiration c. Biot's respiration d. Bradypnea
d. Bradypnea
grab bars
metal bars mounted on walls for patients to hold onto for balance as they transfer, they are commonly found in bathrooms next to tubs, showers, and toilets
How can the nurse best obtain an accurate measurement of a patient's respiratory rate? a. Inform the patient when monitoring his or her respirations. b. Assess the respirations while the patient is talking. c. Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. d. Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest.
d. Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest. If the patient is aware that the nurse is monitoring his or her respirations, the patient will most likely alter the breathing pattern. It is best to discretely observe the rise and fall of the patient's chest. Assessing the patient's respirations while they are talking may make it more difficult to assess and may affect the rate. Auscultation will enable the nurse to identify lung sounds, but having the patient take deep breaths would affect the accuracy of the rate.
Prior to taking her temperature, Mary Helen tells you that she just drank some ice water. What is your best action? a. Praise her for increasing her fluid intake as this will help lower her temperature. b. Take her temperature orally and document that the patient reports having drank cold water prior to assessment. c. Take her temperature by another route. d. Inform her to refrain from eating or drinking until you return in 20 minutes to assess her oral temperature.
d. Inform her to refrain from eating or drinking until you return in 20 minutes to assess her oral temperature.
The NAP reports to you that a patient is "feeling different" and appears less alert. Your first action should be to: a. Notify the health care provider. b. Inform the NAP of the patient's "normal" values for vital signs. c. Instruct the NAP to retake the vital signs and report back. d. Obtain the vital signs yourself. e. Instruct the NAP to continue to assess and monitor the patient closely.
d. Obtain the vital signs yourself.
Pete is a 62-year-old man admitted to the hospital with prostate cancer. Where will you best be able to auscultate Pete's apical pulse? a. The right 2nd ICS b. The left 2nd ICS c. Erb's point d. The 5th ICS/left MCL
d. The 5th ICS/left MCL The apical pulse is best auscultated at the PMI or AI, located at the 5th ICS, left MCL
The nursing student administered morphine 5 mg IV at 1330 for pain to a postoperative knee replacement patient. The nursing student returned to the patient's room in 30 minutes to determine whether the medication was effective. The nursing student noticed that the patient's respirations were regular at 8 per minute. What is the most likely explanation for this breathing pattern? a. The patient is in pain. b. The patient is anxious. c. The patient is anemic from blood loss during the surgery. d. The patient is experiencing an effect of the morphine.
d. The patient is experiencing an effect of the morphine. Pain, anxiety, and anemia will all increase the respiratory rate. Opioid analgesics, such as morphine, will depress the rate and depth of respirations in toxic or high doses. This patient's respiratory rate is below the normal range of 12-20 for an adult, most likely from the effects of the morphine on the central nervous system.
The students are administering flu shots to the residents in a nursing home. Prior to administering the flu shots, the students have been instructed to obtain the vital signs, auscultate lung sounds, and document their findings in the residents' medical record. They should hold the flu vaccine if a resident's temperature is elevated. Why do you think the students have been asked to do this? a. To get more practice assessing vital signs and lung sounds. b. To prevent the resident from having an allergic reaction. c. To get to know the residents better prior to an invasive procedure. d. To verify the resident does not have a fever and can receive a flu shot.
d. To verify the resident does not have a fever and can receive a flu shot.
You enter the patient's room to take routine vital signs. You see that the patient has just finished exercising with physical therapy. What is your best action? a. Skip this routine vital sign assessment. b. Wait 30 minutes to 1 hour before assessing the pulse. c. Take the patient's radial pulse. d. Wait 5 to 10 minutes before assessing the pulse.
d. Wait 5 to 10 minutes before assessing the pulse.
When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? a. Have someone else assess the patient's respiratory rate. b. Remove the patient's gown so you have better visualization of the patient's chest for assessment. c. Document the inability to visualize inspiration and expiration. d. While holding the patient's wrist, move the patient's arm over the chest or abdomen, then feel the rise and fall of inspiration and expiration and assess the rate.
d. While holding the patient's wrist, move the patient's arm over the chest or abdomen, then feel the rise and fall of inspiration and expiration and assess the rate. If unable to visualize respirations, the nurse should discreetly feel the patient's respirations. The nurse should first attempt to hold the patient's wrist and move it over the patient's chest or abdomen, feel the rise and fall of inspiration and expiration, and assess the rate. The nurse needs to obtain the patient's respiratory rate. Documenting inability to visualize respirations may imply the patient is deceased or that the nurse is incompetent.
atrophy
decrease in size, wasting away, or progressive decline of a body part or tissue
Kussmaul's
deep regular respiration, common with diabetics
body mechanics
describes the safe use of the body to maintain balance, posture, and alignment during movement, especially bending, lifting, and walking.
Patients who are on bed rest or immobile because of an illness, injury, or surgery are at risk for developing...
developing deep vein thrombosis (DVT).
sphygmomanometer
device for measuring the arterial blood pressure that consists of an arm or leg cuff with an air bladder connected to a tube and bulb for pumping air into the bladder and a gauge for indication the amount of air pressure being exerted against the artery.
dorsal
directed toward or situated on the back surface
hypertension
disorder characterized by an elevated blood pressure persistently exceeding 120/80 mmHg
the diaphragm relaxes upward, and the ribs and sternum return to their relaxed position, and the abdominal organs return to their original position.
expiration
distal
farthest from the origin of a part
A nurse is caring for a hospitalized pt who is performing active range of motion exercises. Which of the following body movements should indicate the nurse the patient has full range of motion of the shoulder?
flexing the shoulder by raising the arm from a side position to a 180* angle.
You'll use a _____ for patients who need help with ambulation or with transferring from the bed to a chair.
gait belt
apical pulse
heartbeat as listened to with the bell or diaphragm of a stethoscope placed on the apex of the heart
A nurse in the emergency department is caring for a pt who has a knee injury. The pt will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include when discharging this pt?
hold the cruthces on the unaffected side when preparing to sit in a chair
What part of the brain controls the temperature?
hypothalamus
You'll help prevent deformities and contractures by placing a hand roll...
in the patient's hand to position and maintain the wrist and fingers in a functional position. You can roll up a washcloth to make a hand roll.
Patients are often placed in Fowler's position to...
increase comfort, to improve ventilation, and to promote relaxation after thoracic surgery or for patients with cardiovascular problems. For this position, the head of the bed is elevated 45 degrees. The patient's hips may or may not be flexed. You'll place pillows behind the patient's head and lower back and underneath the forearms, thighs, and ankles for support. You might also use a footboard to keep the patient's feet in proper alignment and to help prevent footdrop.
hypertrophy
increase in the volume of a tissue or organ produced entirely by enlargement of existing cells
Decreased hemoglobin levels lower the amount of oxygen carried in the blood, which results in...
increased respiratory rate to increase oxygen delivery.
An increase in altitude lowers the amount of saturated hemoglobin, which lowers the amount of saturated hemoglobin, which...
increases respiratory rate and depth.
the diaphragm contracts, causing abdominal organs to move to increase the size of the chest cavity. At the same time, the ribs and sternum lift outward to promote lung expansion.
inspiration
The body uses more energy during __________ than during __________.
inspiration; expiration
Placing a patient in Trendelenburg's position...
involves lowering the head of the bed and raising the foot of the bed. Patients who have hypotension can benefit from this position because it promotes venous return.
Cheyne-Stokes
irregular rate and depth of respiration with mixed periods of apnea and increased depth
Patients who have breathing problems are often placed in the orthopneic, or tripod, position since....
it allows maximum expansion of the chest. For this position, the patient sits in bed or on the side of the bed with an overbed table in front to lean on and several pillows on the table to rest on.
When caring for patients using a CPM machine...
it is important to check the alignment and positioning of the leg frequently and to inspect the skin for any areas of redness or irritation. It is also important to rest the joint throughout the day. The provider commonly prescribes the frequency of rest periods and the length of time to keep the CPM machine off.
A nurse is observing an assistive personnel (AP) who is using a mech lift with a hammock sling to transfer a pt from the bed to a chair. The nurse should intervene if the AP...
leaves the bed in the lowest position throughout the procedure.
prone
lying on the abdomen with the legs extended and the head turned to the side
supine
lying on the back, usually slightly elevated with a small pillow
antipyretic
substance or procedure that reduces fever
A nurse stands facing a pt to demonstrate active range of motion exercises. Which of the following should the nurse do when demonstrating hyperextension of the hip?
move the leg behind the body
abduction
movement away from the midline of the body
hyperextension
movement of a body part beyond its usual resting and extended position
pronation
movement of a body part so that its front or ventral surface faces downward
supination
movement of a body part so that its front or ventral surface faces upward
flexion
movement that decreases the angle between two adjoining bones; bending of a limb
adduction
movement toward the midline of the body
proximal
nearest to the origin of a part
eupnea
normal respirations that are quiet, effortless, and rhythmical
Patients who have been immobile or on bed rest...
often experience vertigo and orthostatic hypotension the first few times they sit up in bed or try to stand. Therefore, it is often beneficial to break the ambulatory process into stages to ensure safety.
external rotation
outward rotation (turning around an axis) of a joint
Before assisting a patient with ambulation, transferring, or range-of-motion exercises, it is important to...
perform a thorough assessment of the patient's muscle strength, ability to move, and activity tolerance as well as the need for assistive devices or additional staff.
Assessing the patient's __________ __________ sites offers valuable data for determining the integrity of the cardiovascular system.
peripheral pulse
diastolic
pertaining to diastole, or the pressure at the instant of maximum cardiac relaxation
febrile
pertaining to or characterized by an elevated body temp
systolic
pertaining to or resulting from ventricular contraction
Vital signs are important indicators of the body's __________ __________.
physiologic status
For patients who are ill or recovering from surgery...
provide a simple "assist." It can involve just walking alongside the patient or using a gait belt for additional stability. For patients who need more than that, offer an assistive device such as a cane, a walker, or crutches.
elastic stockings
provide continuous pressure to the lower extremities to keep blood from pooling and blood clots from developing in the deep veins of the lower extremities; surgical patients wear them preoperatively, intraoperatively, and postoperatively as prescribed.
Sequential Compression Devices (SCDs)
provide intermittent compression to the lower extremities to promote venous return and to help prevent DVT; they can be applied to one or both lower extremities, depending on the patient's specific needs. SCDs are contraindicated for patients who have severe arterial disease.
The supine position...
provides comfort in general and specifically for patients recovering from some types of surgery. To provide support and maintain body alignment in this position, place a pillow under the patient's head and shoulders and a towel roll or small pillow under the small of the back and under the thighs to keep the patient's knees slightly flexed. You can also elevate the patient's forearms on pillows placed at the patient's sides.
When there is a difference between the heart rate and a peripheral pulse rate, a __________ __________ exists.
pulse deficit
The difference between systolic and diastolic pressure is called the ______________ ______________.
pulse pressure
tachycardia
rapid regular heart rate ranging between 100 and 150 beats per minute
Tachypnea
rate is regular but greater than 20 breaths per minute
Bradypnea
rate is regular but less than 12 breaths per minute
You are giving a patient several PO medications to take. THe patient tells you that she can only take one pill at a time. It is appropriate to
remain at the bedside until you are sure the patient has taken all of the medications
A drug's generic name is the
same as it's nonpropritary name
diaphoresis
secretion of sweat especially profuse secretion associated with an elevated body temp, physical exertion, or emotional stress
Once you place the patient's leg in the CPM machine and make sure it is in proper alignment...
secure it to the machine with Velcro straps. When you turn the machine on, the frame will slide back and forth, gently flexing and extending the joint to the prescribed degree and at the prescribed speed.
dangling
sitting on the side of the bed with the legs suspended freely from the knees
bradycardia
slower-than-normal heart rate; heart contracts fewer than 60 times per minute
body mechanics
the coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during movement, especially bending, lifting, and walking
friction
the force that resists relative motion between two objects in contact
In Sims' position...
the patient is halfway between the lateral and the prone positions. The upper arm is flexed at the shoulder and elbow, and the lower arm is positioned behind the patient. Both legs are in a flexed position in front of the patient, with the upper leg more flexed than the lower one. This position is most often used when patients are receiving an enema or for an examination of the perineal area.
In the lateral or side-lying position...
the patient lies on one side of the body with the top leg in front of the bottom leg and the hip and knee flexed. This position helps relieve pressure on the sacrum and is especially useful for patients who are on bed rest and spend a lot of time supine or in Fowler's position. To maintain proper body alignment in this position, place a pillow under the patient's head and neck, another under the upper arm (with the lower arm flexed), and another between the legs to keep the hips properly aligned.
gait
the pattern of how a person walks
center of gravity
the point at which a body's entire weight is concentrated so that, if supported at this point, the body would remain in equilibrium in any position
passive range of motion
the process of putting a joint through its full extent of movement by someone other than the patient
active range of motion
the process whereby a patient puts a joint through its full extent of movement
base of support
the space between the feet that bears the weight of the body
The strength or amplitude of a pulse reflects...
the volume of blood ejected against the arterial wall with each heart contraction.
If a patient becomes weak or dizzy during ambulation and begins to fall, it is important...
to protect both yourself and her from injury. Instead of trying to hold the patient up or catch her, help ease her gently to the floor.
Mechanical lifts are used...
to transfer patients who are very heavy or extremely incapacitated. They consist of a wheeled base, an overhead bar with a sling suspension system, and a sling that supports the patient's weight. Depending on the lift used, the lifting bar may be moved using a manual hydraulic pump or a remote-control electrical device.
Use a _______ to move a patient from a stretcher or a gurney to a bed. You'll use a draw sheet to reposition a patient in bed.
transfer board
Use _______ for patients who have muscle weakness or paralysis on one side of the body. The roll keeps the patient's hips in a neutral position. You can make a _____ by folding and rolling up a bath blanket.
trochanter rolls
eversion
turning of a body part away from the body's midline
inversion
turning of a body part toward the body's midline
How many fingers should be able to fit in SCD sleeve to determine the correct size?
two fingers
dorsiflexion
upward bending of the toes and the foot
Elastic stockings can be difficult to apply because of their firmness and lack of stretch. Thus...
using an "inside out" technique can make the process much easier and more comfortable for the patient.
If the __________ __________, the pulse often becomes weak and difficult to palpate. A full bounding pulse is an indication of __________ __________.
volume decreases; increased volume.
afebrile
without fever
Pillows help...
you support and maintain the patient in specific positions. For example, place several behind the patient's back to help maintain a lateral position or between the patient's knees and ankles for comfort and to keep them from rubbing together and possibly causing skin breakdown. Use pillows to elevate the patient's extremities or upper body as well.