Foundations Final

Dysuria

A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing:

Negative airflow room

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room

Urinary Output Last Serum Potassium Level patency of the IV Access

A client is scheduled to receive an IV infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following?

Crackles in the lungs

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?

Bargaining

A dying patient is overheard promising to make amends with her estranged brother if she can live long enough to see the birth of her grandchild. the patient is in which stage of grief

1,2,4

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Select all that apply.) 1 Oral temperature 98.2° F 2 Apical pulse 88 beats per minute and regular 3 Respiratory rate of 30 per minute 4 Blood pressure 116/78 mm Hg while in a sitting position 5 Oxygen saturation of 92%

Power of attorney

A nurse informs her client that he should give someone authority to make medical decisions for him in the event that he is unable to do so. What is the the document that allows this

Urin output less than 20 mL/hr

A nurse is assessing a patient postopritivley \. Which finding noted 8 hours after surgery should be reported to the surgeon

Change in mental status

A nurse is working in the emergency department and is assessing a 79 year old patient who arrived via ambulance. Which of the following found during assessment would be considered an early sign of dehydration

56 year old client on warfrin with an INR of 7.5

A nurse receives report on the following clients which one should receive care first

Who uses a cane to ambulate

A nurse recognizes that the patient at the highest risk for falls is the patient

The nurse should get a detailed history of the pain and perform a focused assessment

A patient presents to the emergency department complaining of abdominal pain. Which component of the health examination should the nurse consider doing first?

Call the provider to discuss the inappropriate order

A provider orders a medication for a patient with liver failure that is contraindicated in the patients condition what would be the most appropriate action for the nurse to take

Nosococimal

A surgical client develops a wound infection during hospitalization. How is this type of infection classified

Clarifying the physicians order

According to the Nurse Practice Act, the nurse is liable for

Increased heart rate, independent edema, and chest pain

An elderly patient was on bedrest for 3 days and is not hospitalized for RA. which of the following should be a primary concern to the nurse performing an initial assessment

Tachycardia

An expected finding for a patient in acute pain is

State of depression that occurs after loss

Bereavement is best defined as

Narcolepsy

During assessment, the patient tells the nurse he has irresistible sleep attacks at multiple times in the day. Each lasts about 10 minutes. The nurse expects the patient may be experiencing

Cardiac function

Potassium is needed for neural, muscular, and

Tissue Ischemia

Pressure ulcers form primary as a result of

a,b,d

The body's response to a stressful situation includes which of the following dilated pupils increased pulse hypoglycemia bronchial dilation

Determine if client goals were met

The most important purpose of the evaluation component of the nursing process is

Activities of daily living

The nurse is assessing the patient's ability to bathe and dress himself. The nurse knows this type of assessment is considered

Removal of all iv's and other medical tubing

The nurse is preparing the body of a patient who died following an accident at work. Which of the following would be contraindicated

2,4,5

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging, such as: (Select all that apply.) 1. Hearing loss related to aging begins in the mid 40s. 2. The progression is slow. 3. The aging person has low-frequency tone loss. 4. The aging person may find it harder to hear consonants than vowels. 5. Sounds may be garbled and difficult to localize. 6. Hearing loss reflects nerve degeneration of the middle ear.

Remove debris from the wound

The nurse prepares to irrigate the client's wound. The primary reason for performing this procedure is to:

Paralytic ileus

The patient complains of severe abdominal pain on the third postoperative day. The patients bowel sounds are absent. What does the nurse suspect

route

The physician orders ampicillin 1 g every 6 hours for Mr. Smith. what is missing from the order

cortisol

The primary hormone secreted by the adrenal cortex during stress response is

Before, during, and after the procedure

The term perioperative refers to

2,4,5

What are the best ways for a nurse to be protected legally? (Select all that apply.) 1.Ensure that a therapeutic relationship with all clients has been established. 2.Provide care within the parameters of the state's nurse practice act. 3.Carry at least $100,000 worth of liability insurance. 4.Document consistently and objectively. 5.Clearly document a client's non-adherence to the medical regimen.

the prevent bladder distention

What is the rationale for having a patient void before surgery

Allergic

When a patient develops a rash 30 mins after receiving antibiotics, he is likely receiving which type of reaction

Chronic venous insufficiency

When assessing a client a nurse finds that a patient has coarse, thickened skin and brown discoloration on lower legs. This finding is most liekly a result of

18 guage

When starting an iv in the preoperative adult patient, which gauge of iv catheter should be used

Incisional edges approximated without redness or drainage, two 4 4s applied.

Which nursing entry is most complete in describing a client's wound

Turn and position the client at least every 2 hours

Which of the following interventions is most likely to minimize the cause of a pressure ulcer on the left buttock of a client that is comatose?

Elderly

Which of the following is most likely to have altered metabolism of medications

Surgeon

Which of the following personnel have the legal responsibility to obtain informed consent for a surgical procedure

Why did you come in today

Which of the following questions would likely warrant the best response

Grandparents live next door

Which of the following would generally not be considered a factor for altered family functioning

Notify the clients physician with the results

a nurse recieves abnormal results of diagnostic testing. what is the nurses ethical and legal accountability

a systemic approach to obtaining subjective information

the nurse is completing a review of systems (ros) during a health assessment. the nurse knows that the ROS is considered what?

upon admission

the nurse is preparing for discharge planning for a hospized patient. when should the discharge planning begin

The nurse should introduce himself and wash his hands

the nurse is preparing to perform a physical assessment on a hospitalized patient. what sequence should the nurse use

a,b,d

the nurse should know what is true about iv fluid overload Select all that Apply a. The use of packed cells instead of whole body will decrease the fluid volume given to the patient b. a symptom of fluid volume overload is distended neck veins c. the patient will likely develop a fever in the presence of the overload d. the infusion rate must be carefully monitored during the administration of the blood

Infiltration

the site of a pateints iv is cool pale and swollen and the solution is not infusing. which of the following is the patient experiencing

Aspiration pneumonia

when providing care for a patient with an ng tube, the nurse should take measures to prevent what serious complications?

drink a glass of milk with a turkey sandwich

which of the following activities would be appropriate to suggest for the patient who has difficulty falling asleep every evening

Reflecting on thoughts before reaching a conclusion

which of the following are essential elements to critical thinking

Maintain patency by flushing with a heparinized solution

which of the following nursing actions is appropriate in the care of a patient with an implanted vascular access device

Preventing an older adult from getting up at night due to a nurse shortage

which of the following would be an inappropriate use of a restraint device