Fundamentals Test 2

When should the 3 checks be done prior to administering a medication?

2 while preparing medication in the medication room 1 while at bedside before administering medication

A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in which of the following? (Select all that apply.) 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Outcome setting

2,3,4

The nurse plans care for a 16-year old male, taking into consideration that stressors experienced most by adolescents include which of the following? Select all that apply 1.Loss of autonomy caused by health problems 2.Physical appearance and body image 3.Accepting one's personal identity 4. Separation from family 5. Taking tests in school

2,3,4,5

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in an apartment with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes." The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb). The nurse documents the assessment findings listed below. Which of the assessment findings require priority follow-up by the nurse? (Select all that apply.) 1. The patient has no history of chronic disease. 2. Patient urinates at night. 3. Patient reports having difficulty cleansing herself after voiding or passing stool. 4. Body temperature 38°C (100.4°F) 5. Recent history of weight gain 6. Knowledge of perineal care 7. Last normal bowel movement 2 days ago 8. Frequency of diarrhea

2,3,4,5,6,8

The nurse is visiting a patient who lives alone at home. While talking with the patient's family caregiver, the nurse learns that the patient has been missing doses of medications. The patient currently self-medicates. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to help the patient improve adherence? (Select all that apply.) 1. Reviewing the family caregiver's understanding of purpose of medications 2. Determining the value the patient places on taking medications 3. Reviewing the number of medications and time each is to be taken 4. Determining patient's perceptions of consequences associated with missing specific medicines 5. Reviewing the therapeutic actions of the medications

2,4

A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to AMDS or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADMS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside

2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR.

Which complementary therapies are most easily learned and applied by a nurse? (Select all that apply.) 1. Therapeutic massage therapy 2. Traditional Chinese medicine 3. Progressive relaxation 4. Breathwork and guided imagery 5. Therapeutic touch

3,4

The nurse is interviewing a patient in the community clinic and gathers the following information about her: She is intermittently homeless and is a single parent with two children who have developmental delays. She has had asthma since she was a teenager. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during a complete patient assessment? (Select all that apply.) 1. Posttraumatic stress disorder 2. Rising hormone levels 3. Chronic illness 4. Insomnia 5. Depression

3,4,5

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

3,5

Name the years/age range in what Erickson's stage of Psychosocial development this occurs: Stage 3: Initiative versus guilt

3-6 years

A nursing student is providing a hand-off report to the RN assuming the patient's care. The nursing student explains, "I ambulated him twice during the shift; he tolerated walking to end of hall and back each time with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS." Which intervention is a dependent intervention? 1. Providing hand-off report at change of shift 2. Enhancing the patient's sleep hygiene 3. Administering IV fluids 4. Taking vital signs

3. Administering IV fluids

While planning care for a patient, a nurse understands that providing integrative care includes treating which of the following? 1. Disease, spirit, and family interactions 2. Desires and emotions of the patient 3. Mind-body-spirit of patients and their families 4. Muscles, nerves, and spine disorders

3. Mind-body-spirit of patients and their families

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? 1. Patient in pain 2. Patient newly admitted 3. Patient who returned from surgery 4. Patient requesting assistance with meal tray

3. Patient who returned from surgery

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2

3. Respiratory rate of 8 breaths/min

A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which of the following is appropriate for evaluating a patient's expectations of care? 1. On a scale of 0 to 10 rate your level of nausea. 2. The nurse weighs the patient. 3. The nurse asks, "Do you believe that you received the information you needed to follow your diet?" 4. The nurse states, "Tell me four different foods included in your diet."

3. The nurse asks, "Do you believe that you received the information you needed to follow your diet?"

How many minutes do you have to give a STAT medication?

30 minutes

Lauren is to receive 6 tsp of medication, how many mLs of medication would she receive?

30 ml

Mrs.Jones has a temperature of 100 F , what would her temperature be in C (celcius)?

38 C

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and does not see how he can go on much longer. Which statement would be the nurse's best response? 1. "Are you thinking of suicide?" 2. "You've been doing a good job raising your children. You can do it!" 3. "Is there someone who can help you during the evenings and weekends?" 4. "Tell me what you mean when you say you can't go on any longer."

4. "Tell me what you mean when you say you can't go on any longer."

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced range of motion of lower hip, reduced strength in left leg, and difficulty turning in bed without assistance. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster. 5. Validated data set

4. Data Cluster

A patient has been admitted from the emergency department (ED) with a primary problem of abdominal pain. Diagnostic tests performed in the ED are pending. The nurse focuses an examination on the abdomen and uses the following techniques. Which technique is correct? 1. Perform auscultation first. 2. Have patient place folded arms under the head. 3. Palpate the patient's painful area first. 4. Observe the contour of the abdomen while asking the patient to take a deep breath and hold it.

4. Observe the contour of the abdomen while asking the patient to take a deep breath and hold it.

A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 1 hour ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient's heart rate is 92 compared with 76 immediately postoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postoperative dose of an ordered analgesic has not yet been given. Which of the following factors is most likely to cause the nurse to reflect on the patient's situation? 1. The patient is recovering normally. 2. The nurse observes symptoms of restlessness 3. The patient's blood pressure trend 4. The delay in administration of the analgesic

4. The delay in administration of the analgesic

How many stages of Erikson's Psychosocial development are there?

8

Emerald is to receive 120 mL of medication, how many tablespoons (tbsp) would she receive?

8 tbsp

How many minutes do you have to give a NOW medication?

90 minutes

A nurse is caring for a patient who has poor pain control. The patient has a history of opioid abuse. During the day, the patient made frequent requests for a pain medication. To make an effective clinical decision about this patient, the nurse needs to ask questions about the data available on the patient to make a thorough and thoughtful decision. The nurse asks herself, "How does my view about the patient's pain tolerance compare with the patient's, and does that pose a problem?" This is an example of 1.A question about assumptions 2. A question about evidence 3. A question about perspective 4. A question about procedures

A question about perspective

Mr. Smith is given 2 medication orders to be given prn, which one would you give first? 1.Zofran 4 mg SL q 12 hours prn 2. Acetaminophen 325 mg PO q 4 hours prn

Acetaminophen Rationale: it is PO so should be given first as Zofran is SL (sublingual) so may be swallowed with the acetaminophen if given first.

What are some Physiological Responses that you're likely to see in the a patient in Alarm Reaction Stage: (There are so many)

Alert, Anxious, Restless, Senses are fine-tuned Elevated BP, Pulse, Stress Hormones, Blood Glucose Dilated Pupils Increased Depth and Rate of Respirations Pale skin, cool hands and feet Dry Mouth Peristalsis Decreased Increased Muscle Tension Sleep Disturbances Changes in appetite and weight Urinary decrease or increase

Which of the following guidelines must a nurse use for taking verbal or telephone orders? (Select all that apply). 1. Follow the health care agency guidelines regarding authorized staff who may receive and record verbal or telephone orders. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

All 1-5

A nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls and stuffed animals as if they have thoughts and feelings. This is an example of:

Animism

What heart sound is this?

Aortic Stenosis

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: 1Creativity 2Fairness 3Applying ethical criteria 4Clinical Reasoning

Applying ethical criteria

The reaction to any kind of stressor is? 1. Distress 2.Illness 3. Appraisal 4. Eustress

Appraisal

What two systems does GAS primarily involve? 1.Sympathetic and Cardiovascular System 2.Respiratory System and Endocrine System 3. Autonomic Nervous System and Endocrine System 4. Lymphatic and Autonomic Nervous System

Autonomic Nervous System and Endocrine

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying "The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? 1.Conversion 2.Denial 3.Dissociation 4.Displacement

Denial

A nurse is caring for a man who is recently retired and who appears withdrawn. He says he is "bored with life." The nurse helps this individual find meaning in life by: 1Encouraging him to adopt a new pet 2Encouraging relocation to a new city 3Explaining the need to simplify life 4Encouraging him to reflect on his relationships with others

Encouraging him to reflect on his relationships with others

What 2 hormones are released during the Alarm Reaction?

Epinephrine and Cortisone

True or false: nursing students can take medication orders

FALSE! only licensed nurses can do so

True or False: Distress is Positive Stress.

False

True or False: Eustress is Negative Stress

False

True or False:Health Belief Model and Health Promotion Model are the same thing

False

True or False:The second level of Maslows is Love and Belonging Needs

False

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) 1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure

1,2,3,5

Name the 3 levels of GAS. 1.Alarm Reaction 2.Exhaustion Stage 3.Bell Stage 4.Resistance Stage

1,2,4

An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What actions should the nurse take to help the older adult patient? (Select all that apply.) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when.

1,2,5

When assessing an older woman who is recently widowed, the nurse suspects that the woman is experiencing a developmental crisis. Which questions provide information about the impact of this crisis? Select all that apply 1.With whom do you talk on a routine basis? 2.What do you do when you feel lonely? 3.Tell me what your husband was like. 4.I know this must be hard for you. Let me tell you what might help 5. Have you experienced any changes in lifestyle habits, such as sleeping, eating, smoking, or drinking?

1,2,5

Setting priorities for a patient's nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply.) 1. Priority setting establishes a preferential order for nursing interventions. 2. In most cases wellness problems take priority over problem-focused problems. 3. Recognition of symptom patterns helps in understanding when to plan interventions. 4. Longer-term chronic needs require priority over short-term problems. 5. Priority setting involves creating a list of care tasks.

1,3

Which cognitive skills can a patient develop while practicing relaxation? (Select all that apply.) 1. Increasing an ability to focus attention for an extended period of time 2. Limiting stimuli that come into one's field of vision 3. Stopping a focus on unnecessary goal-directed activity 4. Being able to tolerate experiences that are uncertain 5. Building relationships with significant others

1,3,4

Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation involves reflection on the approach to care. 2. Evaluation involves determination of the completion of a nursing intervention. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is performed only when a patient's condition changes

1,3,4

The nurse is caring for a patient who is suffering from posttraumatic stress disorder (PTSD) after a motor vehicle accident. What assessment findings reported by the patient provide cues to validate the diagnosis of PTSD? (Select all that apply.) 1. Frequent feelings of anxiety 2. Need to be around people 3. Frequent nightmares 4. Flashbacks to the accident 5. Feelings of sadness

1,3,4,5

The nurse is caring for a patient who is suffering from posttraumatic stress disorder after a motor vehicle accident. What assessment findings reported by the patient provides cues to validate the diagnosis of PTSD? Select all that apply. 1. Frequent feeling of anxiety 2. Need to be around people 3. Frequent nightmares 4. Flashbacks to the accident 5. Feelings of sadness

1,3,4,5

Name the years/age range in what Erickson's stage of Psychosocial development this occurs: Stage 2: Autonomy versus shame and doubt

1-3 years

Mr. Doe has a temperature of 40 C, what would his temperature be in F?

104 F

John Doe weighed in at 250 lbs, what would his weight be in kg?

113.6 kg

The nurse encourages family to bring music that helps the patient relax. The nurse is practicing which model of care?

Holistic

What heart sound is this?

Holistic Murmur

Lanoxin (digoxin)- Order: Digoxin 0.25 mg PO daily for irregular heart rate How many tablets will the nurse administer per dose? What vital sign might we check before administering this medication? (hint: think back to med CLA)

How many tablets per dose? 4 tablets We would check the apical pulse since it is administered for irregular heart rate. Note-if no parameters we would make sure to administer only if apical heart rate was above 60 bpm.

What are the 3 areas focused on in the Health Promotion Model? 1 Behavioral outcome, individual characteristics and experiences, sociopsychological variable 2 Individual characteristics and experiences, sociopsychological variable, behavior-specific cognition and affect 3.Sociopsychological variable, behavior-specific cognition and affect, behavioral outcome 4,Individual characteristics and experiences, behavior-specific cognition, behavioral outcome

Individual characteristics and experiences, behavior-specific cognition, behavioral outcome

A nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Eriksons stages of development? Trust vs Mistrust Initiative vs Guilt Industry vs. Inferiority Autonomy vs. Sense of shame and guilt

Initiative vs. Guilt

What heart sound is this?

Innocent Murmur

Dave Reports being happy and satisfied with his life. What do we know about him? 1He is one of the later developmental periods, concerned with reviewing his life 2He is atypical. since most people in any of the developmental stages report significant dissatisfaction with their lives. 3It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages. 4He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships

It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages.

True or false: you cannot delegate passing meds to another person, including RNs

True, even if it is another RN we have to give the medication we prepared. Only time we can do so is if it is a code situation

What lung sound is this? (Play the speaker)

Wheezing

What is the definition of health? The complete absence of disease a state of complete physical, mental, and social well-being State of complete physical and mental well being State of complete physical and social well being

a state of complete physical, mental, and social well-being

Stress is...

actual or alleged hazard to the balance of homeostasis

Name the years/age range in what Erickson's stage of Psychosocial development this occurs: Stage 1: Trust versus Mistrust

birth to 1 year

If patient does not meet the first level of Maslow's hierarchy of needs, what can this lead to?

illness

What is GAS triggered by? 1. Annoying events 2.Psychological events 3. Physical Events 4. Physical and Psychological Events

physical or psychological events

What Gland initiates GAS? 1. Pineal 2. Pituitary 3.Thyroid 4.Adrenal

pituitary

What does Maslow Hierarchy's thrid level consist of?

Love and Belonging

How long is the Alarm Reaction Stage?

Minutes to Hours

GAS is also called ___________. 1.Cardiovascular Response 2.Farting 3.Respiratory Response 4. Neuroendocrine Response

Neuroendocrine Response

Ordered: Tylenol 325 mg 1 tablet q 4 h prn, moderate pain 1-3 Patient reports pain of 2, can this medication be given if patient had Tylenol 3 hours ago?

No because it is every 4 hours. Patient falls into the pain scale category, but does not meet time criteria.

When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of:

Object Permanence

You are conducting a home visit with a new mom and her 3 kids. While in the home you weigh each family member and reviews their 3-day food diary. You check the moms blood pressure and encourages the mom to take the kids for a 30 minute walk every day. You also encourage healthy food choices. You are addressing which level of need, according to Maslow's Hierarchy of Needs?

Physiological

What lung sound is this? (Play the speaker)

Pleural Friction Rub

When preparing a 4 year old child for a procedure, which method is developmentally most appropriate for the nurse to use? 1Talking to the child in simple terms about what will happen 2Showing the child pictures of what will be experienced 3Preparing the child through play with a doll and toy medical equipment 4Allowing the child to watch another child undergoing the same procedure

Preparing the child through play with a doll and toy medical equipment

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the health care provider's order. At the bedside, the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude? 1. Humilty 2. Accuracy 3.Responsibilty 4.Fairness

Responsibility

What of the following rights is missing? Ordered: diazepam 2 mg po TID Given: diltiazem 2 mg po TID

Right drug

What of the following rights is missing from this ordered: Xanax 0.25 mg stat

Right route

What lung sound is this? (Play the speaker)

Ronchi

Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" This is an example of adolescent: 1False-belief syndrome 2Sense of invulnerability 3Personal Fable 4Imaginary audience

Sense of invulnerability

Match the elements for correct identification of outcome statements with the SMART acronym terms below. 1. Specific 2. Measurable 3. Attainable 4. Realistic 5. Timed a. Mutually set an outcome a patient agrees to meet. b. Set an outcome that a patient can meet based upon physiological, emotional, economic, and sociocultural resources. c. Be sure an outcome addresses only one patient behavior or response. d. Include when an outcome is to be met. e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status

Specific: C Measurable: E Attainable: A Realistic: B Timed: D

Which one of Freud's stages of development falls between birth to 12-18 months?

Stage 1: Oral

Which one of Freud's stages of development falls between 12-18 months to 3 years?

Stage 2: Anal

Which one of Freud's stages of development falls between 3-6 years

Stage 3: Phallic or Oedipal

Which one of Freud's stages falls between 6-12 years

Stage 4: latency

Which one of Freud's stages of development falls between puberty through adulthood?

Stage 5: Genital

A 34 year old female executve has a job with frequent deadlines. She notes that when the deadlines appear, she tends to eat high fat high carbohydrate foods. She also explains that she gets frequent headaches and stomach pain during these deadlines. After receiving health education from the nurse, the executive decides to try yoga. In this scenario yoga is best described as which one of the following? 1Health Promotion activity 2Stress-management technique 3Counseling technique 4Outpatient referral

Stress-management technique

What lung sound is this?

Stridor

What are the similarities with both distress and eustress?

The body goes under the same nonspecific response to various stimuli acting upon it

What is another name for the Alarm Reaction?

'Fight or Flight'

Patient has an order for 15 mL of penicillin to be administered, how many ounces would that be?

0.5 ounces

What is not one of the 3 components of The Health Belief Model? Individuals perception of the seriousness of illness Likelihood that a person will take preventative action Individuals perception of susceptibility to an illness Behavior cognition

Behavior cognition

What is on the first level of Maslows Hierarchy of needs?

Body Temperature, Elimination, Sex, Shelter, Nutrition, Fluids, Oxygen

What lung sound is this?

Coarse Crackles

A 9 year old has a difficult time making friends at school and being chosen to play on teams. He also has trouble completing his homework and, as a result, receives little positive feedback from his teacher and parents. According to Erikson's Theory failure at this stage of development results in:

Feeling of inadequacy and inferiority

What lung sound is this? (Play the speaker)

Fine crackles

What does GAS stand for?

General Adaptation Syndrome

A 50-year-old woman has elevated serum cholesterol levels that increase her risk for cardiovascular disease. The nurse helps this patient control this risk factor by assessing the patient's current diet trends and describing dietary changes to reduce the patient's risk for developing cardiovascular disease. This nursing activity is a form of 1.Health Education 2.Referral 3.Counseling 4. Stress-Managment Techniques

Health Education