GOOD STUDY STUFF - EXAM 1
A nurse makes preliminary observations about a patient. What is the term for this action? General survey Health history Physical assessment Review of systems
A
Which action to reduce the spread of infections is the nursing taking by avoiding going to work when sick? Personal Community Home Employee
A
Which body system has proteins with antimicrobial properties and promotes phagocytosis? Respiratory system Gastrointestinal system Integumentary system Musculoskeletal system
A
Which characteristic of the nursing process refers to changes over time in response to patients' individual needs? Dynamic Analytical Organized Adaptable
A
Which component is part of innate immunity and participates in the inflammatory response? Leukocytes Helper cells Cytotoxic T cells Immunoglobulins
A
Which device is best to measure a shock patient's blood pressure? Doppler Sphygmomanometer Intraarterial catheter Electronic blood pressure machine
A
Which type of immunity protects a person from infection after receiving a skin laceration? Adaptive immunity Innate immunity Humoral immunity Passive immunity
B
By which means are pathogens transmitted through droplets and require infected patients to be placed on protective precautions? Select all that apply. Coughing Sneezing Suctioning Eating Talking
ABCE
Which signs or symptoms would constitute a nursing diagnosis of Excess Fluid Volume related to renal compromise? Select all that apply. Dyspnea Orthopnea Excessive blood loss Increased blood pressure Decreased blood pressure
A,B,D
Which patient objective findings alert the nurse to the presence of infection or the risk for infection? Select all that apply. Pressure ulcers Enlarged lymph nodes Hyperactive bowel sounds Complaints of pain Decreased breath sounds
ABCE
Which patients would most likely require a Doppler to assess pulse? 45-year-old male with intestinal problems 34-year-old male with an irregular heart rhythm 62-year-old female with obstructed blood vessels in the feet 56-year-old morbidly obese female with hardening of arteries 26-year-old female with poor circulation in the lower extremities
C,D,E
A nurse is caring for a patient with a UTI. Which of these interventions address the patient's short-term goals? Select all that apply. Teaching hygiene practices to prevent further UTIs. Educating the patient on the signs and symptoms of UTIs. Applying a heating pad to the low back or abdomen. Refraining from sexual intercourse. Discussing the possibility of using a different type of birth control.
CD
What is the definition of a Nursing Diagnosis?
The nursing diagnosis identifies an actual or potential problem or response to a problem.
When blood pressure goes down, pulse/heart rate go
Up
when is body temp lowest and highest?
lowest at 3am and highest at 6pm
A 21-year-old college football player has been in the hospital 24 hours for observation following a concussion. His blood pressure (BP) has been stable at 118/62 mm Hg, but suddenly he complains of a severe headache and his BP is 170/94 mm Hg. The nurse orders vital sign monitoring with what frequency? Every 4 hours Every 8 hours Every 5 minutes Once per shift
C
A nurse assessing a patient suspects moderate to severe hypoxia. Which oxygen saturation range would indicate this condition? 95% to 100% 90% to 94% 85% to 89% Less than 85%
C
A nurse enters a patient room to assess the patient's blood pressure, temperature, pulse, and pain. What type of assessment is being performed? Comprehensive Emergency Focused Shift
C
It is permissible for the nurse to use alcohol-based hand sanitizer on which occasion? Before eating lunch or ingesting food Nothing can be visibly seen on hands After use of the bathroom by nurse After known exposure to norovirus
B
NANDA is known for its pioneering work in which aspect of nursing? Nursing autonomy Nursing language and classification Analysis of assessment data Identification of illnesses to guide nursing care
B
What type of symptoms is a consequence of illness and disease? Primary Secondary Tertiary Insidious
B
Which data collected during the nurse-patient interview is a subjective finding? Bowel sounds active Allergic to penicillin Swollen left elbow Blood pressure of 150/72 mm Hg
B
Which example provides a realistic goal for a patient with altered ventilation and oxygenation? The patient will breathe without difficulty while not on oxygen therapy. The patient will develop and maintain an effective breathing pattern before discharge to home. The patient will develop and maintain an effective breathing pattern after being discharged to home. The patient will verbalize understanding of how to safely implement oxygen therapy after discharge to home.
B
Which intervention will the nurse implement for a patient with the goal of consuming 50% of meals within 5 days? Assess skin for signs of weight loss. Determine patient's food likes and dislikes. Weigh when the patient outcome is met. Encourage between meal supplements.
B
Which patient behavior supports the nursing diagnosis of Knowledge Deficit? Refusal to eat yogurt served on lunch tray. Inability to perform incisional care. Explanation from patient about correct diet. Untouched informational booklets at bedside.
B
Which statement describes medical asepsis? Absence of all infectious agents Procedure known as clean technique Requires use of sterile gloves Prevents microbial entry into body
B
Risk Factor Nursing Diagnosis
environmental, physical, psychological, or situational concerns that increase a patient's vulnerability to a potential problem or concern. Risk for Self-Mutilation with the risk factors of low self-esteem and history of harming self.
what are the signs of fever?
hot dry skin, shivering, decreased urinary output
What is the Body's Thermostat?
hypothalamus The anterior hypothalamus promotes heat loss through the mechanisms of diaphoresis (sweating) and vasodilation of blood vessels, which enable heat loss. The posterior hypothalamus conserves heat through mechanisms, such as vasoconstriction, to reduce heat loss and shivering. Disease or trauma to the hypothalamus or spinal cord can, therefore, cause alterations in temperature control.
Nursing Diagnosis
identification of actual or potential health problems or life processes and responses to a problem when a nurse uses clinical judgment to describe a patient's response or potential response to a medical diagnosis, health condition, or life event. Problems or processes may be physical or psychological.
medical diagnosis
identifies and labels medical illnesses. Illnesses may be physical or psychological
what is CHF (congestive heart failure)
left vent failure with pulmonary edema
A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen? The plan of care follows directly from the diagnosis. Revisions will be avoided until after the evaluation phase of the care plan. Information from other steps will be used to complete the plan of care. The patient will improve during each step of the nursing process.
C
The _________characteristic of the nursing process is that nursing care plans can be developed for patients in any care setting, as well as for targeted populations and communities. Dynamic Analytical Organized Adaptable
D
The five steps that make up the nursing process allow it to be: Collaborative Analytical Outcome based Dynamic
D
The nurse advises the patient to avoid which item in relation to taking an accurate blood pressure reading? Avoid caffeine 60 minutes before reading. Avoid smoking 15 minutes before reading. Avoid exercise 20 minutes before reading. Avoid physical activity 5 minutes before reading.
D
What is Preload/Afterload
Preload is the initial stretching of the cardac muscles prior to contraction and affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.
respiration is controlled by
Respiratory control center in the medulla of the brain Cerebral cortex controls voluntary breathing
What is Pneumothorax (PTX)
positive pressure created in intrapleural space and lung collapses CHEST TUBE connected to Pleur Evac machine that restores negative pressure in thorax
what are the five cardinal signs of inflammation?
redness, swelling, heat, pain, loss of function
Which information is obtained from the patient's chart, medical records, and diagnostic testing?
secondary
What is proprioception?
sense of body position and movement; sometime described as the "sixth" sense
what are objective findings perceived by the practitioner called?
signs
what factors affect thermoregulaton
stress, hormones, exercise, environment, circadian rhythm, age
what hormones increase body temp?
thyroxine, epinephrine, and norepinephrine during ovulation
hypoventilation
ventilation of the lungs that does not fulfill the body's gas exchange needs <10 respiratory center (medulla oblongata) is suppressed Opiods, Narcotics (Morphine) - Naloxone (Narcan) - when reps are less than 10
what is secondary intention?
wounds that require a great deal more tissue replacement (open wound); heal from the bottom up (granulation)
Actual Nursing Diagnoses: 3 parts (PES)
(1) The patient's identified need or problem (2) The etiology or underlying cause (3) Signs and symptoms
standard pulse volume (amplitude) scale
0 Absent pulseNo palpable pulse 1+ Weak and thready pulseDifficult to palpate 2+ Normal pulseAble to palpate with normal pressure 3+ Bounding pulse. May be able to see pulsation
To avoid an error in stating the nursing diagnosis, how would the nurse think of the related factor? Broad statement of causality Specific data that supports the diagnosis Cue that supports the diagnosis Medical diagnosis
A
What does the nurse do after identifying interventions during the planning phase of the nursing process? Individualize nursing actions to patient needs. Determine nursing action effectiveness. Evaluate patient movement toward goals. Revise ineffective nursing activities.
A
why do older adults need assistance with temp control?
cognitive impairment, illness, or an altered level of consciousness
What is the Intervention step of the nursing process?
Implementation includes initiating specific nursing interventions designed to help achieve established goals that were created in the planning step.
What should the nurse do when a patient with a wound infection shows no improvement in assessment baseline after a week? Review interventions to determine need for revision. Contact the provider to discuss current medications. Question patient to determine whether instructions were followed. Increase patient education about incisional care.
A
Which factors increase the older adult's susceptibility to infections? Select all that apply. Slowing of immune responses Increased cortisol production Decreased cough reflex Incomplete bladder emptying Reduced vascular supply Excessive epidermal thickening
A
Which immune response is mediated by circulating antibodies that coat antigens and target them for destruction? Humoral immunity Innate immunity Adaptive immunity Cellular immunity
A
Which nursing diagnosis would the nurse identity for a 3-day postoperative patient with a clean surgical incision without drainage? Risk for Infection Infection, Surgical Acute Pain Risk for Contamination
A
What is the chain of infection?
1. agent 2. portal of exit 3. mode of transmission 4. portal of entry 5. susceptible host
normal respiratory rate
12-20 breaths per minute over 30 indicates CO2 is accumulating in the body, CO2 is higher than 45, poor tissue diffusion, gas exchange impaired - something is wrong, AUSCULTATE the lungs YOU CAN SEE ELEVATED RESPIRATIONS, YOU CAN SEE THAT THEY ARE IN DISTRESS - CO2 IS ACCUMULATING IN BODY
When was the word "nursing process" first used by Lydia Hall?
1955
The nursing process was first used to define steps used in patient care when?
1960's
ANA identified 5 steps of the nursing process in its Standards of Practice when?
1973
Outcome identification was added to the nursing process by the ANA at what time?
1991
Which personal protective equipment (PPE) will the nurse don before observing a sterile procedure in the emergency department? Mask Gown Hair cover Sterile gloves
A
Which piece of personal protective equipment (PPE) will the nurse consistently don when anticipating that contact with the patient's body secretions will be possible? Gloves Masks Eyewear Gown
A
Which statement is correct regarding hand hygiene in the health care setting? Soap and water effectively reduce microorganisms on visibly dirty hands. Infectious agents are killed when using soap and water for washing hands. Washing hands with very hot water helps eliminate a greater number of bacteria. Non-alcohol-based hand sanitizers inhibit microorganism growth on hands.
A
infants under what age can't control their temp?
3 months
Which type of immunity provides long-term, active immunity for an individual who recovered from a viral infection? Adaptive immunity Innate immunity Passive immunity Humoral immunity
A
Which type of symptom is intrinsically associated with a disease? Primary Secondary Tertiary Insidious
A
A nurse is caring for a patient with nervous system impairment. What symptoms may be associated? Select all that apply. Poor balance Circulatory stasis Involuntary movement Decreased muscle tone Tissue ischemia
AC
While taking the temperature of a patient the nurse learns that the patient exercised before arriving at the appointment. Which explanation describes why the nurse assumes the temperature reading will not reflect an accurate body temperature? Body temperature increases with exercise. Body temperature fluctuates with exercise. The energy used during exercise will cause the patient to experience vasodilation, which cools the body. The energy used during exercise will cause the patient to experience vasoconstriction, which cools the body.
A
Why is it important to ensure diagnostic validity when selecting a nursing diagnosis? To develop an effective, personalized plan of care To ensure understanding of pathophysiology To verify regulatory standards are met To enhance patient satisfaction with care
A
Which are the appropriate Nursing Outcome Classifications (NOC) to include in the plan of care for a patient with the nursing diagnosis of risk for decreased cardiac output? Select all that apply. Vital sign status Circulatory status Personal health status Tissue perfusion: Cerebral Tissue perfusion: Abdominal organs
ABDE
Which medical asepsis interventions by the nurse protect the patient from infection? Select all that apply. Cleaning patient bedside equipment routinely Disposing of used needles in sharps containers Placing items wet from body fluids in biohazard bags Providing leak-proof receptacles at bedside for tissues Preventing contamination of intravenous sites and ports Removing excess linens from the patient's room
ABDE
To reduce the risk of hypertension, adults should engage in aerobic physical activity for at least _______minutes per day.
30
what is the normal CO2 range?
35-45 IF HIGHER THAN 45 CO2 ACCUMULATING - respiratory acidosis - Getting rid of CO2 is the bigger issue than getting O2. Respiratory acidosis...we can give supplemental O2, but we can't get rid of CO2
The nurse is caring for a patient who has suffered multiple fractures after a motor vehicle accident. What assessment finding would be most critical? Respiratory distress Elevated heart rate Pain Decreased mobility
A
The nurse is identifying which type of NANDA-I nursing diagnosis to use for a clinical situation and has determined there is an identifiable patient response to a current life process. Which type of NANDA-I nursing diagnostic label should the nurse select? Actual Risk Health-promotion Medical
A
The nurse is teaching a class on appropriate temperature assessment questions. Which statement made by the student nurse shows that the teaching has been effective? "I will ask if the patient has been sleeping well." "I will ask if the patient has a family history of fevers." "I will ask if the patient has exercised within the last 24 hours." "I will ask when the patient last had a fever."
A
The nurse is writing a NANDA-I actual nursing diagnosis. What component of the nursing diagnosis follows the diagnostic label? Related factors Defining characteristics Interventions Goals
A
The nurse is writing a NANDA-I risk nursing diagnosis. What component of the nursing diagnosis follows the diagnostic label? Risk factors Defining characteristics Interventions Goals
A
Which factors can compromise a pulse oximetry reading? Jaundice Respiratory rate Peripheral edema Some fingernail polishes Cold or injury to extremities
A,C,D,E
normal stroke volume
60-70ml into aorta with each vent. contraction
The saturation of venous blood (SvO2) is _____ because the tissues have removed some of the oxygen from the hemoglobin molecules.
70%
"Patient will demonstrate correct handling of dirty and clean dressings" is a measurable patient-centered goal for which nursing diagnosis? Knowledge Deficit Risk for Infection Impaired Skin Integrity Compromised Coping
A
A health care-associated infection (HAI) may be acquired under which circumstance? A treatment is received for another condition in the health care setting. A health care provider prescribed the incorrect treatment or medication. A complication from a treatment or medication develops that could have been avoided. An infection fails to respond to treatment or at least two different antibiotics.
A
Laboratory and other diagnostic tests are obtained during a patient office visit. These tests are associated with which type of patient assessment? Comprehensive Emergency Focused Shift
A Laboratory tests and other diagnostic tests are generally included in a comprehensive assessment.
NANDA-I for child with broken wrist
Acute pain (NANDA-I, ICNP®); Impaired physical mobility (NANDA-I) or Impaired mobility (ICNP®)
hypervolemia interventions
Antihypertensive meds Diuretics - gets rid of excess fluid
what should you ask the patient before taking their temperature?
Are you in pain? Have you had anything to eat or drink or chewed gum in the last 15 minutes? Have you been exercising in the last 30 minutes? Have you been sleeping? Do you smoke? When was your last cigarette? Have you been feeling hot, sweaty, or cold?
Bradycardia Factors
Athletic fitness level Sleep state Hypothermia Medications (such as beta blockers) Tracheal suctioning Increased intracranial pressure Myocardial infarction
At the end of the interview, the nurse lets the patient know the interview is complete and the doctor will be in shortly. Before leaving the room, the nurse asks the patient if there are any questions. Which phase of the patient interview is represented by this statement? Orientation Transition Working Termination
D
Checking the patient's previous hemoglobin and hematocrit levels is an example of collecting what type of data? Primary Secondary Subjective Objective
D
During the general survey, the nurse notices the patient uses an assistive device. This observation should prompt the nurse to ask which important question? "How much do you currently weigh?" "Do you have any personal safety issues?" "How long have you used your walker?" "Is your walker being correctly maintained?"
D
Nutrition and metabolism is a component of which model of data organization? Medical Head-to-toe Body systems Gordon's functional health patterns
D
adventititious lung sounds
Crackles (fine, high-pitched/short, or coarse, low-pitched/longer-lasting) Rales (synonymous with crackles) Rhonchi (low-pitched) Wheezes (whistling sound, heard in asthma) Stridor (high-pitched, predominantly inspiratory, may be indicative of emergency)
A patient with which infection will be admitted to the airborne infection isolation room? Pharyngeal diphtheria Meningococcal sepsis Staphylococcus aureus Varicella zoster
D
defining characteristics
cues or clusters of related assessment data that are signs, symptoms, or indications of an actual or health-promotion NANDA-I nursing diagnosis Actual: Ineffective Airway Clearance related to retained secretions, as evidenced by thick secretions and unproductive cough. Health-promotion: Readiness for Enhanced Immunization Status, as evidenced by expressed desire to identify providers of pneumonia vaccine.
signs of hypothermia
decreased body temperature and respirations, pale and cool skin, hypotension (decreased blood pressure) decreased muscle coordination and urinary output, disorientation/confusion, and drowsiness progressing to coma.
coronary artery disease (CAD)
a condition affecting arteries of the heart that reduces the flow of blood and the delivery of oxygen and nutrients to the myocardium Ø Arteriosclerosis - hardening and thickness of the wall of the coronary artery which causes narrowing and a decrease in oxygenated blood flow to the heart muscle Ø Atherosclerosis - accumulation of fatty lipids and cholesterol plaque build up on the inside of the walls of the coronary artery which causes a decrease in oxygenated blood flow to the heart muscle Ø CAD - causes a decrease in oxygenated blood flow to the heart muscle - myocardium which causes ISCHEMIA
The student nurse is having difficulty palpating the radial pulse on a postoperative adult patient who has a blood pressure of 126/74 mm Hg. Which statement is true about palpating a pulse? Too much pressure can obliterate the pulse. A Doppler is necessary to palpate a radial pulse. Palpating a pulse is best done utilizing a stethoscope. Too little pressure can result in the inability to feel the pulsations. The radial pulse is best palpated along the thumb side of the inner aspect of the wrist along the radial bone.
A,D,E
A 35-year-old woman delivered a 9 lb, 7 oz baby boy 24 hours ago via cesarean section. Her vital signs were stable, pulse 74 bpm and temperature 99°F, 4 hours ago. The unlicensed assistive personnel (UAP) reports to the nurse that this patient's pulse is now 100 bpm, her temperature is 101.8°F, and she is complaining of chills. The room temperature is 73°F. The nurse interprets the data and takes which action? Assess the patient. Direct the patient to take a shower to freshen up. Advise the UAP to wait 1 hour and repeat vital sign measurement. Notify the maintenance department to increase the room temperature.
A
A nurse educator is reviewing the steps of the nursing process with the class. While reviewing a case study, the educator asks the students to determine which part of the process a nurse uses when establishing short- and long-term goals with the patient. How should the students respond? Planning Diagnosis Implementation Evaluation
A
A student nurse is describing the process of taking a patient's temperature to the charge nurse. Which statement made by the student nurse indicates teaching has been effective? "I must determine the patient's baseline temperature." "I will be alert to evaluate emotional changes in the patient." "Patients usually cannot maintain normal body temperature." "It does not matter whether the patient has taken medication."
A
An older adult patient presents for a yearly physical examination. The female patient is 5'4" and 115 lb. She loves fried foods and occasionally drinks a glass of red wine before going to bed. Her blood pressure is 105/60 mm Hg. The nurse realizes that a risk factor for hypotension for this patient is most likely which attribute? Age Obesity Alcohol use High-fat/high-calorie diet
A
During the respiratory assessment, the nurse hears "wheezes." Which type of sound is the nurse hearing? Whistling Low-pitched High-pitched Fine, high-pitched/short
A
During which phase of the patient interview does the nurse state the purpose of the interview? Orientation Transition Working Termination
A
During which process is a patient's illness identified in order to provide appropriate medical care? Medical diagnosis Nursing diagnosis Identification of risk or related factors Identification of defining characteristics
A
In most cases, what type of data is best to obtain first? Primary Secondary Subjective Objective
A
In which way does the nursing diagnosis provide an effective means of communicating the patient's status? By consolidating a great volume of information into a concise statement. By narrowly defining the patient's illness as explicitly as possible. By clearly identifying the patient's medical diagnosis. By listing all of the patient's responses to medical and nursing care.
A
NANDA identified which goal initially during the development process? Implement nursing diagnostic categories. Promote research to validate diagnostic labels. Encourage nurses to use taxonomy in practice. Revise nursing taxonomy.
A
The nurse assigning a NANDA-I diagnostic label of Impaired Skin Integrity asks, "Is this nursing diagnosis correct? Which step in the selection of an accurate nursing diagnosis is the nurse performing? Validation Data clustering Planning Evaluation
A
The nurse assigns a NANDA-I diagnostic label of Impaired Skin Integrity. How does the nurse ensure the diagnosis is valid? Consult the official NANDA-I list to ensure she has interpreted and applied the label correctly. Review the related factors to ensure they make sense. Determine the defining characteristics to ensure they relate to the diagnosis. Consult with a second nurse to make sure the diagnosis reflects the patient's condition.
A
The nurse implements which type of intervention after consultation with respiratory care about a patient with a productive cough? Interdependent Independent Nurse-initiated Dependent
A
The nurse recognizes that a patient's surgical incision is no longer inflamed, but infected, by noting which finding? Greenish drainage Warm to the touch Swelling at the edges Slightly red color
A
The nurse recognizes which manifestation indicates systemic infection and warrants further patient assessment? Temperature 101.3°F (38.5°C) orally Heart rate 82 beats per minute Respiratory rate 16 breaths per minute Skin warm to touch and moist
A
The nurse will implement contact precautions when learning that a patient is being admitted with which infection? Hepatitis A Streptococcal pneumonia Influenza Chickenpox
A
The student nurse discusses goals for thermoregulation with a patient. Which statement made by the patient shows proper understanding of treatment outcomes? "I will have an oral temperature of 98.4°F." "My intake and output must be equal for the next 24 hours." "I will dress appropriately for cold weather sports in the future." "My body temperature will maintain in the normal range within 7 hours of drinking warm fluids."
A
The student nurse is discussing arterial blood gases (ABGs) with the instructor. Which statement made by the nurse reflects the student needs further education? Nurses do not draw ABGs. ABGs are used to establish baseline values. Arterial blood is used for ABGs because venous blood values are too variable. ABGs assess for oxygenation and respiratory components of acid-base balance.
A
What type of data includes the patient's medical history, feelings, and management of health and health concerns in the past? Primary Secondary Tertiary Objective
A
Which option exemplifies a short-term goal the nurse may identify during the planning step of the nursing process? Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. Patient verbalizes a pain level of 2 or 3, out of 10, during A.M. care within 24 hours. Patient verbalizes a pain level of 1 out of 10 at the 2-week provider follow-up appointment. Patient verbalizes a pain level of 0 out of 10 at the 1-month provider follow-up appointment.
A
A NANDA-I diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms as evidenced by anasarca and pulmonary congestion is written for a patient. How does the nurse ensure validity of the defining characteristics? Verifies that each component accurately reflects the patient's condition or situation. Consults the NANDA-I list of official nursing diagnostic labels. Organizes patient assessment data into groupings with similar underlying causes. Stays current in nursing practice and seek out opportunities to improve skills and techniques.
A When formulating the defining characteristics of the nursing diagnosis, the nurse should validate each component by making sure that each component accurately reflects the patient's condition or situation.
A NANDA-I diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms, as evidenced by generalized, massive edema and pulmonary congestion is written for a patient. How does the nurse ensure validity of the related factors? Verifies that each component accurately reflects the patient's condition or situation. Consults the NANDA-I list of official nursing diagnostic labels. Organizes patient assessment data into groupings with similar underlying causes. Stays current in nursing practice and seek out opportunities to improve skills and techniques.
A When formulating the related factors of the nursing diagnosis, the nurse should validate each component by making sure that each component accurately reflects the patient's condition or situation.
A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits? Ensure individualized care. Concern over the baby arriving prematurely. Facilitate setting patient outcomes. Determine if the patient has other children.
A During evaluation, nurses need to ask questions where answers help determine how best to proceed with individualized care.
The patient fell and fractured his hip. He also has diabetes, heart failure, and osteoporosis. Which aspect of the patient's history would a nursing diagnosis focus on? Sudden onset of pain Intertrochanteric hip fracture Degenerative joint disease Left-sided heart failure
A Sudden onset of pain identifies a health problem the patient may have in response to a medical problem. This aspect of the history would be the focus of a nursing diagnosis.
A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient's pain level, is the nurse assessing subjective or objective data? Subjective data, because only the patient can experience the pain. Subjective data, because the blood pressure is an accurate measure of the patient's pain. Objective data, because the pain level can be turned into a number on a one to ten scale. Objective data, because the patient can point to the "oucher" picture indicating the experienced pain level.
A The pain level is subjective, because it is spoken or pointed out as an "oucher" card in the case of the patient with a tracheotomy.
A 6-year-old child is carried into the emergency department (ED) by the mother. The child has a history of asthma and is gasping for breath and wheezing. The child's vital signs are respirations 30 bpm, pulse 120 bpm, SpO292%, and BP 90/50 mm Hg. The nurse takes which actions? Obtain oxygen saturation measurement. Call for the appropriate care provider to quickly evaluate. Ask the mother for a medical history, including any medications. Initiate standing protocols for childhood asthma until the appropriate care provider arrives. Explain to the mother that the ED is very busy and to have a seat in the waiting room with the child.
A, B, C, D,
A nurse is caring for a patient with a UTI. The nurse's selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain? Select all that apply. Low back aching Burning upon urination Frequency of urination Urgency of urination Incontinence of urination
AB
Which model focuses on the physical condition rather than the holistic view of a patient? Select all that apply. Medical Body systems Head-to-toe Gordon's functional health patterns General systems
AB
What are purposes of hand hygiene? Select all that apply. Prevents the spread of infection Breaks the chain of infection Interrupts organism transmission Enhances the patient relationship Kills microorganisms
ABC
Which actions will the nurse take for a patient who is experiencing discomfort from an infection? Select all that apply. Assess pain on scale of 1 to 10. Position patient to relieve discomfort. Encourage diversion such as relaxation. Evaluate analgesic effect after 2 hours. Provide pain medication every 4 hours.
ABC
Which are components of the full health history? Select all that apply. Demographic data Medical history Surgical history Cardiac history Respiratory history
ABC
Which infections are considered health care-associated infections (HAIs)? Select all that apply. Urinary tract infection related to indwelling catheter Pneumonia related to presence of ventilator Wound infection related to surgical incision Respiratory infection related to influenza Skin infection related to traumatic injury
ABC
Which statements best describe the purpose for greeting the patient and explaining the need for personal protective equipment (PPE)? Select all that apply. Eases fear and misunderstanding Creates a professional relationship Builds a trusting relationship Fulfills legal requirements Eliminates later confusion
ABC
During which encounters is a patient at risk for acquiring health care-associated infections (HAIs)? Select all that apply. Dialysis treatment Outpatient surgery Provider office visit Rehabilitation session Neighborhood pharmacy
ABCD
The nurse understands that the innate immune response involves which components? Select all that apply. Fungi Low stomach pH Skin Capillary dilation T lymphocytes Immunoglobulins
ABCD
What information should be included in a health history? Select all that apply. Patient's social history Reason for seeking medical care Patient demographic information Medications the patient is currently taking System-by-system review of the entire body
ABCD
Which concepts must the nurse have an understanding of to accurately cluster data? Select all that apply. Pathophysiology Normal structure and function of the body Disease processes Symptomatology Nursing taxonomy
ABCD
Which information would be considered as potentially contributing to the identification of a nursing diagnosis? Select all that apply. Physical assessment findings Provider orders Data from family and patient interviews Documentation from other healthcare providers Joint Commission Patient Safety Goals
ABCD
The nurse recognizes which characteristics of adaptive immunity? Select all that apply. Acquired throughout a person's lifetime Complex, highly organized system Requires exposure to specific antigens Provides immediate, short-term immunity Generates antigen-specific defenses
ABCE
Which are measurable data that can be used to support if a patient is meeting infection-related goals? Select all that apply. Hand washing Perspiring Pain Nausea Fatigue Fever
ABCF Hand washing is an objective finding that can be observed. It is measurable and can be used when determining if patients meet infection-related goals. Patients perspiring can be observed; therefore it is measurable and can be used when determining if patients meet infection-related goals. Pain is an objective measure when using a pain scale, for example, on a scale of 1 to 10. Only then can it be used when determining if patients meet infection-related goals. Nausea is a subjective finding that is not objectively measured. It is not a measurable way to determine whether patients meet infection-related goals. Fatigue is a subjective finding that is not objectively measured. It is not a measurable way to determine whether patients meet infection-related goals. Fever is an objective finding. It is measurable and can be used when determining if patients meet infection-related goals.
The nurse completes which patient assessments during the general survey? Select all that apply. Safety Vital signs Allergies Speech Dietary intake
ABD
The nurse has the patient's health history. Which questions will the nurse ask during an initial interview? Select all that apply. How are you feeling today? What are your health concerns? Which illnesses have you had? Are you feeling unusually tired? How is the health of your family?
ABD
The nurse is caring for a patient with cerebellar damage related to traumatic brain injury. What are expected side effects of this condition? Select all that apply. Uncoordinated movement Poor balance Ability to walk Inability to remain upright Unsteady gait
ABDE
The nurse understands that standard precautions includes which practices? Select all that apply. Hand hygiene Cough etiquette Patient cleanliness Safe injection practices Use of personal protective equipment (PPE)
ABDE
Which actions are required by the nurse when preparing for a sterile procedure? Select all that apply. Keeping sterile surfaces dry Setting up the sterile field Leaving the room for supplies Checking packaging integrity Monitoring activities of others Delegating preparations to unlicensed assistive personnel (UAP)
ABDE
Which are strategies for collecting patient assessment data? Select all that apply. Performing a general assessment Speaking with the patient's family Consulting the patient's medical file Performing the physical assessment Obtaining a thorough history
ABDE
The nurse recognizes that normal flora usually resides in which areas of the body without causing harm? Select all that apply. Skin Mouth Lungs Upper throat Bloodstream Small intestine
ABDF
Which abnormal findings require further evaluation if noted during the general survey of a patient's gait? Select all that apply. Tremor Balanced Shuffling Smooth Symmetry
AC The presence of a tremor is an abnormal finding, which indicates a likely neurological condition. This general survey finding requires further evaluation. Shuffling gait is an abnormal finding, likely indicating a neurological condition. This general survey finding requires further evaluation.
An immobile patient is being discharged to home. The nurse will teach prevention precautions about which potential infections to the patient's caregiver? Select all that apply. Skin infections Cardiovascular infections Urinary tract infections Respiratory infections Musculoskeletal infections
ACD
Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site? Select all that apply. The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse verifies that no pain medications were ordered and tells patient she has no medications ordered. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain.
ACDE
What analytical questions are asked at each step in the nursing process? Select all that apply. "Is the data collection thorough and accurate?" "Are outcomes general and hopeful?" "Have all underlying factors been addressed in the care plan?" "Are the interventions available?" "Could interventions impact the patient negatively?"
ACE
Which formats are commonly used for documenting the patient's health history and physical examination? Select all that apply. Functional Physiological Body system Biological Head-to-toe
ACE
The federal government can order patients with which diseases to be isolated and/or quarantined? Select all that apply. Smallpox HIV/AIDS Measles Cholera Yellow fever Diphtheria
ADEF
Which are important components of the head-to-toe model? Select all that apply. Vital signs Values and beliefs Feelings and perceptions Health perception and management Subjective and objective patient information
AE
Factors influencing blood pressure
Age (older people dont like to drink water, and that causes low fluid volume and low blood pressure) , Stress, Ethnicity, Gender, Daily variation, Medications, Activity and Weight, Smoking.
Which statement made by the nurse shows an understanding of objective and subjective data? "Subjective data are gathered from the patient." "Objective data are gathered through the patient." "Objective data are gathered through observation." "Subjective data are gathered through observation." "Subjective data are gathered from the patient's relatives."
A, C, E
The unlicensed assistive personnel (UAP) reports the current vital sign assessment on a patient who is on the third recovery day after a fractured femur: BP 156/92 mm Hg, P 84 beats per minute, R 18 beats per minute, and T 98.8°F. The nurse takes which actions? Verify the vital signs personally. Review the patient's medical history. Review the patient's vital sign history. Instruct the UAP to record findings on the patient's chart. Instruct the UAP to take the patient's vital signs again in 4 hours.
A,B,C
The nurse is making the daily assignment on the unit. There is an unlicensed assistive personnel (UAP) available to assist with patient care. Which action is the responsibility of the nurse? Interpret vital sign data collected. Reassess any abnormal values measured by the UAP. Ensure the UAP uses the proper tech¬nique for measuring vital signs. Ensure the UAP knows what values need to be reported immediately for each patient. Instruct the UAP to report abnormal values and other significant assessment findings to the appropriate health care provider.
A,B,C,D
Which questions are appropriate for a nurse to ask during a pulse assessment? Do you smoke? What medications do you take? Are your hands or feet swollen? Do you experience shortness of breath? Have you engaged in any type of exercise in the past 60 minutes?
A,B,C,D
Which questions are the most important to ask when assessing blood pressure history? Select all that apply. Are you in pain? Do you feel stressed? When did you exercise last? What medicines are you currently taking? Does your spouse have high blood pressure?
A,B,C,D
A recently hired unlicensed assistive personnel (UAP) wants to please the busy staff nurse. The UAP takes vital signs and records the data on all 10 patients on the step-down coronary unit. The nurse must discuss this action with the UAP and point out why this is not within her scope of patient care. Which duties are strictly nursing responsibilities? Interpret vital sign data. Reassess any abnormal values measured by the UAP. Assess patients to determine whether they are medically stable. Measure, record, and report vital signs for a stable patient. Report abnormal values to the appropriate health care provider.
A,B,C,D,E
Nursing diagnoses and realistic goals for an alteration in pulse are selected after carefully reviewing which pieces of information? Subjective information Patient's knowledge level Laboratory data and test results Orders that were placed by the health care provider Objective data gathered during the pulse assessment by the nurse
A,B,C,E
The charge nurse in an assisted living community has just arrived for the evening shift. During report, the nurse is told a long-time resident fell in the patient's room 2 hours ago. The day nurse contacted the primary care provider, who ordered the patient to be observed unless the patient complains of severe pain. The charge nurse is making the shift assignment for the unlicensed assistive personnel (UAP) this evening. Which parameters will the charge nurse consider when assigning the UAP this evening? UAP obtain vital sign assessments of stable patients. The patient is fully conscious and aware of surroundings. The patient has had a continuous drop in blood pressure since the fall. The charge nurse is busy with paperwork and will assess the patient after the evening meal is served. The patient asks to have the UAP provide patient care because the UAP and the patient have a good relationship.
A,B,C,E
Which signs indicate shock followed by a continuous drop in blood pressure? Select all that apply. Confusion Clammy skin Thready pulse Increased urinary output Altered level of consciousness
A,B,C,E
The nurse working on a busy postoperative floor is making the daily assignment for an experienced unlicensed assistive personnel (UAP) on this unit. Which aspects should the nurse consider regarding delegation? Nurses are responsible for reassessing and reporting any abnormal vital sign measurements. Nurses may delegate vital sign assessments after determining that a patient is medically stable. This UAP is planning to attend nursing school next year and wants as much experience as possible before admission. Nurses must ensure that the UAP is competent to perform vital sign assessments and knows the values that must be reported immediately. This UAP has worked on this unit for 6 months and can be immediately assigned to the patients returning from the recovery room for vital sign assessments.
A,B,D
In which patients would pulse oximetry most likely be utilized? An older adult with hypoxemia A patient with community-acquired pneumonia A pediatric patient whose oxygen saturation is 95% on room air A teenager having an asthma attack with oxygen saturations of less than 92% in air An adult patient in the outpatient clinic who has a history of chronic obstructive pulmonary disease (COPD)
A,B,D,E
The nurse is assessing the patient's ventilation status. Which features will the nurse assess? Chest rise Pulse oximetry Respiratory rate Lung compliance Arterial blood gas
A,C,D
Which statements are true about hypotension? Hypotension can result from dehydration. Peripheral vascular resistance is increased. Blood loss is a risk factor for orthostatic hypotension. Prolonged immobility is a risk factor for orthostatic hypotension. Moving from standing to lying position decreases blood pressure.
A,C,D
What actions must the nurse take before delegating vital sign assessment to unlicensed assistive personnel (UAP)? Assess the patient. Take baseline vital signs. Determine the patient to be medically stable. Verify the UAP uses the proper technique for measuring vital signs. Ensure the UAP knows what values need to be reported immediately for each patient.
A,C,D,E
A NANDA-I diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms, as evidenced by anasarca and pulmonary congestion is written for a patient. How does the nurse ensure validity of the nursing diagnostic label? Thinks of the related factor as a broad statement of causality rather than specific data or cues that support the diagnosis. Consults the NANDA-I list of official nursing diagnostic labels. Organizes patient assessment data into groupings with similar underlying causes. Stays current in nursing practice and seek out opportunities to improve skills and techniques.
B
A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care? Risk, since the patient's identified need is the diagnosis of colostomy. Risk, since the patient is at risk for infection at the site of the surgical incision. Actual, since the patient is at risk from factors indicating vulnerability. Actual, since the patient is in need of health-promotion, given the nursing diagnostic label of colostomy.
B
A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard? Evaluation Implementation Assessment Planning
B
During a review of systems, the patient voices concern about having heart disease because of a strong family history. What should the nurse do next? Gather more information about the patient's family history. Ask a focused question about the patient's concerns. Continue reviewing systems to identify additional health concerns. Investigate the patient's desire for diagnostic testing.
B
Fever, exercise, anxiety, and respiratory disorders are contributing factors to which alteration in breathing pattern? Bradypnea Tachypnea Hyperventilation Hypoventilation
B
In addition to patient statements, what should the nurse be very attentive to during the interview? Family input Non-verbal cues Test results Vital signs
B
Introducing the patient's normal flora into which body area increases the risk for infection? Rectal area Urinary bladder Oral cavity External ear
B
Reviewing data collected during the assessment assists the nurse with which part of the nursing process? Prioritization Planning Implementation Evaluation
B
Stella Jones, RN, reassesses a patient one hour after giving morphine for the patient's pain. The patient states that she is still in horrible pain, eliciting a response of 8 out of 10. What would be the most appropriate intervention? Check blood pressure. Give additional breakthrough pain medication. Reassess pain level in two hours. Monitor heart rate every 30 minutes.
B
The nurse and health care provider have just reviewed the electrocardiogram (ECG) on an adult patient who has been suffering from fainting spells. The provider suspects that the patient may have an arrhythmia even though the ECG reveals sinus rhythm with a rate of 68 bpm. The provider orders a Holter monitor for the patient. Which statement should the nurse tell the patient about the Holter monitor? Transfers cardiac data instantaneously Records the heart's activity continually for a 24-hour period Monitors the heart's activity after being surgically inserted under the skin Converts life-threatening arrhythmias of the heart to normal sinus rhythm
B
The nurse assesses a patient who was admitted to the emergency department with a core body temperature of 93.2°F, after being exposed to freezing temperatures for a long period of time. The nurse feels the patient's skin and documents that it is cool to the touch. Which actions should the nurse take to confirm a nursing diagnosis of hypothermia? Check the patient's pulse. Observe the patient for shivering. Measure the patient's blood pressure. Notice whether the patient is very thirsty. Request a blood draw to check the patient's red blood cell (RBC) count.
B
The nurse is developing a plan of care for a patient with pulmonary embolism. During which step of the nursing process is the nursing diagnosis formulated? First Second Third Fourth
B
The nurse is identifying which type of NANDA-I nursing diagnosis to use for a clinical situation and has determined the patient is vulnerable to developing an infection in a wound that is currently not infected. Which type of NANDA-I nursing diagnostic label should the nurse select? Actual Risk Health-promotion Medical
B
The nurse is providing care for a patient who is displaying symptoms of tissue edema; differences in blood pressure in opposite extremities; skin color changes (pallor); and cool, clammy skin and prolonged capillary refill. Which is the most likely nursing diagnosis for this patient? Ineffective Tissue Perfusion: Cerebral Ineffective Tissue Perfusion: Peripheral Ineffective Tissue Perfusion: Abdominal Organs Ineffective Tissue Perfusion: Cardiopulmonary
B
The nurse is writing a NANDA-I health-promotion nursing diagnosis. What component of the nursing diagnosis follows the diagnostic label? Risk factors Defining characteristics Interventions Goals
B
The nurse must have a written or oral order when implementing which nursing actions? Select all that apply. Administering an oral medication Beginning an intravenous (IV) infusion Repositioning a nonmobile patient Contacting dietary about a patient Teaching about a new medication
B
The nursing diagnosis "Imbalanced Nutrition: Less than Body Requirements related to..." is individualized by which statement? ...patient weight less than admission weight. ...weight loss of 8 pounds in 4 days. ...consuming 80% of meals on most days. ...eating at fast food restaurants three times per week.
B
The patient has a NANDA-I actual nursing diagnosis of Ineffective Airway Clearance related to retained secretions, as evidenced by unproductive cough and tenacious secretions. Which part of the NANDA-I nursing diagnosis is the related factor? Ineffective airway clearance Retained secretions Unproductive cough Tenacious secretions
B
The patient has chronic obstructive pulmonary disease. What is an appropriate NANDA-I risk nursing diagnostic label? Impaired Gas Exchange Risk for Infection Ineffective Airway Clearance Activity Intolerance
B
Which statement is an example of a measurable, short-term goal related to a patient with lower extremity edema? Patient will exhibit increased urinary output after beginning interventions. Increased capillary refill of <3 seconds and circulation to toes exhibiting pink nail beds within 48 hours of interventions. Patient will verbalize an understanding of the need for compression stockings as ordered by the primary care provider. Patient will verbalize an understanding of dietary changes necessary to avoid further heart failure (HF) exacerbations within four office visits.
B
Which statement shows the proper relationship between a patient's condition and temperature site selection? "The unconscious patient will benefit the most from temperature readings taken via the oral route." "Because the patient has a low white blood cell count, the patient will not receive a rectal temperature measurement." "Because the pediatric patient is slightly perspiring, temperature measurement by the temporal artery on the forehead will be contraindicated." "The older adult patient has been sipping on water due to dehydration, but an accurate oral temperature reading is still possible."
B
Which type of immunity will a nurse have after receiving the required three immunizations for HBV (hepatitis B)? Naturally acquired active immunity Artificially acquired active immunity Naturally acquired passive immunity Artificially acquired passive immunity
B
Which statement accurately represents documentation of a patient's review of systems findings? Smokes one pack cigarettes per day. Complains of frequent headaches. Consumes a low fat, vegetarian diet. Weight within normal range for height.
B A complaint is a positive statement about a body system that indicates the need for further investigation. This example represents accurate documentation of a review of systems findings.
A nurse determines the patient's goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised? Add another pillow wedge at night. Add a step to avoid eating after 7 p.m. Increase grapefruit juice taken with meals. Discontinue the plan.
B Revising the plan by adding a step is the right strategy.
A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient's wife prepares the family meals. Why is it important to include the patient's wife in the teaching? She can report when he is not adhering to the care plan. The wife can learn how to follow his new diet too. The main person responsible for managing the patient's diabetes may be the wife. Including a second person in teaching is protocol for the facility.
B The nurse works with family members to develop patient-centered care plans The wife is part of the collaborative team, but the patient is the one responsible for managing his diabetes
The nurse is caring for an 88-year-old patient who is currently in cardiac arrest. A Code Blue has been called and staff is performing cardiopulmonary resuscitation (CPR). When the nurse checks for a pulse, which areas of the body would be most appropriate if resuscitative measures are successful? Radial pulse Carotid pulse Femoral pulse Dorsalis pedis pulse Temporal artery pulse
B, C
Which value represents an acceptable respiratory rate for a 15-year-old patient? 12 15 18 22 25
B,C
Which factors place an individual at risk for hypertension? Select all that apply. Aging Stress Obesity Alcohol use Prolonged bed rest
B,C,D
Which internal factors are associated with dysrhythmias? Stress Heart disease Thyroid problems Inflammatory diseases Automatic nervous system dysfunction
B,C,D,E
The nurse is caring for an adult patient, post laparoscopic cholecystectomy 1 day prior. The patient's heart rate is 132 bpm and temperature is 102°F. The nurse is having a difficult time obtaining a blood pressure reading. Which statements are true of tachycardia in this situation? Due to exercise Indicative of anemia Causes a drop in blood pressure Related to hypothermia Due to hyperthermia
B,C,E
The nurse is ready to give a 60-year-old patient the daily cardiac medication. The certified nursing assistant (CNA) reports that the patient's vital signs are pulse 42 bpm, blood pressure 148/86 mm Hg, and respirations 20 bpm. What interpretation will the nurse make? Call a code for this patient. Withhold the cardiac medication. Recheck the patient's vital signs. Administer the cardiac medication to the patient. Compare the current vital signs with this patient's baseline data.
B,C,E
Why would the nurse use a Doppler unit to assess pulse? Measure blood pressure. Assess peripheral circulation. Listen to blood flow in arteries. Amplify the sound of each pulse wave. Assess pulses that are difficult to palpate.
B,D,E
The cerebral cortex of the brain allows voluntary control of breathing. When a patient sings, to which aspect do the receptors in the medulla react? Hypoxemia Changes in pH High levels of oxygen Low levels of carbon dioxide High levels of carbon dioxide
B,E
Which factors are known to change the appearance of skin and contribute to making patient's appear older than their stated age? Select all that apply. Skin products Sun exposure Tobacco use Excessive makeup Allergy medications
BC
What are the benefits of using nursing diagnoses? Select all that apply. Accurately labels medical illnesses Promotes accountability in nursing care Supports independence in nursing practice Establishes standardization of patient care Clearly identifies a patient's illness
BCD
Which outcomes are the result of using nursing diagnoses? Select all that apply. Accurately labels medical illnesses Promotes accountability in nursing care Supports independence in nursing practice Establishes standardization of patient care Clearly identifies a patient's illness
BCD
The nurse is about to conduct a focused assessment at the beginning of the work shift. Which assessments will be performed? Select all that apply. Airway Peripheral pulses Skin turgor Urinary output Wounds
BCDE
The nurse recognizes which infectious agents as having acquired drug resistance within health care settings? Select all that apply. Streptococcus pneumoniae (pneumococcus) Methicillin-resistant Staphylococcus aureus (MRSA) Vancomycin-resistant Staphylococcus aureus (VRSA) Vancomycin-resistant enterococci (VRE) Clostridium difficile (C-Diff) Staphylococcus aureus (staph infection)
BCDE
Use of properly formulated nursing diagnoses promotes which outcome? Select all that apply. Accurate medical diagnoses Accountability in nursing Independent nursing practice Patient care standardization Effective communication
BCDE
Which goals are appropriate long-term, patient-centered, measurable goals for the nurse to include in the plan of care for a patient with a nursing diagnosis of decreased cardiac output related to decreased myocardial contractility? Select all that apply. Patient will participate in activities that reduce blood pressure/cardiac workload. Patient will have normal heart sounds of S1 and S2 by the fourth follow-up visit. Patient's oxygen saturation will remain at 92% or above within 24 hours of receiving supplemental oxygen. Patient will have strong, palpable peripheral pulses in all extremities within 3 months of treatment. Patient will display hemodynamic stability (blood pressure, cardiac output, urinary output, and peripheral pulses all within normal limits).
BD
What information is obtained during a patient interview? Select all that apply. Financial status Current health concerns Political and social views Medical and surgical history Culture, ethnicity, and spiritual views
BDE
What does the nurse do with the nursing diagnosis during the diagnosis step of the nursing process? Revises Selects Evaluates Prioritizes Individualizes
BE
Which goal is appropriate initially for a patient in the emergency department who "can't catch a breath?" Patient will be able to cough up secretions within 8 hours of beginning respiratory treatments. Patient will exhibit regular breathing pattern with ambulation to the bathroom and back within 24 hours. Patient will be free of signs of hypoxia with arterial blood gases (ABGs) within the patient's normal range within 2 hours of admission. Patient will demonstrate ability to complete activities of daily living (ADLs) with an increase in dyspnea before discharge.
B`
A nurse is performing an interview and asks the patient about allergies and medications. These questions occur during which phase of the patient interview? Orientation Transition Working Termination
C
A nursing diagnosis of left-sided heart failure is written for a patient with a medical diagnosis of heart failure. Which diagnostic error did the nurse make? Error in data clustering Error in data collection Stating a medical diagnosis rather than a nursing diagnosis Using more than one nursing diagnosis per nursing diagnostic statement
C
A patient admitted to the hospital has been exposed to below-freezing temperatures while attempting to engage in sports in extreme weather conditions. During assessment, the nurse observes the patient is shivering and learns that the patient was not wearing adequate clothing. The patient has a weak pulse, rapid heart rate, and is slightly delirious. Which nursing diagnosis is appropriate for this patient? Hyperthermia related to extreme physical activity, as evidenced by delirium Ineffective thermoregulation, as evidenced by inability to complete physical performance in below-freezing temperatures Hypothermia related to exposure to below-freezing temperature without adequate clothing, as evidenced by a weak pulse and rapid heart rate Imbalanced body temperature with the risk factor of trauma to the body, as evidenced by shivering due to exposure to below-freezing temperatures
C
A patient with swollen feet from heart failure might have which one of these nursing diagnoses? Deficient Fluid Volume related to fluid volume loss, as evidenced by increased temperature, decreased blood pressure, and change in mental status Decreased Cardiac Output related to altered contractility of the heart as evidenced by shortness of breath and tachycardia Ineffective Peripheral Tissue Perfusion related to decreased peripheral circulation, as evidenced by pedal edema and the need for Doppler ultrasound to detect pedal pulses Activity Intolerance related to immobility, as evidenced by shortness of breath with ambulation
C
A student nurse is taking the temperature of a patient at 6 p.m. and realizes that the temperature is higher than it was only an hour ago. Which statement made by the student nurse indicates effective learning? "It is normal for temperatures to fluctuate from one hour to the next." "I should let the patient tell me whether the patient feels worse from an hour ago." "The temperature of most people is lowest around 3 a.m. and highest around 6 p.m." "This is alarming and should be reported immediately to the health care provider."
C
After educating a patient about respiratory etiquette, which behavior indicates the need for additional teaching? Using sanitizer hand wipes after sneezing Dropping used tissues into waste receptacle Reusing tissues for a productive cough Wearing a mask when leaving the room
C
Chemical receptors that stimulate inspiration are located in the a. Brain. b. Lungs. c. Aorta. d. Heart.
C
The _____________ characteristic of the nursing process describes when nurses ask questions and demonstrate the use of critical thinking for each step. Organized Outcome-oriented Analytical Dynamic
C
The nurse is caring for a patient in the emergency department. The health care provider has ordered antibiotics for a positive fluid specimen of the synovial joint. Which joint is infected? Rib Skull Knee Vertebrae
C
The nurse is caring for a patient with seizures who is not critically ill. Which equipment should the nurse select to measure blood pressure for this patient? Doppler Arterial line Sphygmomanometer Electronic blood pressure machine
C
The nurse is caring for an older adult patient who experienced a heart attack 1 hour ago. The blood pressure is 110/60 mm Hg and the pulse is 108 beats per minute. The patient is becoming cool, clammy, and confused. The nurse understands that if the patient's blood pressure continues to fall, this is probably due to which physiological factor? Decreased heart rate Increased blood volume Decreased cardiac output Increased peripheral vascular resistance
C
The nurse is taking care of a patient with a cervical spinal cord injury. The patient is a quadriplegic with a C5 fracture. The patient is sweating profusely and is afebrile with a temperature of 37°C. What does the nurse know about spinal cord injuries and thermoregulation? Patients with spinal cord injuries always have a normal body temperature. Spinal cord injuries do not affect the ability of the brain to regulate sweating. Disease or trauma to the brain or spinal cord can cause alterations in temperature control. The spinal cord does not play a role in thermoregulation of the body.
C
The nurse is thinking of related factors as broad statements of causality rather than specific data or cues that support each diagnosis.Which error in the diagnostic process is the nurse likely to avoid? Clustering unrelated data Errors in data collection Errors in stating nursing diagnostic label-related factors Using multiple diagnoses in one nursing diagnosis
C
The nurse is unable to assess an indirect blood pressure in using the patient's brachial arteries due to bilateral upper extremity injuries. Which alternate artery should the nurse use to assess the patient's blood pressure? Carotid artery Femoral artery Popliteal artery Temporal artery
C
When assessing a patient's lung sounds, the nurse should keep in mind that the right lung has how many lobes? One Two Three Four
C
Which adaptive immune system cells release interleukins to stimulate antibody production by B cells? Complement Macrophages Helper T cells Basophils
C
Which cells are responsible for the production of antibodies? Helper T cells Phagocytes B lymphocytes Interferon
C
Which complication associated with immobility affects the neurologic system? Decreased physical exercise Compromised cardiac function Damage to the cerebrum of the brain Chronic obstructive pulmonary disease
C
Which factor contributed to the development of a health care-acquired respiratory infection in an ambulatory diabetic patient receiving an intravenous antibiotic? Excessive activity Decreased oxygenation Current comorbidity Incorrect antibiotic
C
Which is an example of a NANDA-I health-promotion nursing diagnosis? Ineffective Airway Clearance related to retained secretions, as evidenced by thick secretions and unproductive cough. Risk for Falls with the risk factors of advanced age, dizziness, low blood pressure, and anemia. Readiness for Enhanced Family Processes, as evidenced by verbalized willingness to attend family counseling. Acute Pain related to physical injury, as evidenced by complaint of pain level 8 on a scale of 0 to 10, and inability to move without grimacing and yelling.
C
Which laboratory finding is abnormal and must be reported to the health care provider? White blood cell (WBC) count of 10,100 cells/mm3 Erythrocyte sedimentation rate (ESR) 20 mm/hr Serum complement 140 hemolytic units C-reactive protein of 0.9 mg/L
C
Which patient (susceptible host) is at greatest risk for developing an infection? 46-year-old recovering from elective noninvasive surgery 30-year-old with newly diagnosed early eating disorder 70-year-old with diabetes and an indwelling urinary catheter 50-year-old smoker who is receiving an intravenous antibiotic
C
Which patient is considered to be a susceptible host in the chain of infection? 22-year-old undergoing noninvasive treatment for back painThe 22-year-old patient is not likely a susceptible host because of younger age and noninvasive treatment regimen. 30-year-old receiving an immunization for hepatitisThe 30-year-old patient is not likely a susceptible host because of younger age. Also, immunizations are protective. 70-year-old with diabetes learning about insulin therapyThe 70-year-old patient is a susceptible host because diabetes is a chronic disease. Also, the patient is of older age, which is a risk factor for infection. 45-year-old being discharged after minor knee therapyThe 45-year-old patient is not likely a susceptible host because of mid-age and minor knee therapy, which carries little risk.
C
Which patient's symptoms are consistent with a chronic inflammatory disorder? 30-year-old with redness, swelling, and pain from a sprained ankle 22-year-old with pain and fever from a streptococcal sore throat 45-year-old with pain and swelling of the knees from arthritis 60-year-old with discomfort from a strained back muscle
C
Which short-term goal would be appropriate for a patient experiencing an abnormal pulse rate? Patient will exhibit normal pulse, blood pressure, and respirations within 2 hours of beginning prescribed interventions. Patient will maintain capillary refill time to fingers/toes, skin color, skin integrity, skin temperature of extremities at the 2-week follow-up appointment. Patient will maintain adequate fluid volume as evidenced by stable vital signs, adequate urinary output, and moist mucous membranes within 12 hours. Patient will maintain adequate tissue perfusion as evidenced by capillary refill time to toes <3 seconds.
C
Which statement accurately represents documentation of a patient's focused health history? Patient is a Hispanic male appearing stated age. Denies chest pain or rapid heart rate over the past week. Strong family history of type 2 diabetes mellitus. Reports allergies to shell fish and peanuts.
C
Which statement comparing medical diagnosis and nursing diagnosis is true? Nursing diagnosis identifies and labels medical illnesses in addition to life processes. Medical diagnosis identifies and labels medical illnesses. The scope of nursing diagnosis is narrow while the scope of medical diagnosis is broad. The purpose of nursing diagnosis is to clearly identify problems so appropriate nursing care can be provided. The purpose of medical diagnosis is to identify illness so medical treatment can be provided. Nursing diagnosis identifies psychological problems while medical diagnosis identifies physical problems.
C
Which statement describes Cheyne-Stokes respirations? Absence of breathing for several seconds Respirations that are abnormally deep, regular, and increased in rate Rhythmic respirations, going from very deep to very shallow or apneic periods Respirations that are abnormally shallow for two or three breaths, followed by an irregular period of apnea
C
Which statement describes why arterial blood gases are used in patient assessment? To trend values For diagnostic testing To obtain baseline values To calculate pulse oximetry
C
Which subcategory of planning is recognized by professionals and educators as part of the traditional five-step nursing process? Nursing interventions classification Medical outcome identification Outcome identification Medical interventions classification
C
Which goal is realistic for a hospitalized patient who has an infection with the nursing diagnosis of Nutrition Imbalance, Less Than Body Requirements? Patient will gain 1 or more pounds before discharge. Patient will consume 100% of meals during hospitalization. Patient will eat 75% of meals by the end of 3 days. Patient will gain 2 pounds within 7 days.
C Patient will gain 1 or more pounds before discharge.This goal is not realistic because the patient may only be in the hospital for a day or two. Patient will consume 100% of meals during hospitalization.This goal may not be realistic because it does not consider the patient's infection, possible presence of fever, etc. Patient will eat 75% of meals by the end of 3 days.This goal is realistic for a patient with an infection. It allows for eating 75% of meals and allows 3 days for the patient to achieve eating the meals because the patient may have a fever and fatigue. Patient will gain 2 pounds within 7 days.This goal is unrealistic for a patient with an infection who may be experiencing nausea and a fever.
During which part of the health history will the nurse ask about environmental exposures? Medical Sensitivity Social Demographic
C The nurse will ask questions about environmental exposures, caffeine, tobacco, alcohol, and other related exposures when addressing social history.
What is the focus of the body systems model? Vital signs General health status Physical examination Objective and subjective patient information
C physical exam
Which nursing diagnoses are appropriate initially for a patient in the emergency department who "can't catch a breath?" Anxiety Acute Pain Impaired Gas Exchange Ineffective Breathing Pattern Ineffective Peripheral Tissue Perfusion
C,D
Which vital sign functions might the nurse delegate to unlicensed assistive personnel (UAP)? Interpret vital sign data collected. Record vital signs for any patient. Report vital signs for a stable patient. Measure vital signs for a stable patient. Measure vital signs before the nurse has assessed a patient.
C,D
A frail older adult patient who is experiencing shortness of breath is only able to breathe laying on the right side. The patient has a current respiratory rate of 28 breaths per minute (bpm). Which terms describe the signs and symptoms the patient is exhibiting? Apnea Eupnea Dyspnea Orthopnea Tachypnea
C,D,E
Listening to the apical pulse with a stethoscope is best heard between the left fifth and sixth intercostal spaces. In which instances would a nurse auscultate heart sounds? To assess a pedal pulse To measure the radial pulse In the presence of an irregular rhythm If the patient has weak heart contractions When a medication regimen may alter cardiac function
C,D,E
The nurse is caring for a patient diagnosed with a head and brain injury. Which alterations in breathing pattern could possibly occur? Apnea Tachypnea Hypoventilation Biot's breathing Cheyne-Stokes respirations
C,D,E
Under which conditions is an apical pulse considered a better alternative to a radial pulse? Before surgical procedures Before giving a patient thyroid medication If the nurse is unable to accurately palpate a radial pulse When there is need for a more accurate pulse assessment When a patient is on a medication that could affect cardiac function
C,D,E
Which outcomes are appropriate for a patient with Ineffective Peripheral Tissue Perfusion related to decreased cardiac contractility, and who recently suffered a myocardial infarction? Altered Mental Status Urine output <20 mL/hour Palpable peripheral pulses Warm extremities without pallor Blood pressure within normal range for the patient
C,D,E
When is a focused health history obtained instead of a full health history? Select all that apply. Patient admission five years ago. Initial visit to new healthcare provider. Emergency room visit for chest pain. Clinic visit following hospitalization. New patient upon hospital admission.
CD
Which elements are essential when formulating goals for patients with infections? Select all that apply. Subjective data Objective data Realistic Measurable Idealistic
CD
The nurse is preparing to delegate the task of blood pressure (BP) measurement for several patients on a surgical unit. Which patient condition requires special instructions for the unlicensed assistive personnel (UAP) before delegating this task? Select all that apply. Has the right leg in traction Experienced a right-sided stroke Has intravenous (IV) fluids running in the left arm Underwent a right-sided mastectomy Had a cast and pins placed in the left arm
CDE
Which are appropriate measurable, short-term goals for a patient with a diagnosis of Ineffective Tissue Perfusion: Peripheral? Select all that apply. Patient will show no signs of edema. Patient will demonstrate improved perfusion. Patient's skin color will return to normal within 48 hours of medication. Nail beds will return to pinkish color within 3 seconds of nail bed compressions. Patient will increase behaviors that increase tissue perfusion by the next health care provider appointment.
CDE
Common hospital-associated infections are:
Catheter-associated urinary tract infections (CAUTIs) Pneumonia and ventilator-associated pneumonia (VAP) Injection site infections Surgical site infections Central line-associated bloodstream infections (CLABSIs) Gastrointestinal infections from Clostridium difficile
what is COPD?
Chronic obstructive pulmonary disease (chronic bronchitis and emphysema) O2 1-2L/min only, or you'll stop stimulus for breathing Clubbing Barrel chest
A patient comes to the emergency department complaining of fever and diarrhea. What should the nurse ask the patient first? "Do you have a family history of diabetes? "Are you taking any medications? "Have you had any surgeries in the past? "What is the severity and duration of your fever and diarrhea?
D
A patient in the telemetry unit is preparing for discharge after suffering an acute myocardial infarction. What does the nurse tell the patient about his expected level of activity after discharge? The patient should expect to resume all previous activity. The patient should begin an aggressive physical fitness plan. The patient should be on complete bed rest for two weeks. The patient should expect that previous levels of activity will take time to rebuild.
D
A patient is admitted to the nursing unit with cellulitis in the right leg and a fever of 102°F. Which goal is an appropriate short-term goal for this patient? Report thermal comfort with temperature of 98.4°F. Dress more appropriately to maintain normal body temperature. Maintain temperature within normal range within 10 minutes of placement on an aquathermia pad. Maintain temperature within normal range within 1 hour of initiation of warmed intravenous fluids
D
A registered nurse is assessing a patient with decreased respirations, cool skin, and decreased muscle coordination. Which action made by the nurse supports the nursing diagnosis of hypothermia? Asks the patient about feeling feverish Requests laboratory work to check the patient's iron levels Checks the patient's urinary output, which is increased Takes the patient's blood pressure, which shows hypotension
D
A young mother and an infant were involved in a car crash. As the baby is removed from the car seat, the off-duty nurse notices that the baby appears lifeless. What is the best area of the baby's body for the off-duty nurse to check for a pulse? Pedal pulse in the foot Popliteal pulse in the leg Carotid pulse in the neck Brachial pulse in the arm
D
An 82-year-old patient is 2 days postoperative with right hip replacement. The patient has comorbidities of hypertension, atrial fibrillation, and type 2 diabetes. The patient is scheduled for transfer to a rehab unit later today. Vital signs have been stable since surgery. How often should the patient's vital signs be monitored? This patient only requires a pulse check once a day. All postoperative patients require monitoring every 2 hours until discharge. The patient is stable and no longer needs any vital sign monitoring. Vital signs need to be monitored at the time of morning care and again 1 hour before transfer.
D
The nurse assesses an adult patient who is 3 days postoperative from a femoral-popliteal bypass of the right leg. The nurse assesses the patient's femoral, posterior tibial, and pedal pulses of both legs. What is the purpose of checking these three pulse sites? Determine heart rhythm. Check the patient's blood pressure. Assess circulation to his upper extremities. Determine circulatory status of the legs/feet.
D
The nurse has a patient who was admitted 24 hours ago for asthma exacerbation. The patient is currently on 8 liters high flow oxygen with respiratory treatments every 2 hours. Which statement reflects a realistic goal for this patient? The patient will be weaned off of oxygen in the next 12 hours. The patient will have a normal arterial blood gas in the next 8 hours. The patient will exhibit regular breathing patterns with ambulation to the bathroom by tomorrow morning. The patient will demonstrate the ability to complete all activities of daily living with no increase in dyspnea before discharge.
D
The nurse is caring for an older adult patient with heart failure (HF) and atrial fibrillation with rapid ventricular response. The patient's blood pressure is 88/56 mm Hg with a heart rate of 156 beats per minute. The nurse contacts the health care provider to prescribe medication to slow down the patient's heart rate. Why is this important? The patient can feel the rapid heart rate and is uncomfortable. When the heart rate increases, it increases the contractility of the heart. A rapid heart rate will raise the blood pressure, placing the patient at risk for stroke. With an increased heart rate, there is less time available for the heart to contract and fill with blood, leading to decreased cardiac output.
D
The nurse is educating a student nurse about appropriate sites to assess temperature. Which statement made by the student nurse indicates the need for further teaching? "Rectal temperature readings are contraindicated for infant patients." "I can get an accurate tympanic temperature reading on an unconscious patient." "A patient who uses an oxygen mask may have an inaccurate temperature measurement if taken by mouth." "I can get an accurate temperature reading by placing the thermometer to the right of the patient's axilla."
D
The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient? Respiratory therapist, cardiologist, and nephrologist Cardiologist, urologist, and pulmonologist Rheumatologist, respiratory therapist, and cardiologist Respiratory therapist, cardiologist, and pulmonologist
D
The nurse must assess the patient's indirect blood pressure using the popliteal artery due to bilateral injuries to the upper extremities. Which nursing action is accurate when assessing the indirect blood pressure using this artery? Apply the cuff to the patient's calf Apply the cuff 2.5 cm below the popliteal artery Ensure the bladder of the cuff is located on the front of the thigh Inflate the cuff 30 mm Hg above the palpable pulsation of the popliteal artery
D
The nurse obtains an arterial blood gas (ABG) on a patient and the pH is 7.33 and the PaO2 is 103. Which action should the nurse take? Run another blood gas in 30 minutes. Collect labs to send out for more results. Nothing, these results are within normal limits. Call the health care provider because these results are abnormal.
D
The nurse performs assessment on newborn infant patient who weighs 6 lb, 2 oz. The nurse obtains an apical pulse of 60 bpm and notices the infant is not very responsive. Which range reflects the normal pulse rate in a newborn infant? 50-90 bpm 60-100 bpm 75-100 bpm 80-160 bpm
D
The nurse receives a 50-year-old patient back from the endoscopic department. The patient had conscious sedation for an esophageal biopsy. When should the nurse take vital signs? Monitor vital signs every hour. Assess vital signs once per shift because the patient is awake. Take vital signs every 4 hours once the patient is fully awake back on the regular floor. Monitor vital signs every 15 minutes for 1 hour; then if stable, every hour for 2 hours.
D
The nurse recognizes which function as an adaptive immune response? Initiating the inflammatory response Producing chemical mediators Phagocytizing foreign substances Triggering lymphocyte production
D
The nurse would expect a patient to have alterations in temperature control if experiencing which event? Requiring assistance with activities of daily living (ADLs) Recently receiving a series of x-rays for a broken leg during a sports game Undergoing a routine wellness examination before an international flight Being admitted to the hospital after experiencing trauma to the neck
D
The postanesthesia care unit (PACU) nurse is caring for a patient who underwent a femoral-popliteal bypass of the right leg. The nurse assesses pedal pulses every half hour and documents that the patient's pedal pulse in his right foot is 2+ palpable. Which statement describes what this finding means? The pulse is absent. The pulse is bounding and may be visualized. The pulse is weak and thready, difficult to palpate. The pulse is normal and may be easily palpated.
D
The signs and symptoms of inflammation are due to the actions of which white blood cells? Neutrophils Monocytes Eosinophils Basophils
D
What is the purpose of the nursing diagnosis? Label medical illnesses. Define a patient's illness as explicitly as possible. Identify patient's illnesses. Identify health problems or life processes.
D
What policy determines the manner in which medical data is collected and organized? State Federal The Joint Commission Health care facility
D
Which event occurs first when the adaptive immune system is stimulated by an invading antigen? Sensitization of B lymphocytes to non-self-antigen Binding of antigen-specific antibody to foreign antigens Antibody-secreting cells convert into memory cells Decoding of non-self-marker on antigen surface
D
Which mineral is stored in bone and assists with maintenance of phosphorous? Potassium Sodium Chloride Calcium
D
Which nursing diagnosis takes priority for a patient with an open draining wound, fever, and nausea? Impaired Comfort Knowledge Deficit Impaired Skin Integrity Imbalanced Nutrition
D
Which question does the nurse ask first when completing a patient's review of systems? Do you have chest pain? Have you had seizures? When was your last cold? How is your general health?
D
Which site is the most common for indirect blood pressure (BP) measurement? Wrist Lower leg Upper leg Upper arm
D
Which statement illustrates the collaborative characteristic of the nursing process? The nursing process can be used to assess the needs of individuals as well as large communities. The nursing process provides a systematic method of addressing patient needs, and is understood by nurses worldwide. The nursing process allows patient care to be comprehensive and well organized. Nurses may incorporate actions by the patient or family to address patient goals.
D
Which transmission-based precaution will the nurse take for a seriously ill patient being admitted for influenza? Avoid admitting through the reception area. Admit to an airborne infection isolation room. Obtain an N95 disposable respirator mask. Provide a mask for patient if leaving the room.
D
Why does the nurse focus on airway status when developing a nursing diagnosis for a patient with asthma? To label the medical illness To define the patient's illness as explicitly as possible To identify the patient's illnesses To identify the patient's response to illness
D
Which blood test specifically indicates the presence of an active inflammatory response rather than infection? White blood cell (WBC) count Complete blood count (CBC) Culture and sensitivity (C&S) test Erythrocyte sedimentation rate (ESR)
D ESR is elevated during active inflammation. It remains elevated during active inflammation. Because infection causes inflammation, it is also elevated during infection
Which type of physical assessment is usually governed and directed by the policies of the health care facility? Comprehensive Emergency Focused Shift
D Each health care facility has its own policies for what should be included in a shift assessment.
When a patient reports feeling anxious, what is the subjective data called? Cluster of symptoms Diagnosis Sign Symptom
D It can be helpful to remember that symptoms, such as anxiety, may lead a patient to know something is wrong, but signs are objective and taken by the health care professionals.
Which precautions will be implemented for a patient admitted for suspected West Nile virus? Contact Droplet Airborne Standard
D Standard precautions will be implemented for this patient because West Nile virus is transmitted by a vector, specifically mosquitos. There are no other precautions required for vector transmitted pathogens.
During which type of assessment would the nurse be most likely to assess skin turgor and capillary refill to determine the patient's clinical status? Comprehensive Emergency Focused Shift
D The nursing shift assessment requires a nurse to use clinical assessment skills (e.g., assessing skin turgor and capillary refill) to determine the patient's clinical status.
Which goal is measurable for a patient who is experiencing chest discomfort from a cough related to a respiratory infection? Coughing will improve within 12 to 24 hours of initiation of treatment. Patient complaints of chest discomfort from cough will decrease within 4 days. Productive cough will decrease within 48 hours of starting treatment. Patient will verbalize decreased chest discomfort related to cough within 2 days.
D This goal is measurable because it addresses the patient's problem of chest discomfort related to cough, and patient verbalizations are measurable data.
myocardial infarction (MI)
Death of cardiac muscle due to ischemia ETIOLOGY - UNCONTROLLED ANGINA & CAD SIGN & SYMPTOMS - CHEST PAINS with SOB Even at Rest due to complete blockage of coronary artery Chest Pain longer than 20 min Nitroglycerin will not work for the MI chest pain For MI - Give MONA M- Morphine - monitor breathing and heart rate because morphine suppresses them O- Oxygen N - Nitroglycerin A- Aspirin
What happens during the review of systems?
During the review of systems, the nurse first asks about the patient's general health, and then proceeds to ask focused questions about each of the body systems and potential health concerns that may affect them
What is the frequency for vital sign assessment?
Every 4 to 8 hours for a stable patient Every 15 to 60 minutes for postprocedure or postoperative patients Every 5 minutes or continuously for critical or unstable patients
Standard precautions are used:
For all patients when contact with potentially infectious bodily materials is possible. During contact or potential contact with:Blood and bodily fluids (except perspiration), secretions, and excretions.Nonintact skin.Mucous membranes.Other potentially infectious material.
Interventions for respiratory distress
Fowler's postion Albuterol - bronchodilator (for all respiratory problems) - first line medication for Asthma (monitor heart rate, heart rate will rise) Ipratropium - usually given in concert with Albuterol during nebulizer treatment - not first line Maintenance drugs - corticosteroids, prednisone (for all) (reduce immune response) Aminophylline - IV for asthma or severe allergies Antibiotics - pneumonia, bronchitis
Medications for CHF
Furosemide (Lasix): A. Perfect diuretics- gets rid of the fluids including pulmonary edemas. B. Improves gas exchange - check lung sounds to see if diuretic worked - are we still hearing CRACKLING? C.Gets rid of the fluids including electrolytes - Potassium (K+) (normal range 3.5 - 5.0 meq/L) Beta Blockers - ends in lol - Metoprolol, Labetalol, Atenolol, Carvedilol, Propranolol When the patient is experiencing CHF, we don't want the patient to have an elevated heart rate. So, we give the patient Beta Blockers because it not only lowers the heart rate, but lowers the BP too. Digoxin: Classification is a Glycoside - Anti Arrhythmia medication and is given to patient with heart failures. · Decreases Heart rate and maintains contractility. · Do not give if the heart rate is lower than 60 bpm. · Will regulate the HR. · Therapeutic level 0.8-2.0 ng/mL. The toxic level is >2.4 ng/mL · S & S of Digoxin Toxicity(digitalis toxicity) - Bradycardia, Nausea, Vomiting ,Anorexia, Abdominal Pain, Visual Disturbances (blurred vision, halo, green spots) · Hypokalemia puts the client at risk for Digoxin toxicity (because hypokalemia is already causing low heart rate, so adding Digoxin will only exacerbate that)
Factors that can account for slow or fast pulse
Gender (malem lower than female), age (decreases with age), exercise, fever (increases), medications, fluid volume status (increases with hypovolemia), stress, and underlying disease processes, hypoxia (increases)
Hypovolemia interventions
Give IV Fluids, 0.9% normal saline
A nurse is examining a patient in the emergency department (ED) who presents with symptoms of heat exhaustion and has a temperature of 102.9°F. The nurse feels the patient's wet skin and observes the patient shivering. Which action should the nurse take first?
Give the patient intravenous fluids to replace lost electrolytes.
examples of nursing diagnostic labels for temperature
Hyperthermia, Hypothermia, Ineffective Thermoregulation, Risk for Imbalanced Body Temperature
What should the nurse remember about inflammation?
Inflammation is not the same as infection even when inflammation is caused by, or is part of, infection It is important for nurses to understand that inflammation is generally a protective response, but when it becomes chronic, it can cause systemic inflammatory disease. It is essential that nurses understand how to differentiate inflammation from infection. Patients with inflammatory diseases are often treated with immune suppressive therapies that place them at risk for infection. Knowing which manifestations are related to the patient's inflammatory condition and recognizing any new manifestations that signal infection allow for rapid intervention and resolution of the infection.
Nursing care can be categorized as direct or indirect, depending on the nursing ___________.
Interventions (are direct or indirect)
what are living and nonliving antigens?
Living antigens are usually proteins, such as molecules on the surface of pathogens, and nonliving antigens include substances such as toxins, chemicals, or drugs.
Tachycardia causes
MAY INDICATE STIFFNESS OF AORTA WHICH MAY INDICATE ATHEROSCLEROSIS (FATTY DEPOSITS ON WALLS OF ARTERIES), ANEMIA (LOW RBC'S/HEMOGLOBIN), OR HYPERTHYROIDISM decrease B/P elevated temperature poor blood oxygenation exercise prolonged application of heat pain strong emotions some medication
Medications for left ventricular failure
Medication given are: 1. Diuretics= furosemide/lasix - gets rid of fluids in the lungs and extremities. 2. Hypertension (HTN) medication= to maintain the BP because these patients usually have existing HTN. So, we give both medications
What is the diagnostic label?
Standardized language to identify patient problems and plan customized care
What happens during the general survey?
The general survey is the visual evaluation of the patient, including the reason for the visit and current health status. The nurse makes basic observations about the patient's characteristics, comparing them to behavioral, societal and cultural norm age race sex dress hygiene affect safety - risk factors? safety and security issues? habits speech gait vital signs height/weight
What happens during the health history?
The interview provides essential patient data that is not available in the patient's health records. This is subjective information that is obtained either directly from the patient, or indirectly from a family member if the patient is unable to provide an adequate or accurate health history. The review of medical records provides patient data that is available in the patient's health records. This is objective information about the patient's demographics and medical/surgical history. The review of medical records ideally is completed prior to the patient interview to help the nurse focus the interview questions and physical assessment.
two types of pulses
apical, peripheral
An elevated pulse may indicate...
arterioscleriosis, atherosclerosis, anemia, hyperthyroidism
what are used to obtain objective data?
auscultation, observation, palpation, percussion, diagnostic testing
What are outcomes of patient care?
behaviors or observable actions that indicate attainment of a goal; outcomes are set during planning step
left ventricular failure
blood is not pumped to the aorta, instead it is backed up into the valves and eventually reaches Pulmonary capillaries. Since capillaries are very tiny, they cannot take all that volume, the fluids will leak out of the capillaries and will seep into the alveolar sac. As a result, we have pulmonary edema (you will hear "crackles" in the lungs) with resp rate above 28. (CHF)
the_______ regulates coordination in the body
cerebellum
what is orthostatic hypotension?
drop in systolic by at least 20mmHg or a drop in diastolic by at least 10mmHg within 3 mins of rising to an upright position § Risk factor for falls, especially elderly patients with hypertension
what can be ordered to define a specific dysrhythmia
electrocardiogram, Holter monitor, or telemetry monitor is necessary to define the specific dysrhythmia. Holter monitor - portable device, collects cardiac data continually for a few days, and must be removed to retrieve captured data Telemetry monitor - portable device, collects cardiac data for up to a month, and transmits captured data instantaneously
why can't infants thermoregulate?
have immature regulatory mechanisms, causing constant body temperature instability
Hypertension
high blood pressure
Receptors in the medulla react to _______. This push-pull between the two groups of receptors creates breathing.
high levels of carbon dioxide (hypercapnia) and changes in pH
the cerebral cortex regulates ____activity
mortor
Angina pectoris occurs when:
myocardial o2 demand exceeds supply Stable - chest pain with exertion but goes away with rest or relaxation Unstable - chest pain even at rest Prinzmetal (Variant) - almost always occurs when a person is at rest, usually between midnight and early morning Medication of Choice NITROGLYCERIN - Coronary Artery Dilator 1 tablet sublingual q5 min - Maximum 3 times Main Side Effects - Headache, Hypotension, Tachycardia
Which are subjective indications of a disease or a change in condition as perceived by the patient called?
symptoms
Chemoreceptors in _______ react to hypoxemia (low oxygen levels in the blood)
the aortic arch and carotid arteries
What is the Evaluation step of the nursing process?
the nurse determines goal attainment, the effectiveness of interventions, and whether the plan of care should be discontinued, continued, or revised
What is the Planning step of the nursing process?
the nurse prioritizes a patient's various nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals