Nursing Fundamentals NUR 120D Exam 1
What are the side effects of metoprolol?
• AV block • Bradycardia • Dizziness • Decreased cardiac output • Bronchospasm
What are the seizure precautions?
• Bed in lowest position • Pillow under head • Oxygen & suction apparatus • Loosen clothing • Client in side-lying position (immediately post-seizure) • Side rails up & padded • Privacy provided as soon as possible
Portal of exit examples
• Blood • Skin • Mucous membranes • Respiratory tract • Genitourinary tract • Gastrointestinal tract
What are the side effects of Furosemide?
• Blood dyscrasias • Dehydration • Hypokalemia (low K+) • Hyponatremia (low Na+) • Ototoxicity (hearing loss) • Hypochloremia
Portal of entry examples
• Break in skin • Mucous membrane • Mouth, nose • Genitourinary tract
What causes hypotension?
• Causes = disruption in cardiovascular dynamics. • Decreased blood volume (hemorrhage). • Decreased cardiac output (heart attack or heart failure). • Decreased peripheral vascular resistance (shock).
What is Battery?
Actual physical harm caused to another person
Individualized map to obtain specific patient goals and outcomes a. Assessment b. Implementation c. Planning d. Evaluation
C. Planning
Full-spectrum nursing is a unique blend of ______ and ______that translates caring into action.
thinking and doing
Cheilosis
Ulceration of the lips (reddened fissures at the angles of the mouth).
For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?
1. Inspection 2. Palpation 3. Percussion 4. Auscultation
To reduce shearing force to an elderly patient or an immobilized patient, position them with the head of the bed at no less than what angle?
30º
Direct contact?
Person to person or physical contact between source and susceptible host
End result of planning phase
A holistic nursing care plan, individualized to reflect the client's problems and strengths
Susceptible host?
A personal who becomes ill after pathogens enter the body because they cannot fight off the pathogen
What is the chain of infection?
A sequence of circumstances where all events must occur to develop an infection
What is planning?
A series of steps by which the nurse and the patient set priorities and goals.
What is a Felony?
A serious crime that results in the perpetrator being imprisoned in a state or federal facility for more than a year
A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? SELECT ALL THAT APPLY. a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism
A. Code of ethics B. Licensing C. Body of knowledge E. Altruism
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address." b. "I will review the past medical history on the clients records to get more information." c. "I will carry out the new prescriptions from the provider." d. "I will ask the client if their nausea has resolved."
A. "I will determine the most important client problems that we should address." Rationale: Prioritize the client's problems during the planning step of the nursing process.
Which statement or command mean by the nurse is an example of the evaluation phase of the nursing process? a. "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." b. "Mr. Sullivan will be able to walk the length of the hallway before discharge." c. "Mr. Sullivan may be able to ambulate with the use of a walker and standby assistance." d. "Ambulate Mr. Sullivan in the hallway three times today, please."
A. "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal."
The nurse is giving a bed bath to an elderly patient. What are factors to consider when assessing this patient's skin? SELECT ALL THAT APPLY. A. Color. B. Emotions. C. Sensation. D. Skin lesions. E. Vital signs (VS).
A. Color C. Sensation D. Skin lesions
The nurse is giving a bed bath to an elderly patient. What are factors to consider when assessing this patient's skin? SELECT ALL THAT APPLY. a. Color. b. Emotions. c. Sensation. d. Skin lesions. e. Vital signs (VS).
A. Color. C. Sensation. D. Skin lesions.
Which factors are affecting the nursing shortage? SELECT ALL THAT APPLY. a. Aging faculty b. Increasing elderly population c. Job satisfaction due to adequate number of nurses d. Aging nursing workforce e. Greater autonomy for nurses
A. Aging faculty B. Increasing elderly population D. Aging nursing workforce
The nurse is completing a postoperative assessment on a client in the post-anesthesia recovery unit. Which VS requires further assessment by the nurse for the possible hypovolemic (low blood volume) shock? a. An increase in HR b. An increased temp. reading c. A decrease in BP d. A decrease in RR
A. An increase in heart rate
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway. B. Provide pain relief. C. Encourage deep breathing and coughing. D. Splint the chest wall with a pillow.
A. Assess the client's airway.
The nurse is assessing the dorsalis pedis pulses on an 88-year-old patient. She notes the feet to be cool and assesses weak, thready pulses. What should the nurse do next? a. Assess the popliteal and femoral pulses. b. Assess a 1-minute apical pulse. c. Apply a warm pack and reassess in 20 minutes. d. Notify the provider STAT.
A. Assess the popliteal and femoral pulses.
A charge nurse is observing a newly licensed nurse caring for a client who reports pain. The nurse checked the clients MAR and noted the last dose of pain medication was six hours ago. The prescription reads every four hours PRN for pain. The nurse administered the medication and checked with the client 40 minutes later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation
A. Assessment
An adult client's vs are: BP 160/98, temp 99.0 F, HR 80, and RR 18. The VS that should be of most concern to the nurse is: a. BP b. Temp c. Pulse d. RR
A. BP
A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? A. Baked beans, hamburger, and milk B. Spaghetti with cream sauce, broccoli, and tea C. Bouillon, spinach, and soda D. Chicken cutlet, spinach, and soda
A. Baked beans, hamburger, and milk
A nurse is performing a physical assessment on a patient and instructs the patient to stand with his feet together and arms at his side. The purpose of positioning the patient in this manner is to test which of the following? a. Balance b. Muscle strength c. Reflexes d. Coordination
A. Balance
The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD) and hypertension (HTN). Before administering Propanolol, the nurse assesses the patient carefully. What is the most likely complication of this medication? a. Bronchospasm b. Heart block c. Heart failure d. Tachycardia
A. Bronchospasm
A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? SELECT ALL THAT APPLY. a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism
A. Code of ethics B. Licensing C. Body of knowledge E. Altruism
Which statement illustrates the most measurable outcome indicator? a. Demonstrates dressing changes b. Shares innermost thoughts c. Understand instructions d. Shows personal remorse
A. Demonstrates dressing changes
Analyze assessment data to focus on client's priority needs a. Diagnose b. Planning c Implementation d. Evaluation
A. Diagnose
When caring for a client with rubella, in addition to standard precautions, which precautions would be used? a. Droplet precautions b. Airborne precautions c. Contact precautions d. Universal precautions
A. Droplet precautions
Which action should a nurse take 30 minutes after administering oral pain medication to a patient? a. Evaluate the effectiveness of the administered pain medication b. Teach progressive relaxation strategies to relieve muscle tension c. Assess the patients coping skills to reduce expression anxiety. d. Encourage the patient to read or watch tv to provide pain distraction
A. Evaluate the effectiveness of the administered pain medication
Which action should the nurse take 30 mins. after administering oral pain medication to a client? a. Evaluate the effectiveness of the administered pain medication b. Teach progressive relaxation strategies to relieve muscle tension c. Assess the client's coping skills to reduce expressed anxiety d. Encourage the client to read or watch TV to provide pain distraction
A. Evaluate the effectiveness of the administered pain medication
Which action should the nurse take 30 minutes after administering oral pain medication to a patient? a. Evaluate the effectiveness of the administered pain medication b. Teach progressive relaxation strategies to relieve muscle tension c. Assess the patient coping skills to reduce expressed anxiety d. Encourage the patient to read or watch TV to provide pain distraction
A. Evaluate the effectiveness of the administered pain medication
Which of the following is the most effective way to break the Chain of Infection? a. Hand hygiene. b. Placing patients in isolation. c. Providing private rooms for patients. d. Wearing gloves.
A. Hand hygiene
What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: A. Identify personal biases that may affect his thinking and actions. B. Identify the most effective interventions for a patient. C. Communicate more efficiently with colleagues, patients, and families. D. Learn and remember new procedures and techniques.
A. Identify personal biases that may affect his thinking and actions.
Specific nursing interventions to meet patient goals and outcomes. a. Implementation b. Planning c. Evaluation d. Diagnosis
A. Implementation
The nurse is caring for a client who experienced major trauma and has lost approx. 2 units of blood. Which initial compensatory mechanisms would the nurse expect the client to exhibit. SELECT ALL THAT APPLY. a. Increased BP b. Increased urinary output c. Increased pulse rate d. Decreased temp. e. Decreased respirations
A. Increased blood pressure C. Increased pulse rate
A nurse goes to another unit to see a friend who has been admitted. The nurse goes to look at a friend's medical record. This is an example of: a. Invasion of privacy b. Breach of confidentiality c. Liability d. Malpractice
A. Invasion of privacy
Which nursing intervention would be effective when dealing with the family members of a critically ill client? A. Involve the family members in care conferences about the client's care. B. Complete all of the client's care so the family is not inconvenienced. C. Select the eldest child to involve in care conferences. D. Invite the family member with better coping skills to the care conference.
A. Involve the family members in care conferences about the client's care.
A nurse stands facing a client to demonstrate AROM exercises. which of the following should the nurse do when demonstrating hyperextension of the hip? a. Move the leg behind the body b. Move the leg forward and up c. Move the leg medically towards the other leg d. Turn the foot and leg away from the other leg
A. Move the leg behind the body
Johnston would like to better understand his hospital bill. He calls the hospital and the billing department suggest he meet with a representative and get an explanation. What is this an example of? a. Patient care partnership b. Good Samaritan law c. Standard of practice d. Nurse practice acts
A. Patient care partnership
What is Convalescent period?
Recovery from infection.
The nurse is explaining the health insurance portability and accountability act to a group of new employees. What should the nurse include when explaining its purpose? SELECT ALL THAT APPLY. a. Protects health insurance benefits b. Provide transferability of insurance to others c. Protects family members d. Protects those with pre-existing conditions e. Provides personal health information privacy
A. Protects health insurance benefits D. Protects those with pre-existing conditions E. Provides personal health information privacy
This nurse works with the government to provide millions of immunizations at no charge to those within the community. Which type of nursing is this? a. Public health clinics b. Community-oriented Nursing c. Community health nursing d. School nursing
A. Public health clinics
The nurse is tracking the trend of increased measles outbreak's in state public universities and providing immunization boosters to the campus health clinics. Which type of nursing is this? a. Public health nursing b. Community health nursing c. Public health clinics d. Parrish Nursing
A. Public health nursing
While performing a complete bed bath for a patient, the nurse should a. Raise the room temperature b. Completely remove the linens c. Add soap to the water in the basin before beginning the bath d. Complete the bathing for one side of the body and a time
A. Raise the room temperature
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? A. Sitting upright. B. Lying flat on the back with knees flexed. C. Lying flat on the back with arms and legs fully extended. D. Side-lying with the knees flexed.
A. Sitting upright.
Calvin is considering a transfer to the interventional radiology department. He's unfamiliar with the expectations in the nursing role within that department and looks for practice guidelines. What is this an example of? a. Standard of practice b. Scope of practice c. American nurses Association code of ethics d. Nurse practice acts
A. Standard of practice
The nurse understands that which statements regarding BP and the BP requirement are true? SELECT ALL THAT APPLY. a. The highest pressure is the systolic pressure; the lowest pressure is the diastolic pressure b. The client should be in a comfortable lying or sitting position when taking the blood pressure c. Maximum BP is created in the arteries when the right ventricle pushes blood into the aorta d. The difference between systolic pressure and diastolic pressure is known as pulse deficit e. The point on the gauge where the 1st faint but clear sound appears is known as diastolic pressure
A. The highest pressure is the systolic pressure; the lowest pressure is the diastolic pressure B. The client should be in a comfortable lying or sitting position when taking the blood pressure
The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? SELECT ALL THAT APPLY. A. Used a vague generality. B. Did not use the patient's exact words. C. Used a "waffle" word (e.g., appears). D. Recorded an inference rather than a cue. E. Did not record the patient's vital signs.
A. Used a vague generality. C. Used a "waffle" word (e.g., appears). D. Recorded an inference rather than a cue. E. Did not record the patient's vital signs.
When providing home-going instructions for a recently discharged client, which statement by the client's son would indicate an understanding of methods to prevent complications from immobility? a. We'll make sure that Dad eats plenty of lean protein foods b. We will limit Dad's fluid intake to prevent bladder incontinence c. Dad should sit more and restrict the time he walks around the house d. His arm sling should be kept on at all times to prevent an elbow contracture
A. We'll make sure that Dad eats plenty of lean protein foods
The nurse is caring for a client that has a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control practices should the nurse implement? SELECT ALL THAT APPLY. a. Wear a protective gown when entering the client's room b. Don a particulate respirator mask when administering medication to the client c. Ensure all staff serving the client's meal trays don gloves d. Instruct all visitors to wear a surgical mask when entering the client's room e. Use sterile gloves when performing dressing changes f. Use a face shield before irrigating the client's wounds
A. Wear a protective gown when entering the client's room C. Ensure all staff serving the client's meal trays don gloves F. Use a face shield before irrigating the client's wounds
The nurse would monitor the body temperature most closely/frequently in the care of the patient: a. With a head injury. b. With an infection. c. Who has experienced a heat stroke. d. Who is an infant.
A. With a head injury.
An infection occurs as a result of a cyclical process. The 6 components of infection are: a. infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host. b. infectious agent, reservoir, portal of exit, vehicle of movement, portal of entry, and susceptiblehost. c. infectious agent, reservoir, portal of exit, vehicle of transmission, portal entry, and unsusceptible host. d. invading agent, reservoir, portal of exit, vehicle transmission, portal of entry, and susceptible host.
A. infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host.
Critical thinking skills
Refer to cognitive processes used in complex thinking operations like problem-solving and decision making
Apnea
Absence of breathing
Implementation
Action phase; carry out or delegate the actions that you planned already
Contextual Awareness
An awareness of what's happening in the total situation, including values, cultural issues, interpersonal relationships, and environmental influences. • Deciding what to observe and consider
What is evaluation?
Assessing the patient's response to the nursing interventions
Five Steps of Nursing Process
Assessment Diagnosis (PROBLEM STATEMENT) Planning Outcomes and Interventions Implementation Evaluation
Intellectual Humility
Aware they do not know everything and not afraid to ask for help
Normal oral temp. is 98.6 F. What is the temp for axillary, rectal, and tympanic?
Axillary: one lower than oral Rectal: one higher than oral Tympanic: same as oral
The nurse is caring for a patient admitted with a history of hypertension (HTN). The patient's medication history includes Hydrochlorothiazide for the past 10 years. Which parameter would indicate the optimal intended effect of this medication? a. Absence of ankle edema. b. Blood pressure 116/70. c. Output of 600 mL per 8 hours. d. Weight loss of 2 lbs.
B. Blood pressure 116/70.
A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is an appropriate response by the nurse? a. "Since you are not eating, we can wait and do it before bedtime." b. "Oral care is still important even though you are not eating." c. "I'll give you a sip of water to swish around in your mouth, and then you can spit it out." d."We will wait until your family gets here to help."
B. "Oral care is still important even though you are not eating."
The nurse completed an admission history & physical examination on a client admitted for chest pain (CP), rule out (R/O) myocardial infarction (MI) [or "heart attack"]. Which of the following are objective data? Select all that apply. A. "I have chest pain." B. 57-year-old client. C. Blood pressure (BP) 158/90. D. Heart rate (HR) 110. E. "I am afraid something serious is wrong."
B. 57-year-old client. C. Blood pressure (BP) 158/90. D. Heart rate (HR) 110.
Which of the following clients are not able to give consent? SELECT ALL THAT APPLY. a. Legal guardian b. A mentally incompetent adult c. A married 16 yr old d. An intoxicated adult e. The health care proxy
B. A mentally incompetent adult D. An intoxicated adult
Which intervention is an example of primary prevention? A. Administering digoxin (lanoxicaps) to a patient with heart failure. B. Administering measles, mumps, and rubella immunization to an infant. C. Obtaining a Papanicolaou smear to screen for cervical cancer. D. Using occupational therapy to help a patient cope with arthritis.
B. Administering measles, mumps, and rubella immunization to an infant.
Which are roles of the community health nurse. SELECT ALL THAT APPLY a. Facilitator b. Advocate c. Teacher d. Counselor e. Case manager
B. Advocate C. Teacher D. Counselor E. Case manager
Accepted money from a client as a "thank you" gift. Her employer found out and fired her. When is this an example of? a. Standard of practice b. American Nurses Association Code of ethics c. Nurse practice act d. Scope of practice
B. American Nurses Association Code of ethics
A postoperative patient is breathing rapidly. You should immediately: a. Ask the patient if he feels uncomfortable. b. Assess the oxygen saturation. c. Call the physician. d. Count the respirations.
B. Assess the oxygen saturation.
A nurse admits a patient to the cardiac care unit following the place of a cardiac stent. Which step of the nursing process does the nurse do first? a. Planning b. Assessment c. Evaluation d. Implementation
B. Assessment
A nurse has performed a physical examination of the client and reviewed the laboratory and diagnostic test results on the client's chart. The nurse is performing which specific nursing function. a. Diagnosis b. Assessment c. Education d. Avocacy
B. Assessment
Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asked what Mr. Patel has eaten in the last 24 hours. What is the step of the nursing process this represents: a. Diagnosis b. Assessment c. Planning d. Implementation e. Evaluation
B. Assessment
A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed corn
B. Bananas and oranges
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessment B. Nursing diagnosis C. Planning D. Evaluation
B. Nursing diagnosis
Which specific aspect of a profession does the development of theories provide? a. Altruism b. Body of knowledge c. Autonomy d. Accountability
B. Body of knowledge
Which specific aspect of a profession does the development of theories provide? a. Atruism b. Body of knowledge c. Autonomy d. Accountability
B. Body of knowledge
What actions by the nurse are critical to ensure client safety? SELECT ALL THAT APPLY. a. Place the call light on the client's nightstand b. Clean up fluid spills on the floor immediately c. Instruct the client to wear socks when ambulating d. Keep linens and intravenous tubing off the floor e. Return the bed to low position prior to exiting the room
B. Clean up fluid spills on the floor immediately D. Keep linens and intravenous tubing off the floor E. Return the bed to low position prior to exiting the room
The nurses working at a low-income prenatal clinic providing free services, including dietary counseling, exercise, and parenting classes. Which type of nursing is this? a. Public health nursing b. Community health nursing c. Community-oriented Nursing d. School Nursing
B. Community health nursing
A patient, with a right-sided weakness, is being ambulated at least twice a day in a healthcare facility. Since the patient is elderly, what other factors besides decreased joint mobility might affect ambulation? a. Decreased ability to learn how to use a walker. b. Decreased muscle strength & tone. c. Increased cardiac workload & pulse rate. d. Increased sensory perception.
B. Decreased muscle strength & tone.
The global health nurse will often see which of these conditions? SELECT ALL THAT APPLY a. Metabolic syndrome b. Dehydration c. Malnutrition d. Insect-related illness e. Parasite infections
B. Dehydration C. Malnutrition D. Insect-related illness E. Parasite infections
In which step of the nursing process does the nurse analyze data and identify client problems? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation
B. Diagnosis
One aspect of implementation related to drug therapy is: A. Developing a content outline. B. Documenting drugs given. C. Establishing outcome criteria. D. Setting realistic client goals.
B. Documenting drugs given.
Using Abraham Maslow's hierarchy of human needs, a nurse assigns highest priority to which client need? A. Security B. Elimination C. Safety D. Belonging
B. Elimination (because it's physiological, which beats out safety. But if we're being honest? If a bear is attacking me, I'm going to piss my pants so we're gonna have both, ok?)
A nurse is caring for a hospitalized patient who is performing active range of motion exercises. which of the following body movements should indicate to the nurse and the patient has full range of motion of the shoulder? a. I don't think the arm so that it lies next to the patient side b. Flexing the shoulder by raising the arm from a side position to a 180° angle c. Abducting the arm to a 90° angle from the side of the body d. Circumducting the shoulder in a 180° half circle
B. Flexing the shoulder by raising the arm from a side position to a 180° angle
Rosalee, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying the patient's needs. Which of the steps of the nursing process does this represent? a. Planning outcomes b. Planning interventions c. Implementation d. Evaluation e. Diagnosis f. Assessment
B. Planning interventions
Which of the following are classified as skilled nursing services? SELECT ALL THAT APPLY a. Meal prep b. IV therapy c. Ostomy care d. bathing e. assistance with feedings f. respiratory care
B. IV therapy C. Ostomy care F. Respiratory care
A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? A. Inadequate vitamin D intake. B. Inadequate protein intake. C. Inadequate massaging of the affected area. D. Low calcium level.
B. Inadequate protein intake.
The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first? A. Auscultation B. Inspection C. Percussion D. Palpation
B. Inspection
A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a patient from the bed to a chair. The nurse should intervene if the AP a. Places the sling under the patient from shoulders to knees b. Leaves the bed in the lowest position throughout the procedure. c. Locks the hydraulic valve before attaching the sling to the lift d. Raises the head of the bed to a sitting position just before transfer
B. Leaves the bed in the lowest position throughout the procedure.
Bones function in what important roles within the body? SELECT ALL THAT APPLY. a. Regulate potassium levels b. Maintain calcium balance c. Protect critical organs d. Produce blood cells e. Control motor activity
B. Maintain calcium balance C. Protect critical organs D. Produce blood cells
A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client? A. Promote fluid balance B. Prevent infection C. Promote rest D. Prevent injury
B. Prevent infection
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following? A. Fail to show changes in blood pressure. B. Produce a false-high measurement. C. Cause sciatic nerve damage. D. Produce a false-low measurement.
B. Produce a false-high measurement.
A patient is admitted for dehydration & SOB caused by pneumonia (PNA). He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement(s) should you reassess? SELECT ALL THAT APPLY a. Right arm BP: 120/80. b. Radial pulse rate: 72 and irregular. c. Temporal temperature: 37.4°C (99.3°F). d. Respiratory rate: 28. e. Oxygen saturation: 90%.
B. Radial pulse rate: 72 and irregular. D. Respiratory rate: 28. E. Oxygen saturation: 90%.
A patient is admitted for dehydration & SOB caused by pneumonia (PNA). He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement(s) should you reassess? SELECT ALL THAT APPLY. a. Right arm BP: 120/80. b. Radial pulse rate: 72 and irregular. c. Temporal temperature: 37.4°C (99.3°F). d. Respiratory rate: 28. e. Oxygen saturation: 90%.
B. Radial pulse rate: 72 and irregular. D. Respiratory rate: 28. E. Oxygen saturation: 90%.
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important? A. A history of increased aspirin use. B. Recent pelvic surgery. C. An active daily walking program. D. A history of diabetes.
B. Recent pelvic surgery.
You are making a home visit to a family of 5 children. The youngest, aged 5, has a temp of 101.1 F, is lethargic, and has a poor appetite. This assessment leads you to the diagnosis of influenza. Based on your knowledge that influenza is an airborne communicable disease, all of the following patient teachings regarding infection are appropriate for the mother and family except: a. Keep children home from daycare and school while symptoms are present b. Remind family that they only need to wash their hands if they are visibly dirty c. Do not share tissues, dishes, or personal care items to reduce the risk of transmission d. Encourage the family to receive their annual influenza vaccine
B. Remind family that they only need to wash their hands if they are visibly dirty
The nurse provides perineal care to a middle-aged female patient who just got off the bedpan. Before leaving the patient's room, what should the nurse do to ensure bedside safety? SELECT ALL THAT APPLY. a. Functioning call light out of patient's reach. b. Room is free of clutter. c. The bed is in its highest position. d. The bed controls are not functioning. e. The casters or wheels are locked.
B. Room is free of clutter. E. The casters or wheels are locked.
A new grad is exploring the role of the community health nurse. What services might be provided by this person? SELECT ALL THAT APPLY. a. Trending of community illness b. Running a health clinic for uninsured children c. Monitoring polio outbreaks in a geographic location d. Conducting diabetic education at the senior community center e. Performing tuberculosis testing for high-risk homeless individuals
B. Running a health clinic for uninsured children D. Conducting diabetic education at the senior community center E. Performing tuberculosis testing for high-risk homeless individuals
What are common expectations of the community-based nurse? SELECT ALL THAT APPLY. a. Previous hospital experience b. Sensitive to differences in people c. Live in the community they serve d. Nonjudgmental e. High level of professionalism
B. Sensitive to differences in people D. Nonjudgmental E. High level of professionalism
The nurse is caring for a client with a temp of 103 F, respirations of 30 per min., pulse rate of 50 beats per minute, and BP of 100/60. The client is cold and clammy. What does the nurse conclude about these findings? a. The temp is causing a lowered pulse rate; it will improve if the temp. decreases. b. The low pulse rate is causing a decreased cardiac output, which has caused a low BP c. The pulse rate and BP are compensatory mechanisms to decrease the increased metabolic rate from the temp. d. The cool, clammy skin will help to increase the BP and pulse as the body tries to warm the skin
B. The low pulse rate is causing a decreased cardiac output, which has caused a low BP
Which actions by the nurse could result in a BP measurement error? SELECT ALL THAT APPLY. a. Placing the diaphragm of the stethoscope over the brachial artery b. Using the same cuff for all clients c. Wrapping the bottom edge of the cuff over the antecubital space d. Releasing the valve quickly to prevent client discomfort e. Taking a measurement after the client rests quietly for 5 mins.
B. Using the same cuff for all clients C. Wrapping the bottom edge of the cuff over the antecubital space D. Releasing the valve quickly to prevent client discomfort
A postoperative patient is breathing rapidly. You should immediately: a. ask the patient if he feels uncomfortable. b. assess the oxygen saturation. c. call the physician. d. count the respirations.
B. assess the oxygen saturation.
What are the vital signs?
BP Temp HR RR O2 Sat Pain
Intellectual Courage
Being willing to consider and examine fairly your own beliefs and the views of others. They will rethink and even change their views
What is the drug class for Metoprolol?
Beta Blockers
What is blood pressure?
Blood pressure (BP): the force of the blood against arterial walls rises as the ventricle contracts (systole), and it falls as the heart relaxes (diastole) creating a pressure wave through the arterial system.
You are caring for a 22-year-old female client admitted with complaints of headache. She was accompanied by her roommate, her best friend since age 5, who confidentially confides that the patient is a victim of dating violence. What is the nurse's initial best response? A. "I can only take a history from the client." B. "Thank you. I will pass the information to the provider." C. "Tell me more and how this relates to her headaches." D. "What is his name and how have you tried to help her get out of the relationship?"
C. "Tell me more and how this relates to her headaches."
Which assessment findings would require the nurse to further assess the client? A. A young adult male with a pulse rate of 136 after running 2 miles B. A 40 yr old female with a BP of 110/70 when 1st awakened C. A 72 yr old female with a respiratory rate of 10 breaths per min. D. A 50 yr old male with a pulse rate of 88 beats per min.
C. A 72 yr old female with a respiratory rate of 10 breaths per min.
Which assessment findings would require the nurse to further assess the client? a. A young adult male with a pulse rate of 136 after running 2 miles b. A 40 yr old female with a BP of 110/70 when 1st awakened c. A 72 yr old female with a respiratory rate of 10 breaths per min. d. A 50 yr old male with a pulse rate of 88 beats per min.
C. A 72 yr old female with a respiratory rate of 10 breaths per min.
To prevent injury to a client during logrolling, which action by the nurse is most important? a. Place an ankle-foot orthotic on the client prior to movement b. Remove the client's drawsheet to avoid lower extremity entanglement c. Position a pillow between the client's legs to maintain body alignment d. Raise all four side rails prior to initiating logrolling independently
C. Position a pillow between the client's legs to maintain body alignment
A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? a. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. b. A nurse overheard another nurse telling an older adult that if he doesn't stay in bed, she will have to apply restraints. c. A family has conflicting feelings about the initiation of external tube feedings for their father who is terminally ill. d. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.
C. A family has conflicting feelings about the initiation of external tube feedings for their father who is terminally ill.
A nurse makes a medication error, immediately assesses the client, and reports the error to the nurse manager and the primary care provider. Which characteristic of a professional is the nurse demonstrating? a. Autonomy b. Collaboration c. Accountability d. Altruism
C. Accountability
A nurse is about to transfer to a chair a client who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique? a. Positioning the chair slightly behind the nurse so that the seat faces the clients bed. b. Placing the clients left leg infront of her right leg just prior to the transfer. c. Aligning the nurses knees with the clients knees just before the transfer. d. Grasping the client under the axils to assist her to her feet.
C. Aligning the nurses knees with the clients knees just before the transfer.
The nurse, Susie, has an allergy to latex. Her employer and replaced all latex Products used on the unit with non—latex substitutions so Susie will not get sick. What is this an example of? a. EMTALA b. PSDA c. ADA d. HIPPA
C. Americans with Disabilities Act
The nurse notes that the client has an irregular pulse. What is the 1st action the nurse should take? a. Asses the pulse at the carotid artery b. Asses the pulse with a Doppler ultrasound c. Assess the pulse for a full minute d. Asses the pulse at two different sites
C. Assess the pulse for a full minute.
The statement "ongoing collection of data" best describes which phase of the nursing process? a. Planning b. Evaluation c. Assessment d. Implementation
C. Assessment
The nurse admits a chest pain patient to the cardiac care unit. Which step of the nursing process does the nurse do first? A. Planning. B. Evaluation. C. Assessment. D. Implementation.
C. Assessment.
Healthcare workers are discussing a diverse group of clients respectfully and are being responsive to the health beliefs and practices of these clients. What important aspect of nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Leadership
C. Cultural competence
Healthcare workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of Nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Leadership
C. Cultural competence
What term best describes the nature of the nursing process? a. Static b. Linear c. Dynamic d. Predictable
C. Dynamic
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? A. Ongoing assessment B. Comprehensive physical assessment C. Focused physical assessment D. Psychosocial assessment
C. Focused physical assessment
Henry, a nurse, is driving home from work when there is a major motor vehicle accident in front of him. He runs to the side of the driver, finding him bleeding from the nose and mouth. Henry calls 911 and begins treating the driver after receiving consent. What is this an example of? a. Nurse practice acts b. Standard of practice c. Good Samaritan law d. American nurses Association code of ethics
C. Good Samaritan law
The nurse performs care on an unconscious person at the grocery store. What law protects the nurse in this situation? a. Medical treatment and Active Labor Act b. American Nurses Association Code of ethics c. Good Samaritan laws d. Nurse practice act
C. Good Samaritan laws
A nurse in the emergency room is caring for a client who has a knee injury. The client will be Discharged and will be using a pair of axillary crutches for the first time. which of the following instructions should the nurse include when discharging this patient? a. Leeane on the crutches to support body weight when standing b. Fully extend arms when holding onto the hand grips c. Hold the crutches on the unaffected side when preparing to sit in a chair d. Hold the crutches 9 to 12 inches in front of and to the side of each foot
C. Hold the crutches on the unaffected side when preparing to sit in a chair
Nurses may be held liable for actions that are considered unintentional torts. Which of the following actions is an example of this type of tort? a. Restraining a client who refuses care and wants to leave the hospital. b. Taking photos of a client surgical wound to post to a website. c. Leaving the side rails down, leading to the client falling and becoming injured. d. Discussing the clients sexually transmitted disease while riding the elevator with visitors.
C. Leaving the side rails down, leading to the client falling and becoming injured.
The doctor has ordered progressive ambulation for a patient who has been on bed rest. When the nurse prepares to assist the patient out of bed for the first time, the patient becomes dizzy as the head of the bed is raised to high Fowler's. The nurse should: a. Direct the patient to focus on control of dizziness. b. Inform the physician that the patient is not ready to ambulate. c. Lower the head of the bed and wait until dizziness subsides. d. Move the patient very slowly out of bed.
C. Lower the head of the bed and wait until dizziness subsides.
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: SELECT ALL THAT APPLY. A. A body systems model B. A head-to-toe framework C. Maslow's hierarchy of needs D. Gordon's functional health patterns E. Adaptation Model of Nursing
C. Maslow's hierarchy of needs D. Gordon's functional health patterns
Annie is planning to move to another state. She looks at the board of nursing website to explore the state's regulations for registered nurses. What is this an example of? a. Standard of practice b. Scope of practice c. Nurse practice acts d. Patient care partnership
C. Nurse practice acts
A client is asking about developing a living will. What act protects this right? a. Americans with disabilities act b. Emergency medical treatment and active labor act c. Patient self-determination act d. Health insurance portability and accountability act
C. Patient self-determination act
The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has: A. Extravasation B. Osteomalacia C. Petechiae D. Uremia
C. Petechiae
The nurse is performing an assessment on a client. What should be included in this process? a. Ability to pay for a hospital stay b. Who brought patient to the hospital c. Religious and spiritual needs d. Level of education
C. Religious and spiritual needs
When learning a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the: A. Atria contract vigorously B. Ventricular walls vibrate C. Semi lunar valves close
C. Semi lunar valves close
The nurse knows that the family of the patient receiving home healthcare needs further education about that service when the family requests the RN to A. Teach the patient how to administer his own insulin. B. Change the patient's PICC line dressing. C. Take the patient shopping to buy high-protein foods. D. Call the social worker to obtain information about Medicare.
C. Take the patient shopping to buy high-protein foods.
The nurse is caring for a client who was burned in a house fire. The right arm is heavily bandaged and there is an intravenous line that was placed in the left forearm after 3 attempts. Which action does the nurse take related to obtaining VS? a. A BP is not needed because the client is awake, alert, and talking to the nurse. b. A smaller cuff should be used to cover less of the upper arm c. The BP should be taken on the popliteal artery d. The systolic pressure should be palpated from the radial artery
C. The BP should be taken on the popliteal artery
Which organization is directly responsible for regulating the practice of nursing in each state? a.The American Nurse's Association (ANA). b.The American Medical Association (AMA). c.The state board of nursing. d.The state legislature.
C. The state board of nursing.
A client has been diagnosed with cancer, but the primary care provider is hesitant to share the information with her. The nurse encourages the provider to tell the client so that she can make decisions about her care. The nurse is using th ethical principal of: a. Justice b. Fidelity c. Veracity d. Nonmaleficense
C. Veracity
During normal client care that does not soil hands, effective hand hygiene between clients require: a. at least a 20-sec soap and water scrub b. at least a 23 min, scrub with antimicrobial soap c. use of an alcohol-based antiseptic hand rub d. a mask must be worn while scrubbing is occurring
C. use of an alcohol-based antiseptic hand rub
What is Negligence?
Careless neglect, often resulting in injury.. "Creating a risk of harm to others by failing to do something a reasonable person would ordinarily do, or do something that a reasonable person would ordinarily not do."
What is implementation?
Carrying out the nursing interventions in a systematic way.
Decision making
Choosing the best action to take; usually action best for the desired patient outcome
Nursing process is _______________.
Client-centered, goal-directed, and involves thinking and doing.
Critical thinking
Combination of reasoned thinking, openness to alternatives, ability to reflect, and a desire to seek truth
Indirect contact
Contact with contaminated inanimate objects
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client? A. Semi-Fowler's B. Supine C. High-Fowler's D. Side-lying
D. Side-lying
Of the following clients, which client is at a higher risk of infection? a. 27 yr old female who is an athlete b. 60 yr old male with arthritis c. 12 yr old female with a broken leg d. 36 yr old female with HIV
D. 36 yr old female with HIV
Assessment
Data gathering stage; from multiple reliable sources. Data found will help draw conclusions about client's health status
A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action? a. Tell the child that if she stops crying, her parents can be with her. b. Check to see what pain medication is ordered for the child. c. Notify the surgeon of the child's postoperative condition. d. Assess the child to determine why she is crying.
D. Assess the child to determine why she is crying.
Prior to identifying accurate nursing diagnosis, which action MUST be taken by the nurse? a. Reading the patients history b. Setting realistic, measurable goals c. Comparing evidence- based practices d. Clustering related patient data
D. Clustering related patient data
A new nursing graduate has an interest in a position that will provide health promotion, illness prevention, early detection, and treatment within her rural community. Which type of nursing is this? a. International Nursing b. Public health nursing c. Community health nursing d. Community-oriented Nursing
D. Community-oriented Nursing
How does the nurse obtain a full set of data when performing an assessment of a client? A. Take a set of vital signs. B. Review diagnostic studies. C. Performing a client interview. D. Complete a nursing history & physical examination.
D. Complete a nursing history & physical examination.
Which statement illustrates the most measurable outcome indicator? A. Shows remorse. B. Understands instructions. C. Verbalizes a dressing change. D. Demonstrates self-injection of insulin.
D. Demonstrates self-injection of insulin.
It is Important for the nurse to understand the structure of the client's family so that he or she can... A. Address the various family members correctly. B. Tailor visiting hours to the family's needs. C. Avoid embarrassing moments during client interventions. D. Develop a holistic plan that includes the whole family.
D. Develop a holistic plan that includes the whole family.
A nurse is revising a client's care plan. During which step of the nursing process does such revision take place? A. Assessment B. Planning C. Implementation D. Evaluation
D. Evaluation
Critique care plan and revise as needed, especially if patient situation has changed a. Diagnosis b. Implementation c. Assessment d. Evaluation
D. Evaluation
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation
D. Evaluation
Following hip surgery, a trochanter roll is used to prevent what type of movement? a. Supination b. Pronation c. Internal rotation d. External rotation
D. External rotation
What nursing intervention would be the 1st priority to prevent constipation in an immobile client? a. Administration of a soap suds enema b. Decreased dietary fiber consumption c. Narcotic analgesic pain relief use d. Increased daily oral fluid intake
D. Increased daily oral fluid intake
While taking an adult patient's pulse, a nurse assesses a new finding of the rate to be 150 beats per minute up from 80s-90s over the past 2 days. What should the nurse do first? a. Assess the popliteal and femoral pulses. b. Assess a 1-minute apical pulse. c. Apply a warm pack and reassess in 20 minutes. d. Notify the provider STAT.
D. Notify the provider STAT.
The population served by this nurse is the congregation of the church. Which type of nursing is this? a. School nursing b. Public health clinics c. Community health nursing d. Parish Nursing
D. Parish Nursing
Josephine wants to make her own decisions about her end-of-life care. She talks to her significant other about creating a LivingWell and durable power of attorney. What is this an example of? a. HIPPA b. EMTALA c. ADA d. PSDA
D. Patient Self-Determination Act
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime. B. Ask the client each morning to describe the quantity of sleep during the previous night. C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation. D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
Which client care activity can be delegated by the RN to unlicensed assistive personnel? a. Completing an admission skin assessment b. Administering an ordered stool softener c. Teaching deep vein thrombosis prophylaxis d. Range of motion exercises
D. Range of motion exercises
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery. B. Deficient fluid volume related to blood and fluid loss from surgery. C. Impaired physical mobility related to surgery. D. Risk for aspiration related to anesthesia.
D. Risk for aspiration related to anesthesia.
Which statement regarding heart sounds is correct? A. S1 and S2 sound equally loud over the entire cardiac area. B. S1 and S2 sound fainter at the apex. C. S1 and S2 sound fainter at the base. D. S1 is loudest at the apex, and S2 is loudest at the base.
D. S1 is loudest at the apex, and S2 is loudest at the base.
Which of the following teaching points for older adults would directly and immediately decrease fall risk? a. Exercise as per practitioner. b. Maintain proper weight. c. Proper body mechanics. d. Safety-proof home.
D. Safety-proof home.
What phrase BEST describes the essence of critical thinking? a. Understanding without conscious reasoning b. Providing care based on nursing experience c. Consulting with a primary care provider d. Seeking solutions to problems
D. Seeking solutions to problems
What info should the nurse include when teaching a client abt deep vein thrombosis (DVT) prevention? a. Avoid movement of the extremities to prevent potential DVT formation b. Encourage use of sequential compression devices (SCDs) during ambulation c. Utilize an ankle foot orthotic (AFO) or pressure relief orthotic (PRAFO) to stretch ligaments d. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.
D. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.
A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality. B. Provide time for privacy. C. Provide support for the spouse or significant other. D. Suggest referral to a sex counselor or other appropriate professional.
D. Suggest referral to a sex counselor or other appropriate professional.
Patient advocacy is best demonstrated by the nurse: a. Learning how to do a new procedure b. Returning with the client at the agreed-upon time. c. Preparing the client's room for comfort and privacy. d. Supporting the client's right to refuse treatment.
D. Supporting the client's right to refuse treatment.
Jason just vomited blood but is hesitant to go to the emergency department because he does not have insurance. He tells this to the admitting nurse, who assured him he won't be turned away from medical care. What is this an example of? a. HIPPA b. PSDA c. ADA d. EMTALA
D. The Emergency Medical Treatment and Labor Act
A nurse observes an assistive personnel make a clients bed while the client is out of the room. Which of the following actions by the assistive personnel is appropriate for this task? a. The assistive personnel records the task when it is completed. b. The assistive personnel wears sterile gloves while making the bed. c. The assistive personnel makes a miltered corner with the blanket and spread. d. The assistive personnel reuses the patients blanket and spread.
D. The assistive personnel reuses the patients blanket and spread.
Which assessment finding would indicate that a client has hemiparesis (weakness of one side of the body)? a. Bilateral lack of movement in the client's lower extremities b. Complaint of pain when the client attempts to ambulate c. Loss of sensation in both of the client's legs d. Weakness of the client's right arm and leg
D. Weakness of the client's right arm and leg
Intellectual curiosity
Desire for knowledge; ask questions to learn
Evaluation
Determine whether the final outcomes have been successful enough & judge whether your actions have treated or prevented the health problems. After, modify care plan as needed
What is nonmaleficence?
Do no harm; preventing harm
What is beneficence?
Doing good or causing good to be done; being kind
Intellectual Perseverance
Don't jump to conclusions or settle for the quick, obvious answer. Important questions are usually complex and are given serious thought.
What is the drug class for metoprolol, what are the therapeutic uses, side effects and contraindications?
Drug class: Beta Blocker (Beta 1) Therapeutic uses: • decreases BP and HR. Side effects: -ED -hypoglycemia (client cannot tell bc HR is decreased from beta 1) • fatigue • weakness • bradycardia • pulmonary edema • HF Contraindications: • bradycardia • uncompensated HF • pulmonary edema • cardiogenic shock • heart block Use cautiously in: -renal/ hepatic impairment -people with asthma -Diabetes (may mask signs of hypoglycemia) *start medication at low dosage
What is the drug class of Furosemide, what are the therapeutic effects, side effects, and contraindications?
Drug class: Loop diuretic *Most powerful diuretic* Therapeutic effects: decreases BP, HF caused by edema. Used when there needs to be an emergent need for mobilization of fluid, or when client is not responding to other diuretics. Increases excretion of water, sodium, chloride, and magnesium. Side effects: -ototoxicity -hypoKalemia -hypoNatremia -hypochloremia -hypomagnesemia -hypocalcemia -hpotension -dehydration -hyperglycemia Contraindications: -pregnant women (can cause low milk production) -Anuria (no urine output) Use cautiously in: -liver/ renal disease -Diabetes mellitus -patients taking dioxin
What is the drug class for hydrochlorothiazide, what are the therapeutic effects, side effects, and contraindications?
Drug class: Thiazide *Most commonly used diuretic* Therapeutic effects: • choice for HTN • decreases edema from mild/ moderate HF, liver and kidney disease. Side effects: • hypoKalemia • hypoNatremia • HYPERglycemia Contraindications: • Pregnant women • Anuria • Client with renal impairment Precautions: • Renal or liver disorders • diabetes mellitus
Mrs. Clancy is a nursing home patient at risk for falls. The head nurse asked one of the unlicensed assistive Personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. Which of the following Nursing processes does this represent? a. Assessment b. Diagnosis c. Planning outcomes d. Planning interventions e. Implementation f. Evaluation
E. Evaluation
Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this. Which part of the nursing process does this represent? a. Assessment b. Diagnosis c. Planning outcomes d. Planning interventions e. Evaluation f. Implementation
E. Evaluation
What is hypertension?
Elevated blood pressure
What is Autonomy?
Every person has the right to decide their own course of action and make their own medical decisions.
Portal of exit?
Exit route for pathogen to leave its host
Mary is a 17 year old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asked her how being hospitalized is impacting her senior year of high school. What nursing process does this step represent? a. Diagnosis b. Planning outcomes c. Planning interventions d. Implementation e. Evaluation f. Assessment
F. Assessment
Adrian, a nurse, reflects on her client's information, including physical assessment and related family concerns. She considers all information to reach conclusions. Which step of the nursing process does this represent? a. Assessment b. Planning outcomes c. Planning interventions d. Implementation e. Evaluation f. Diagnosis
F. Diagnosis
The nurse, Linda, identifies some concerns about her patients financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. Which step of the nursing process does this represent? a. Assessment b. Diagnosis c. Planning interventions d. Implementation e. Evaluation f. Planning outcomes
F. Planning outcomes
What is Justice?
Fairness, equal treatment to all
What is Fidelity?
Faithfulness, loyalty, keeping promises.
Direct contact examples
Fecal, oral
What is assessment?
Gathering all data (objective and subjective) on the patient
Civil Law
Governs unjust acts against individuals rather than federal or state crimes.
HAI
Hospital-Acquired Infection
Diagnosis
Identify clients health strengths and needs/problems -in nursing, reflects clients responses to actual or potential health problems
Problem-solving
Identifying a problem and finding reasonable solutions to it
What are Nurse practice acts?
In the United States of America (USA), each state enacts its own laws that regulate nursing practice.
Different unique factors to consider on patients may be:
Individual differences, multiple and varying concerns, clients culture, clients roles, age, personal bias, personality, previous experience with healthcare problems
Gingivitis
Inflammation of the gums
Stomatitis
Inflammation of the oral mucosa.
Glossitis
Inflammation of the tongue
Most effective barrier to infection?
Intact skin
What are primary services?
Keeping client well by preventing illness/ promoting illness preventions
Practical knowledge
Knowing what to do and how to do it, consists of processes and procedures and is an aspect of nursing expertise
Theoretical knowledge
Knowing why • consists of info, facts, principles, and evidence-based theories in nursing and related disciplines • to describe patients, understand health status, explain the reasoning, and predict patient responses to treatments
Reasoning
Logical thinking that links thoughts, ideas, and facts together in a meaningful way; used in scientific inquiry and problem-solving
What are tertiary services?
Long term treatment for chronic illness
What is the drug class for furosemide?
Loop diuretic
What is Malpractice?
Negligence committed by people who hold licenses to practice their profession
Eupnea
Normal respiration with a normal rate and depth for the patient's age
The process by which the assessment data are sorted and analyzed so that specific actual and potential health problems are identified.
Nursing diagnosis
What is slander?
Oral defamation of character (slander = spoken)
What is the incubation period?
Organisms growing and multiplying.
Reservoir?
Place where the pathogen grows and may or may not multiply
Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center". Which part of the nursing process does this represent a. Assessment. diagnosis b. Implementation c. Evaluation d. Planning outcomes e. Planning interventions.
Planning outcomes
What is the drug class for spironolactone?
Potassium-sparing diuretics
What is Full stage of illness?
Presence of specific signs and symptoms of disease.
What is Standards of practice?
Provide a guide to the knowledge, skills, and attitudes (KSAs) that nurses must incorporate into their practice to provide safe, quality care.
Independent thinking
Questioning assumptions and interpreting data and events according to one's own beliefs, ideas, and thinking, rather than pre-established rules or categories defined by others
Evidence-based practice
Research-based method for judging and choosing nursing interventions
What is confidentiality?
Respecting the privacy of both parties and keeping details secret
What are secondary services?
Screening/ early detection and treatment of diseases
Model
Set of interrelated concepts that represent a particular way of thinking about something - much in the same way that the shape of a lens affects what you see
What is primary data?
Subjective and objective information obtained directly from the client in what the client says or what you observe
What is orthostatic hypotension?
Sudden drop of 20 mmHg in SBP and or 10 mmHg in diastolic blood pressure (DBP) when the client moves from a lying to sitting to standing position
What is the State boards of nursing?
The agency responsible for regulating nursing practice (e.g., Massachusetts Board of Registration in Nursing or MBORN).
What is pulse pressure?
The difference between the diastolic and systolic pressures
Mode of transmission
The manner in which an infectious agent moves from one source to another
What is the Prodromal stage?
The person is most infectious, experiencing nonspecific (vague) signs of disease.
If you are unable to obtain BP on either arm, where else could you use use to find BP?
Thigh
Four main concepts that describe full-spectrum nursing
Thinking, doing, caring, & patient situation
How does vector transmission occur?
Through a bite
Dental Caries
Tooth decay (cavities)
What is veracity?
Truthfulness, honesty
Fair-mindedness
Try to make impartial judgments; treat all viewpoints fairly, realizing that biases can influence their thinking
Intellectual Empathy
Try to understand feelings and perceptions of others and try to see the situation as the other person sees it
Critical thinking helps you know...
What is important about the patient's situation, when more info is needed, and when you need help to make the best decision
Airborne transmission
When infectious particles dispersed in the air enter the host by inhalation
Droplet infection
When the droplets from an infected hosted person are projected a short distance to the host's nasal mucosa, mouth or conjunctiva
What is Accountability?
Willingness to take credit and blame for ones actions.
What is libel?
Written (text) forms of defamation of character. Online counts too.
What is a Tort?
Wrongful act committed against another person that does not involve a contract
What is Assault?
a threat of bodily harm or violence caused by a demonstration of force by the perpetrator
Dyspnea
difficult, labored breathing - usually with a rapid, shallow pattern - that may be painful.
What is fever (pyrexia)?
an increase in normal body temp; when heat loss mechanisms of the body are unable to keep pace with excess heat production.
Primary Intervention
an intervention that occurs before the onset of the disease
Xerostomia
dry mouth (caused by altered salivation, dehydration, mouth breathing, and/or medications).
What is febrile?
client w/ fever
What is afebrile?
client w/o fever
Any portal of _____ can also because a portal of _____.
exit; entry
Caring
involves personal concern for people, events, projects, and things • specific for each encounter • not an abstraction • involves thinking and acting in ways that preserve human dignity and humanity
Ethical knowledge
knowledge of obligation, or right and wrong. consist of information about moral principles and processes for making moral decisions.
Comorbidities
more than one health problem occurring at the same time
Clinical reasoning
reflective, concurrent, and creative thinking about patients and patient care
orthopnea
shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair.
What are the contraindications of furosemide?
• Chronic kidney disease • Elderly patients • Pregnant women • Hypersensitivity • Anuria • Avoid if alcohol intolerant • Use cautiously in client who has liver disease, cardiovascular disease, diabetus mellitus, electrolyte, electrolyte depletion
What are the therapeutic uses of spironolactone?
• Combined with other diuretics for potassium-sparing effects to treat hypertension and edema • For heart failure • Blocks actions of aldosterone in hyperaldosteronism which causes opposite effect of aldosterone in distal nephrons • Effects can take up to 12-48 hrs
Airborne transmission examples
• Coughing • Sneezing
What are the contraindications Metoprolol?
• DO NOT use in patients w/ bradycardia, heart block, or shock. • Pregnant or nursing women. • Patients with kidney or liver problems, asthma, diabetes, or hyperthyroidism (overactive thyroid). • Patients with hypotension, uncompensated heart failure, pulmonary edema
What are the expected pharmacological action of metoprolol?
• Decrease HR • Decrease cardiac output • Decreased myocardial contractility (ability of the heart to contract)
What are the uses of Metoprolol?
• Decreased BP • Decreased HR • Angina, heart failure, myocardial infarction, tachydysrhythmia • Decreased rate of cardiovascular mortality
Two types of contact for HAIs:
• Direct Contact • Indirect Contact
Roles of the Home Health Nurse
• Direct care provider • Client/family educator • Client advocate • Care coordinator
Vector transmission examples
• Fleas • Ticks • Mosquitoes
What diseases are considered contact?
• Hepatitis A • Antibiotic-resistant bacteria • Scabies • Impetigo • Lice • MDRO (multi-drug resistant organism) • MRSA (methicillin-resistant Staphylococcus aureus) • VRE (vancomycin-resistant enterococcus)
Chain of infection
• Infectious Agent (pathogen) • Reservoir • Portal of Exit • Mode of Transmission • Portal of Entry • Susceptible Host
Five components of caring:
• Knowing • Being with • Doing for • Enabling • Maintaining belief
What diseases are considered droplet?
• Meningitis • Influenza • Mumps • Pertussis • Rubella • Common cold • Measles • Diphtheria • Rubella
Indirect contact examples
• Needles • Utensils • Hospital equipment
Examples of reservoirs
• Patient • Staff member • Animal • Food
What is hypotension?
• Systolic BP of less than 100 mmHg • 20-30 mmHg below the client's normal blood pressure • Diastolic BP of less than 60 mmHg
What diseases are considered airborne?
• TB • Measles • Chickenpox • Herpes zoster (shingles) • Smallpox
Mode of transmission examples
• Touch • Airborne droplets • Medical instruments • Mosquitoes • Vermin
What are the therapeutic uses for furosemide?
• When there needs to be an emergent need for rapid mobilization of fluid. • Pulmonary edema caused by heart failure • Conditions are not responsive to other diuretics • Decreased BP
What are the expected pharmacological action of furosemide?
• Work in the loop of Henle • Block reabsorption of sodium and prevent reabsorption of water • Increases renal excretion of water, sodium, chloride, and magnesium • Causes extensive diuresis even with renal impairment
What makes someone a susceptible host?
• age • illness • poor health • broken skin
What are the side effects of spironolactone?
• hyperkalemia (high K+) • irregular menses in women • male impotence
Planning: outcomes and interventions
• work with the client to decide goals for client care (wanted outcomes) • develop list of possible interventions based on knowledge and then choose the best choice to achieve the client goal
