VSIM Fundamentals Exam 1

The nurse titrates the patient's oxygen to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per the provider's orders. What is the rationale for this order? (select all that apply) 1. allows the body to meet metabolic demands 2. promotes a decrease in myocardial workload 3. promotes a decrease in respiratory effort 4. prevents atelectasis in a pt with pneumonia 5. allows the patient to receive 100% O2

1. allows the body to meet metabolic demands 2. promotes a decrease in myocardial workload 3. promotes a decrease in respiratory effort

Upon entering the room, the nurse observes Mona Hernandez slumped over in a semi-Fowler's position, struggling to catch her breath. What is the priority nursing action at this time? 1. titrate her O2 so that her O2 is greater than or equal to 95% 2. assist the pt into a high Fowler's position 3. obtain vital signs 4. obtain an O2 saturation level

2. assist the pt into a high Fowler's position

Hyponatremia is associated with a decrease of which electrolyte? 1.Phosphorus 2.Potassium 3.Sodium 4.Chloride

3.Sodium

A patient with cystic fibrosis has five capsules of pancrelipase (amylase, lipase, and protease) ordered to be administered now with his breakfast. The patient is currently experiencing nausea and intermittent vomiting. What should the nurse do with this medication? 1.Crush the medication to administer to the patient 2.Administer the medication as ordered 3.Call the provider immediately 4.Hold the medication until the patient is able to eat again

4.Hold the medication until the patient is able to eat again

A nurse is teaching a patient with cystic fibrosis about nutrition in the high-fat, high-carbohydrate diet that has been recommended. Which of the following should be included in this education? 1.It is important to focus on eating calorie-dense foods 2.It is not necessary to monitor dietary intake 3.It is important to only eat high-fat, high-protein and high- carbohydrate foods 4.It is important to select a variety of nutrient-dense foods

4.It is important to select a variety of nutrient-dense foods

Which physical finding poses the greatest safety risk for a patient diagnosed with hyponatremia? 1.Cold, clammy skin 2.Dry mucous membranes 3.Anxiety 4.Orthostatic hypotension

4.Orthostatic hypotension

Hypokalemia is confirmed by what serum blood result? 1.Potassium 5.5 2.Sodium 146 3.Sodium 133 4.Potassium 3.0

4.Potassium 3.0

Which of Mr. Ahmed's lab results best supports his diagnosis of dehydration? 1.Creatinine 1.1 2.WBC 21 x 10^9 3.HgB 16.7 4.Sodium 130

4.Sodium 130

Christopher Parrish has a low body mass index and has lost 12 pounds over the past two weeks. Which method could the nurse use to assess his overall dietary intake in order to provide nutrition education? 1.Obtain a food frequency assessment 2.Ask the patient to keep a food diary log 3.Ask the patient if he has a healthy diet. 4.Track the percentage of food eaten at each meal while in the hospital

1.Obtain a food frequency assessment

A nurse is preparing to admit a patient with cystic fibrosis and altered nutrition status. The nurse plans to implement which precautions to be used in the patient's care? 1.Standard precautions 2.Contact precautions 3.Airborne precautions 4.Droplet precautions

1.Standard precautions

Which diagnostic test serves as the basis for determining acid-base imbalances? 1.Specific gravity of urine 2.Blood urea nitrogen (BUN) 3.Arterial blood gas (ABG) 4.Serum potassium

3.Arterial blood gas (ABG)

When completing discharge instructions with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time? 1. listen to the pt's lungs 2. ask if the pt has support at home 3. determine if the pt has any questions 4. reassure the pt

1. listen to the pt's lungs

A patient in semi Fowler's position is having difficulty breathing. What is the priority action of the nurse? 1. raise the head of the bed. 2. call respiratory therapy 3. conduct a pain assessment 4. auscultate the lungs

1. raise the head of the bed.

Expected assessment findings of a patient with pneumonia may include which of the following? (select all that apply) 1. tachypnea 2. use of accessory muscles 3. malaise 4. enuresis 5. fever

1. tachypnea 2. use of accessory muscles 3. malaise 5. fever

What pathology is responsible for metabolic acidosis? 1.A decrease in bicarbonate or an increase in hydrogen icons 2.A decrease of carbonic acid 3.An excess of HCO3 and/or a decrease in H+ ions 4.An increase of CO2

1.A decrease in bicarbonate or an increase in hydrogen icons

A patient with a low body mass index (BMI) is found to have low albumin and prealbumin levels. Which of the following nursing actions should be considered? (Select all that apply.) 1.Assess gastrointestinal function 2.Assess for signs and symptoms of infection 3.Monitor input and output for the patient 4.Request a nutrition consult 5.Encourage oral intake of foods and fluids as ordered

1.Assess gastrointestinal function 3.Monitor input and output for the patient 4.Request a nutrition consult 5.Encourage oral intake of foods and fluids as ordered

A nurse has just finished placing a nasogastric tube into a patient for the purposes of administering feedings. What should the nurse do first? 1.Confirm the placement of the nasogastric tube per facility policy. 2.Assess how much of the tube was inserted into the patient to verify placement. 3.Irrigate the nasogastric tube with 30 to 60 mL of water. 4.Administer the tube feeding as ordered.

1.Confirm the placement of the nasogastric tube per facility policy.

The nurse is caring for an adolescent patient who appears withdrawn and isolated. What strategy should the nurse use to work with this patient? 1.Develop a therapeutic, trusting relationship with the patient. 2.Leave the patient alone as much as possible. 3.Talk to the patient's parents about what is going on with the patient. 4.Tell the patient what the patient needs to do in order to get better.

1.Develop a therapeutic, trusting relationship with the patient.

Identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? 1.Difficulty breathing 2.Not able to tolerate activity 3.Ineffective respiratory gas exchange 4.Acute pain 5. metabolic acidosis

1.Difficulty breathing 2.Not able to tolerate activity 3.Ineffective respiratory gas exchange 4.Acute pain

A nurse is creating a care plan for a young adult patient with a chronic illness. Which of the following nursing diagnoses might be included in the care plan? (Select all that apply.) 1.Ineffective health maintenance 2.Social isolation 3.Risk-prone health behavior 4.Caregiver role strain 5.Activity intolerance

1.Ineffective health maintenance 2.Social isolation 3.Risk-prone health behavior 5.Activity intolerance

Mona Hernandez's blood gas results indicate respiratory acidosis. Her oxygen saturation is 95% per the pulse oximeter. Which interventions should the nurse provide? 1.Provide supplemental oxygen as ordered 2. none; the pt has a 95% oxygenation 3.Ensure the patient is well hydrated 4.Promote voluntary coughing activities to clear secretions 5.Assist the patient with adequate ventilation

1.Provide supplemental oxygen as ordered 3.Ensure the patient is well hydrated 4.Promote voluntary coughing activities to clear secretions 5.Assist the patient with adequate ventilation

The nurse is preparing to discharge Mona Hernandez from the hospital. Which of the following instructions should the nurse include in the discharge education? (Select all that apply). 1.Use the incentive spirometer every one to two hours to move secretions out of your lungs 2. Continue to focus on ambulating several times per day 3.Take your antibiotics as directed, even if you are feeling better. 4.Quitting smoking will improve your recovery. 5. stop taking your antibiotics once you are feeling better.

1.Use the incentive spirometer every one to two hours to move secretions out of your lungs 2. Continue to focus on ambulating several times per day 3.Take your antibiotics as directed, even if you are feeling better. 4.Quitting smoking will improve your recovery.

A nurse is assessing an adolescent patient. Which of the following questions best represents therapeutic communication techniques? 1.What do you hope happens here today? 2.Are you feeling well? 3.Do you know what to do to stay healthy? 4.You don't smoke, do you?

1.What do you hope happens here today?

Which statement concerning the measurement of intake and output is true? 1.When possible, intake and output should be measured rather than estimated. 2.Health care agencies have adopted standard volumes for common beverage containers 3.Only foods that are consumed as liquids are included in intake calculations 4.Liquid medications are not considered when calculating intake

1.When possible, intake and output should be measured rather than estimated.

Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. What is the best response by the nurse? 1. it was ordered by your provider 2. it helps prevent atelectasis or collapsing of the alveoli in the lungs 3. it decreases cardiac workload during inspiration 4. it increases the O2 taken in by the lungs when you inhale

2. it helps prevent atelectasis or collapsing of the alveoli in the lungs

A patient states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer? 1. the incentive spirometer will cause you to cough less bc you are moving more air through your lungs 2. the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis 3. you have to use your incentive spirometer bc your provider has ordered it for you 4. you should wait to use your incentive spirometer until you are not coughing up so much

2. the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis

What is the initial step in assessing a patient for orthostatic hypotension? 1.Encourage the patient to drink eight ounces of fluid, then take and record blood pressure and pulse 2.After having the patient lie in a supine position for three to 10 minutes, take and record blood pressure and pulse 3.After having the patient sit upright with legs dangling for one to three minutes, take and record blood pressure and pulse 4.Assist patient into a standing position lasting two to three minutes, then take and record blood pressure and pulse

2.After having the patient lie in a supine position for three to 10 minutes, take and record blood pressure and pulse

What information should be included when documenting a change in the infusion rate of an IV solution? (Select all that apply.) 1.Original flow rate 2.Change made to flow rate 3.Date and time change was made 4.Nurse's initials 5.Patient's response to IV therapy

2.Change made to flow rate 3.Date and time change was made 4.Nurse's initials 5.Patient's response to IV therapy

A provider orders a high-fat, high-protein, high-carbohydrate diet for a patient with cystic fibrosis. What is the best rationale for this diet order? 1.Cystic fibrosis is a chronic disease characterized by altered electrolytes. 2.Cystic fibrosis interferes with the digestions of food and absorption of nutrients. 3.Thickened mucus secretions predispose the patient to anemia. 4.The diet was ordered according to the patient's preferred food intake.

2.Cystic fibrosis interferes with the digestions of food and absorption of nutrients.

A patient complains of nausea after a tube feeding. What is the priority action of the nurse at this time? 1.Position the patient on left side. 2.Ensure the head of the bed remains elevated. 3.Aspirate the tube feeding contents from the patient's stomach. 4.Flush the tube with 30 to 60 mL water

2.Ensure the head of the bed remains elevated.

A nurse is planning patient education about a prescribed medication for a patient. What should the nurse do first? 1.Education the patient about potential allergic reactions to the medication. 2.Find out what the patient already knows about the medication. 3.Review the signs and symptoms of drug toxicity with the patient. 4.Educate the patient about potential drug interactions.

2.Find out what the patient already knows about the medication.

Considering Mr. Ahmed's diagnosis of dehydration and the possibility of neurological impairment, which nursing intervention is directed toward minimizing his risk for possible injury? 1.Educating the patient on the use of a calibrated urinal 2.Implementing falls precaution 3.Administrating ondansetron with a full glass of water 4.Assessing for orthostatic hypertension daily

2.Implementing falls precaution

Reduced skin turgor is characteristically altered among which population? 1.Smokers 2.Older adults 3.Infants 4.Premenstrual females

2.Older adults

A nurse plans on assessing the patient's gastrointestinal system. Which statement below reflects the best prioritization of this assessment? 1.The nurse should percuss and then auscultate the abdomen 2.The nurse should auscultate and then palpate the abdomen 3.The nurse should palpate and then auscultate the abdomen 4.The nurse should percuss and then inspect the abdomen

2.The nurse should auscultate and then palpate the abdomen

A patient has just completed a tube feeding that has run throughout the night. What is the best education the nurse can provide to the patient at this time? 1.You should wear your pneumatic compression device when you are in bed. 2.You should remain upright for the next hour. 3.You should lie down to get some sleep. 4.It is important that you ambulate three times today.

2.You should remain upright for the next hour.

Mona Hernandez complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond? 1. you really need to walk as much as possible in order to prevent your pneumonia from getting worse 2. you should wait until your breathing improves to try to get out of bed again, bc it makes you short of breath 3. even short activities such as moving to the chair will help you cough mucus out of your lungs 4. pneumonia causes thick secretions in your lungs, making if difficult to breathe.

3. even short activities such as moving to the chair will help you cough mucus out of your lungs

A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up which of the following test results? 1. white blood cell count 2. chest x-ray 3. hemoglobin 4. gram stain

3. hemoglobin

Mona Hernandez's laboratory work indicates an elevated white blood cell count with a left shift in the differential. The nurse interprets this to mean which of the following? 1.there is a high number of wbc to fight the infection, and the rbc are compensating 2. a left shift in the differential means that there is no infection present 3. there is a high number of wbc and immature wbc present to fight the infection 4. there is a high number of wbc but not immature wbc, present in the circulation

3. there is a high number of wbc and immature wbc present to fight the infection

As the nurse administers Mona Hernandez's prescribed medication, guaifenesin, the patient states: "I don't like this medication. It makes me cough too much." How should the nurse respond? 1. this med will help make your breathing easier 2. this med is given to you bc of your pneumonia 3. when you cough out secretions, oxygenation is more effective 4. i will let your provider know you have questions about your meds

3. when you cough out secretions, oxygenation is more effective

A nurse is planning on administering a tube feeding to a patient with a nasogastric tube. The patient appears asleep flat in bed. What should the nurse do first? 1.Carefully connect the nasogastric tube to the tube feeding 2.Administer the feeding quietly without waking the patient 3.Assist the patient to a semi-Fowler's position or higher 4.Flush the nasogastric tube with 30 to 60 mL water

3.Assist the patient to a semi-Fowler's position or higher

Which statement by Mr. Ahmed best reflects his ability to assume some responsibility in tracking his urinary output? 1.I understand that it is important to measure my urine with the calibrated urinal 2.I listened as you discussed the instructions about the calibrated urinal 3.I will always use the calibrated urinal to measure my urine 4.I will notify staff when I need to use the calibrated urinal

3.I will always use the calibrated urinal to measure my urine

A patient is concerned about a medication the nurse is administering. The patient states that the medication is not normally something that is administered. What is the best response by the nurse? 1.The provider has ordered it for you. 2.It is probably a generic medication for something you normally get. 3.I will hold the medication and find out for you. 4.We should probably update your medical reconciliation forms.

3.I will hold the medication and find out for you.

A nurse is caring for an 18-year-old patient who has recently started living on his own and has experienced a greater than 5% weight loss over two weeks. He has a low body mass index (BMI) and complains of feeling fatigued. According to Maslow's hierarchy of needs, the nurse identifies which of the following as the patient's priority need at this time? 1.Safety and security needs 2.Self-esteem needs 3.Physiological needs 4.Love and belonging needs

3.Physiological needs

In addition to regular monitoring of serum potassium level, which intervention will the nurse implement to address the safety needs of a patient prescribed intravenous potassium chloride? 1.Shading windows to minimize sun exposure 2.Delivering the medication by slow IC push 3.Securing electrocardiograms (ECG) regularly 4.Monitoring for hyperactivity

3.Securing electrocardiograms (ECG) regularly

What determines the acidity of a substance like body fluids? 1.The body's ability to trigger chemical reactions 2.The fluid's pH measurement 3.The number of existing H+ ions 4.The amounts of available HCO3

3.The number of existing H+ ions

Which statement concerning fluid balance demonstrated a need for additional instruction concerning fluid intake and output? 1.A desirable amount of fluid intake and output in adults ranges from 1,500 to 3,500 mL daily 2.It is recommended that a healthy adult consume 1.5 quarts of water daily 3.Fluid output is comprised of feces, sweat, and exhaled air 4.The balance between fluid intake and output must be achieved each day to maintain homeostasis

4. The balance between fluid intake and output must be achieved each day to maintain homeostasis

A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse? 1. ensure a sitter is available to watch the patient 2. document findings in the medical record 3. notify the provider 4. check oxygen sat level

4. check oxygen sat level

A patient demonstrated correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? 1. exhales quickly and forcefully 2. inhales quickly and forcefully 3. exhales slowly and deeply 4. inhales slowly and deeply

4. inhales slowly and deeply

During her hospitalization for pneumonia, the provider orders arterial blood gases for Mona Hernandez. What is the best explanation for why this is ordered? 1. pt has fever and malaise 2. pt has a productive cough with rust colored sputum 3. pt has a hx of smoking half a pact of cigarettes per day 4. pt has shallow, ineffective breathing

4. pt has shallow, ineffective breathing

In preparation for calculating the infusion rate for a newly ordered intravenous (IV) solution, the nurse must first secure what information? 1.When the IV is to be started 2.The status of the patient's IV site 3.Patient's history of allergies 4.The infusion set's drop factor

4.The infusion set's drop factor

Which statement by the nurse indicates a need for further education on the role of water as a body fluid? 1.Tissue lubrication is facilitated by water 2.Water helps maintain normal body temperature 3.Waste products are removed from the cells by water 4.Water is transported to cells when it is attached to electrolytes

4.Water is transported to cells when it is attached to electrolytes

A nurse is assessing a patient with cystic fibrosis. Based on a diagnosis of cystic fibrosis, the nurse expects to find which of the following common physical symptoms upon assessment? 1.Increased activity, diaphoresis, and tachycardia 2.Cyanosis or pallor, dyspnea, and arrhythmias 3.Nausea, vomiting, and hyperreflexia 4.Shortness of breath, headache, and vision changes

2.Cyanosis or pallor, dyspnea, and arrhythmias