fundamental 2 exam #1 vsim ?
calculate the IV infusion rate using the following provider's order: 1000mL of NS over 8hrs. Infusion set has a drop rate of 10drops/mL a) 41 b) 10 c) 30 d) 21
21
hypokalemia is confirmed by what serum blood result? a)K 3.0 b)K 5.5 c) Na 146 d) Na 133
K 3.0
what determines the acidity of a substance like body fluids? a) number of existing H+ ions b) body's ability to trigger chemical reactions c) fluid's pH measurement d) the amount of available HCO3
a) number of existing H+ ions
a patient complains of nausea about a tube feeding. What is the priority action of the nurse at this time? a) flush the tube with 30-60mL of water b) ensure the head of the bed remains elevated c) position the patient on left side d) aspirate the tube feeding contents from the patient's stomach
b) ensure the head of the bed remains elevated
a patient with newly diagnosed pneumonia has a 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 result and looks up which of the following test results? a) gram stain b) hemoglobin c) WBC d) chest x-ray
b) hemoglobin
MH lab work indicates an elevated WBC with a left shift in the differential. The nurse interprets this to mean which of the following? a) high number of WBC, but not immature WBC present in the circulation b) high number WBC and immature WHB present to fight the infection c) high number of WBC to flight the infection and WBC are compensating d) left shift in the differential means that this is no infection
b) high number WBC and immature WHB present to fight the infection
in preparation for calculating the infusion rate for a newly ordered IV solution, the nurse must first secure what information? a) patient's history of allergies b) the infusion set's drop factor c) when the IV is to be started d) the status of the patient's IV site
b) the infusion set's drop factor
which of MR.A lab best supports his diagnosis of dehydration? a) creatinine 1.1 b) WBC 21x 10^9 c) Na 130 d) Hb: 16.7
c) Na 130
upon entering the room, the nurse observes MH slumped over in a semi-fowler's position, struggling to catch her breath. what is the prioirty nursing action at this time? a) titrate her O2 so that her O2 is greater than or equal to 95 b) obtain an O2 sat level c) assist the patient into a high fowler's position d) obtain vital signs
c) assist the patient into a high fowler's position
whcih physical finding poses the greatest safety risk for a patient diagnosed with hyponatremia? a) dry mucous membranes b) cold, clammy skin c) ortherostatic hypotension d) anxiety
c) ortherostatic hypotension
a patient with a low BMI i found to have low abumin and prealbumin levels. Which of the following nursing actions should be considered? (select all) a) assess for signs and symptoms of infection b) encourage oral intake of foods and fluids as ordered c) monitor input and output for the patient d) assess gastrointestinal function e) request a nutrition consult
d) assess gastrointestinal function b) encourage oral intake of foods and fluids as ordered e) request a nutrition consult c) monitor input and output for the patient
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? a) ensure the sitter is available to watch the patient b) notifiy the provider c) document findings in the med record d) check O2 sat level
d) check O2 sat level
a nurse has just finished placing a NG tube into a patient for the purposes of administering feedings. What should the nurse do first? a) admin the tube feeding as ordered b) assess how much of the tube was inserted into the patient to verify placement c) irrigate the NG tube with water d) confirm the placement of NG tube per facility policy
d) confirm the placement of NG tube per facility policy
While completing discharge instructions with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time? a) reassure the patient b) ask if the patient has support at home c) determine if the patient has any questions d) listen to the patient's lungs
d) listen to the patient's lungs
expected assessment findings of a patient with pneumonia may include which of the following (select all) a) malaise b) use of accessory muscles c) enuresis d) tachypnea e) fever
fever, malaise, tachypnea, use of accessory muscles
reduced skin turgor is characteristically altered among which population? a) smokers b) older adults c) infants d) premenstrual females
older adults
hyponatremia is associated with a decrease of which electrolyte? a) sodium b) phosphorus c) potassium d) chloride
soidium
a patient demonstrates correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? a) inhales slowly and deeply b) exhales slowly and deeply c) exhales quickly and forcefully d) inhales quickly and forcefull
a) inhales slowly and deeply
a nurse is preparing to admit a patient with cystic fibrosis and altered nutrition status. The nurse plans to implement which precaution to be used in the patient's care? a) droplet b) contact c) standard d) airborn
c) standard
what pathology is responsible for metabolic acidosis? a) excess of HCO3 and/or decrease in H+ ions b) decrease of carbonic acid c) increase of Co2 d) decrease in bicarb or an increase in hydrogen ions
d) decrease in bicarb or an increase in hydrogen ions
what info will the nurse provide to a patient to best assure min the risk of side effects associated with sulfa-trim therapy? a) increase dietary consumption of dairy products b) notify health care provider immediately if experiencing palpitation c) arrange for a yearly flu vaccination d) increase fluid intake in order to remain well hydrated
d) increase fluid intake in order to remain well hydrated
what diagnostic test serves as the basis for determining acid-base imbalances? a) specific gravity of urine b) arterial blood gas c) serum potassium d) blood urea nitrogen
ABG
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? a) I will hold the medication and find out for you b) we should probably update your medication reconciliation forms c) the provider has ordered it for you d) it is probably a generic medication for something you normally get
a) I will hold the medication and find out for you
a nurse is planning on administering a tube feeding to a patient with a NG tube. The patient appears asleep flat in bed. What should the nurse do first? a) assist the patient to a semi-fowler's position or higher b) flush the NG tube with 30-60ml c) carefully connect the NG tube to the feeding d) administer the feeding quietly without waking the patient
a) assist the patient to a semi-fowler's position or higher
what info should be included when documenting a change in the infusion rate of an IV solution? (select all) a) change made to flow rate b) patient's response to IV therapy c) nurse's intials d) original flow rate e) date and time change was made
a) change made to flow rate e) date and time change was made c) nurse's intials b) patient's response to IV therapy
the nurse is caring for an adolescent patient who appear withdrawn and isolated. What strategy should the nurse use to work with this patient? a) develop a therapeutic, trusting relationship with the patient. b) talk to the patient's parents about what is going on with the patient. c) leave the patient alone as much as possible d) tell the patient what the patient needs to do in order to get better
a) develop a therapeutic, trusting relationship with the patient.
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 the medication? a) hold the medication until the patient is able to eat again b) administer the med as ordered c) call the provider immediately d) crush the meds to administer to the patient
a) hold the medication until the patient is able to eat again
considering mr.A diagnosis of dehydration and the possibility of neurological impairment, which nursing intervention is directed toward minimizing his risk for people injury? a) implementing fall precaution b) education the patient on the use of a calibrated urinal c) admin ondansetron with a full glass of water d) assessing for orthostatic hypertension daily
a) implementing fall precaution
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) a) ineffective health maintenance b) social isolation c) activity intolerance d)caregiver role strain e)risk-prone health behavior
a) ineffective health maintenance b) social isolation c) activity intolerance e)risk-prone health behavior
nurse is preparing to discharge MH from the hospital. which of the following instructions should the nurse include in the discharge teaching (select all) a) use IS every 1-2 hrs to move secretions out of your lungs b) stop taking your antibiotics once you feel better c) continue to focus on ambulating several times per day d) take your antibiotics as directed, even if you are feeling better e) quitting smoking will improve your recovery
a) use IS every 1-2 hrs to move secretions out of your lungs c) continue to focus on ambulating several times per day d) take your antibiotics as directed, even if you are feeling better e) quitting smoking will improve your recovery
a nurse is assessing an adolescent patient. Which of the following questions best represents therapeutic communication techniques? a) what do you hope happens here today? b) you don't smoke, do you? c) are you feeling well? d) do you know what to do to stay healthy
a) what do you hope happens here today?
what is the initial step in assessing a patient for orthostatic hypotension?
after having the patient lie in a supine position for 3-10 min take and record BP and pulse
which statement by mr.A best reflects his ability to assume some resonsiblity to tracking his urinary output? a) listened as you discussed the instruction about the calibrated urinal b) i will always use the calibrated urinal to measure my urine c) i will notify staff when i need to use the calibrated urinal d) i understand that its important to measure my urine with the calibrated urinal
b) i will always use the calibrated urinal to measure my urine
a nurse is caring for an 18 patient who has recently started living on his own and has expereinced a greater than 5% weight loss over 2 weeks. Ha has a low BMI and complains of feeling fatigues. According to Maslow's hierarchy of needs, the nurse identifies which of the following as the patient's priority need at this time? a) safety and security needs b) physiologic needs c) love and belonging needs d) self-esteem needs
b) physiologic needs
a nurse titrates the patient's oxygen to 3L per nasal cannula in order to maintain an oxygen sat of at least 94% per the provider's orders. What is the rationale for this order? (select all) a) promotes a decrease in myocardial workload b) promotes a decrease in resp effort c) allows the body to meet metabolic demands d) prevent atelectasis in a patients with pneumonia e) allows the patient to receive 100% oxygen
b) promotes a decrease in resp effort
MH blood gas indicate resp acidosis. Her O2 sat is 95%. which intervention should the nurse provide? (select all) a) non patient 95 is good b) provide sup oxygen as ordered c) promote voluntary coughing activities to clear secretion d) ensure the patient is well hydrated e) assist the patient with adequate ventilation
b) provide sup oxygen as ordered c) promote voluntary coughing activities to clear secretion d) ensure the patient is well hydrated e) assist the patient with adequate ventilation
which statement concerning fluid balance demonstrates a need for additional instructions concerning fluid intake and output? a) desirable amount of fluid intake ad output in adults ranges from 1500-3500mL daily b) the balance btw fluid intake and output must be achieved each day to maintain homeostasis c) fluid output is comprised of feces, sweat and exhales air d) it is recommended that a healthy adult consume 1 1/2quart of water daily
b) the balance btw fluid intake and output must be achieved each day to maintain homeostasis
which statement concerning the measurement of intake and output is ture? a) only foods that are consumed as liquids are included in intake calc b) when possible, intake and output should be measured rather then estimated c) liquid mes are not considered when calculating intake d) health care agencies have adopted standard volumes for common beverage containers
b) when possible, intake and output should be measured rather then estimated
a patient has just completed a tube feeding that has run throughout the night. What is the best education that nurse can provide to the patient at this time? a) it is important that you ambulate 3x day b) you should remain upright for the next hour c) you should lie down to get some sleep d) you should wear your pneumatic compression device when you are in bed
b) you should remain upright for the next hour
a provider orders a high-fat, high-protein, high-carb diet for a patient with cystic fibrosis. What is the best rationale for this diet order? a) the diet was ordered according to the patient's preferred food intake b) cystic fibrosis is a chronic disease characterized by altered electrolytes c) cystic fibrosis interferes with the digestion of food and absorption of nutrients d) thickened mucus secretions predispose the patient to anemia
c) cystic fibrosis interferes with the digestion of food and absorption of nutrients
MH complains of SOB with activity and does not want to exacerbate her condition by moving to the chair or ambulating 3 times a day as ordered. How should the nurse respond? a) you really need to walk as much as possible in order to prevent pneumonia from getting worse b) you should wait until your breathing improves to try to get out of bed agains, b/c it makes you SOB c) even short activities such as moving to the chair will help your mucus out of your lungs d) pneumonia causes thick secretion in your lungs, making it difficult to breath
c) even short activities such as moving to the chair will help your mucus out of your lungs
MH asks the nurse why it is necessary to use the IS when she is already having difficulty breathing. What is the best response by the nurse? a) decrease cardiac workload during inspiration b) increase oxygen taken in by the lungs when you inhale c) helps prevent atelectasis or collapsing of alveoli in the lungs d) it was ordered by your provider
c) helps prevent atelectasis or collapsing
a nurse is teaching a patient with systic fibrosis about nutrition in the high-fat, high-protein, high-carb diet that has been recommended. What of the following should be included in the education? a) it is important to only eat high-fat, high-protein, and high car foods b) it is important to focus on eating calorie-dense foods c) it is important to select a variety of nutrient-dense foods d) it is not necessary to monitor dietary intake
c) it is important to select a variety of nutrient-dense foods
ID the following potential or actual problems that the nurse should include when planning care for the patient diagnosed with the pneumonia? (select all) a) met acid b) ineffective resp gas exchange c) nota able to tolerate activity d) difficulty breathing e) acute pain
c) nota able to tolerate activity d) difficulty breathing e) acute pain b) ineffective resp gas exchange
C.P has a low BMI and has lost 12lb over the past 2 weeks. Which method could the nurse use to assess his overall dietary intake in order to provide nutrition education? a) ask the patient if he has a healthy diet b) ask the patient to keep a food diary c) obtain a food frequency assessment d) track the % of food eaten at each meal while in the hospital
c) obtain a food frequency assessment
during her hospitalization for pneumonia, the provider order arterial blood gases for Mona Hernandez. What is the best explanation for why this is ordered? a) patient has a history of smoking 1/2 pack of cigarettes per day b) patient has a productive cough with rust colored sputum c) patient has shallow, ineffective breathing d) patient has fever and malaise
c) patient has shallow, ineffective breathing
in addition to regular monitoring of serum K level, which intervention will the nurse implement to address the safety needs of a patient prescribed intravenous potassium chloride? a) shading windows to minimize sun exposure b) monitoring for hyperactivity c) securing ECG regularly d) delivering the medication by slow IV push
c) securing ECG regularly
as the nurse administers MH prescribed medication, guaidensin that patient states "I don't like this med. It make me cough too much" how should the nurse respond a) this med will help make your breathing easier b) i will let your provider know you have questions about your med c) when you cough out secretions, oxygenation is more effective d) this med is given to you because of your pneumonia
c) when you cough out secretions, oxygenation is more effective
a nurse is assessing a patient with cystic fibrosis. Bases on a diagnosis of cystic fibrosis, the nurse expects to find which of the following common physical symptoms upon assessment? a ) increased activity, diaphoresis, tachycardia b) SOB, headache, vision change c) nausea, vomit, hyperreflexia d) cyanosis or pallor, dyspnea, arrhythmia
d) cyanosis or pallor, dyspnea, arrhythmia
a nurse is planning patient education about a prescribed medication for a patient. What should the nurse do first? a) educate the patient about potential allergic reactions to the medication b) review the signs and symptoms of drug toxicity with the patient c) educate the patient about the potential drug interactions. d) find out what the patient already knows about the medication
d) find out what the patient already knows about the medication
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? a) the IS will cause you to cough less b/c you are moving more air through your lungs b) you should wait to use your IS until you are not coughing up so much sputum c) you have to use your IS b/c provider has ordered it for you d) the IS helps you to max lung function and min the risk of atelectasis
d) the IS helps you to max lung function and min the risk of atelectasis
a nurse plans on assessing the patient's GI system. Which statement below reflect the best prioritization of this assessmenet? a) the nurse should percuss and then inspect the abdomen b) the nurse should palpate and then auscultate the abdomen c) the nurse should percuss and then auscultate the abdomen d) the nurse should auscultate and then palpate the abdomen
d) the nurse should auscultate and then palpate the abdomen
which statement by the nurse indicates a need for further education on the role of water as a body fluid? a) water helps maintain normal body temp b) tissue lubrication is facilitated by water c)waste products are removed from the cells by water d) water is transported to cells when it is attached to electrolytes
d) water is transported to cells when it is attached to electrolytes