Fundamentals Exam 1
4. Which questions are appropriate to ask during a transcultural assessment? (Select all that apply.) a. How do you act when you are angry? b. What is your role in your extended family? c. Why do you continue to speak German at home? d. When communicating with friends, how close do you stand? e. What is the purpose of not preparing beef with milk products?
a b d
9. Which factors affect 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 b d
3. An older woman was admitted to the unit with GI bleeding and fluid deficit. Clinical manifestations of this problem are (select all that apply) a. Weight loss b. Dry oral mucosa c. Full bounding pulse d. Engorged neck veins e. Decreased central venous pressure
a b e
3. Which statements reflect the practice of transcultural nursing? (Select all that apply.) a. May be considered a general and specialty practice area b. Focuses on the worldview rather than patient needs c. Challenges traditional ethnocentric nursing practice d. Aims to identify individual patient care preferences e. Focuses patient care on the nurse's cultural norms
a c d
7. It is important for the nurse to assess which of the following manifestation for a patient who underwent a Thyroidectomy? (Select all that apply) a. Confusion b. Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive chvostek's sign
a d e
7. Patients are participating in a study to identify genetic disorders. What is a potential concern? (Select all that apply.) a. Violation of confidentiality if a disorder is revealed b. Possible adverse consequences related to employment c. Possible adverse consequences related to reputation d. Possible adverse consequences to insurability e. Inability to prevent the progression of genetic disorders
a e
11. The nurse recognizes that the least effective strategy that a patient can use in a stressful situation that is unchangeable is: A. Avoidance. B. Coping skills. C. Positive support. D. Emotion-focused coping.
a.
2. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this patient? A. Patient has a balanced intake and output. B. Patient's bedding is changed when it becomes damp. C. Patient understands the need for increased fluid intake. D. Patient's skin remains cool and dry throughout hospitalization
a.
2. During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between the ECF and the cell is a. Osmosis b. Diffusion c. Active diffusion d. Facilitated diffusion
a.
4. The nursing care for a patient with hyponatremia and fluid volume overload includes a. Fluid restriction b. Hypotonic IV c. Admin of cation-exchange resin d. Placement of urinary catheter
a.
6. What aspect of culture is a full-time employed granddaughter of an elderly Asian woman exhibiting if she asks the social worker to place her grandmother in an extended-care facility against the wishes of her parents? a. System change b. Gender role c. Cultural norms d. Shared attributes
a.
7. Culturally competent care would encourage which action by a patient's family? a. Asking the family's spiritual advisor to visit the patient b. Speaking English to everyone involved in patient care c. Adhering to highly publicized restrictive unit visiting hours d. Limiting food consumption to items provided by the cafeteria
a.
7. What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests
a.
9. The lungs act as an acid base buffer by a. Increasing respiratory rate and depth when C02 levels in the blood are high, reducing acid load b. Increasing RR and depth when C02 levels in the blood are low, reducing the base load. c. Decreasing RR and depth when C02 levels in the blood are high reducing acid load d. Decreasing RR and depth when C02 levels in the blood are low, increasing acid load
a.
6. A patient is on the way to the hospital in an ambulance and is asked to participate in a research protocol for a new treatment for myocardial infarction. What is this an example of? (Select all that apply.) a. Standard practice b. An ethical dilemma c. A violation of informed consent d. A patient who is in a vulnerable population category e. Compliance with important ethical issues of justice and autonomy
c d
1. Which statement best serves as a guide for nurses seeking to learn more about ethnicity? a. Ethnicity, like culture, generally is based on genetics. b. A patient's ethnic background is determined by skin color. c. Ethnicity is based on cultural similarities and differences in a society. d. Culture and socialization are unrelated to the concept of ethnic origin.
c.
11. The typical fluid IV for a patient with fluid volume deficit is: a. Dextran b. 0.45 NS (Saline) c. Lactated Ringers d. D5 in 0.45 NS
c.
3. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? A. Monitor for shortness of breath or fatigue after ambulation. B. Instruct the patient about the need to alternate activity and rest. C. Obtain the patient's blood pressure and pulse rate after ambulation. D. Determine whether the patient is ready to increase the activity level.
c.
5. The nurse is instructing a Hypocalcemia patient to eat foods that are high in calcium, such as: A. Orange juice B. Lamb C. Yogurt D. Oatmeal
c.
5. The nurse should be aware of which of the following manifestations for a patient taking loop diuretics? a. Restlessness and agitation b. Paraesthesia and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
c.
6. Which patient is at highest risk for hypermagnesemia? a. 83 y/o man with lung cancer and hypertension b. 65 y/0 female with hypertension taking Beta Blockers c. 42 y/0 woman with systemic lupus and renal failure
c.
8. Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient
c.
9. Which nursing diagnosis is most appropriate for a young Middle Eastern immigrant who expresses concern for the safety of his family members who were unable to relocate with him out of a war zone? a. Risk for Spiritual Distress b. Impaired Role Performance c. Interrupted Family Processes d. Ineffective Coping
c.
9. Which of the following nursing diagnoses (self-care deficit) is written following the appropriate format? A. Patient complains of pain r/t verbalization of 8 out of 10. B. Pain r/t GERD C. Pain r/t injuring agent (chemical burn) D. Free of pain AEB: pain 3 or less on a 0/10 scale.
c.
Independent interventions
doesn't need order from another such as vitals or auscultation.
Orem's Theory: Self Care
individuals perform on their own to maintain well being
Dependent intervention
requires an order such as administering IV solutions or meds
Orem's Theory: SCA: Self care agency
is the ability that a person has to meet these needs
Creatinine normal range
0.8-1.3
BUN normal range
8-21
2.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. B. C. E.
8. Which of the following statements describes a component discussed in nursing theories? (Select all that apply.) a. Optimal functioning of the patient b. Interaction with components of the environment c. The conceptual makeup of the administration of the hospital d. The illness and health concept e. Safety aspect of medication administration
A. B. D.
6. Of the following, which are included in the ANA standards? (Select all that apply.) a. Standards for professional performance b. Code of ethics c. Standards of care d. Legal scope of practice e. Licensure requirements
A. C. ANA standards have two parts: one is standards for professional performance, and the other is standards of care. ANA has a separate document that is a code of ethics. Nurse practice acts are a legal scope of practice.
1. Which action by a patient marks the beginning of the physical assessment process? a. Redressing after a physical examination b. Breathing normally during auscultation c. Greeting the nurse in the examination room d. Sharing work environment information
Answer: c Assessment begins at the moment the patient first interacts with the nurse. Redressing takes place at the end of the physical examination. Breathing during auscultation is part of the respiratory assessment, and sharing health history and demographic information takes place during the patient interview.
3. An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient
Answer: d The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.
6. Three weeks after delivery, a patient started a diet of 800 calories per day and started jogging 2 miles twice per day. The nurse recognizes the patient's behavior may be influenced by which motivating factor? a. Body image b. Family roles c. Illness behavior d. Chronic illness
Answer: a Body image is a self-ascribed attribute that influences a person's ability and desire to change, and it may be a motivating factor to maintain the change. Self-concept is a general and broader factor that motivates less specific responses. Family roles are not an influencing factor because this is a personal and possibly self-destructive behavior pattern for weight loss. Pregnancy is not a chronic illness.
9. In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias? a. Collecting the patient's medical history b. Administering IV medications c. Performing oral care d. Completing a bed bath
Answer: a Donning gloves every time the nurse enters the patient's room may reflect bias related to the care of a patient with HIV infection and may interfere with the development of a therapeutic relationship with the patient. The patient with HIV is on standard precautions unless there are complications that put the nurse at risk of blood or body fluid exposure.
7. Which cue by a patient can be validated by laboratory and diagnostic test results? a. Deeply sighing with fatigue b. Bilateral crackles in the lungs c. Oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feet
Answer: a A cue is a behavioral hint of a potential disease process or concern. In this case, the only cue is a deep sigh indicating fatigue. The level of fatigue can be verified by evaluating the patient's hemoglobin and hematocrit levels for anemia. Crackles, oxygen saturation, and pitting edema are all physical assessment findings, not cues.
6. Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.
Answer: a Goals are to be patient-focused, realistic, and measurable. Only the first goal meets these three criteria.
7. What is the most significant problem that may result from improperly written nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs
Answer: a Accurate nursing diagnostic statements provide direction for the development of individualized plans of care. Orders are part of the patient's assessment data. Combining unrelated patient problems is a function of diagnostic development, not a result of an improperly written statement. Poorly written nursing diagnostic statements may or may not result in increased team collaboration.
6. Interpret the following arterial blood gases. PaO2=91, CO2=32, pH=7.49, HCO3=24 A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
Answer: B
10. Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview
Answer: a Hospice referral requires collaboration with many health care team members. Physical assessment and completion of a health history interview are independent nursing actions that can be performed by a nurse alone. Activities of daily living can be completed by patients independently or with the help of a nurse or unlicensed assistive personnel (UAP), requiring little collaboration among health care team members.
6. Which of the following actions reflects inductive reasoning? a. Using subjective and objective data to confirm a diagnosis b. Assessing for specific clinical presentations based on a disease process c. Correlating elevated blood pressure to pathophysiology d. Validating an automatic blood pressure cuff reading with a manual measurement
Answer: a Inductive reasoning uses specific facts or details to make conclusions and generalizations (i.e., going from specific to general). Using assessment data (specific data) to arrive at a conclusion (diagnosis) is an example of induction. Deductive reasoning involves generating facts or details from a major theory, generalization, or premise (i.e., from general to specific). The validation of a disease process (general) by specific assessment parameters (signs and symptoms, diagnostic study results, etc.) is an example of a deduction.
10. During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse's use of which intellectual standard of critical thinking? a. Clarity b. Logic c. Precision d. Significance
Answer: a Patient information must first meet the intellectual standard of clarity before it is evaluated for precision, logic, or significance.
5. What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis? a. Defining characteristics are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed with a risk diagnosis.
Answer: a Risk diagnoses do not have defining characteristics; actual and health-promotion nursing diagnosis statements have defining characteristics. Risk diagnoses do not establish a cause and effect, because they identify potential rather than existing problems. Risk diagnoses contain related or risk factors rather than defining characteristics, subjective or otherwise. Risk diagnoses, like actual diagnoses, have nursing interventions to address a patient's current or potential problem.
2. Which activity best illustrates the use of the Health Promotion Model (HPM) by the nurse to increase the level of well-being for a patient immediately after surgery? a. Holding a pillow across his chest when coughing and deep breathing b. Encouraging the patient to eat his entire evening meal c. Changing his surgical dressing daily as ordered by the physician d. Asking his family to step out of the room during dressing changes
Answer: a The HPM describes an individual's interaction with his environment as he engages in behaviors that promote health. The patient using a pillow as a splint is interacting with his environment to prevent atelectasis and infection.
3. A nurse providing preventive care to an overweight patient with a family history of diabetes should engage in which priority care-planning activity for this patient? a. Calculating the patient's body mass index (BMI) and recommending a daily exercise routine b. Instructing the patient to perform blood glucose monitoring once daily c. Giving the patient a month's supply of insulin needles and syringes d. Participating in diabetes education classes offered at a local health facility
Answer: a The patient does not have diabetes but is overweight and at risk due to a family history of diabetes. The best way to prevent diabetes is to keep the BMI in the optimal range (<25). Beginning an exercise program with walking and progressing as tolerated increases muscle mass, improves depression, and strengthens the heart.
9. A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.
Answer: a When a patient shares a concern, the first action by the nurse is to assess potential reasons for the patient's problem. Depending on the underlying reason for the patient's inability to sleep, the nurse may then want to administer prescribed sleep medication, teach the patient some relaxation techniques, or discuss patient behaviors with the primary care provider.
1. What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change
Answer: a, b, c, d Cultural practices, functional status, communication barriers, and scope of practice influence whether an intervention should or may be implemented. Shift change time is not necessary to consider before implementation of most interventions.
7. Which action is a part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan b. Documenting performed nursing interventions c. Determining if nursing interventions were completed d. Reviewing whether a patient met their short-term goal e. Identifying realistic outcomes with patient input
Answer: a, d Determining whether a goal or outcome is met is part of the evaluation. Making sure interventions are completed and documenting them are part of implementation. Identifying outcome criteria is done during the planning stage of the nursing process.
10. What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 BPM c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone."
Answer: b, c, e An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are consistent with extreme anxiety and should be clustered together. Ease of falling asleep and being able to focus on a challenging task, such as giving an injection, are not indicative of a patient experiencing a high level of anxiety.
5. Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient's white blood count will remain within normal range throughout hospitalization. c. Patient's visitors will be instructed in proper hand washing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.
Answer: b A patient's white blood cell count is a laboratory test that is a measurable indicator of infection. The correct answer is also patient-focused and realistic. Encouraging the use of sterile technique by the nurse during each dressing change and instructing the patient's visitors in the proper handwashing technique before direct interaction with the patient are not patient-focused. The patient understanding the importance of cleaning around the incision with a clean cloth during bathing uses a nonmeasurable verb, which should be avoided when formulating patient goals.
3. If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Knowledge Deficit d. Body Image Disturbance
Answer: b Acute Pain is the most urgent nursing diagnosis to address. Fatigue may be a result of the pain and may be alleviated if the patient's pain level is reduced. Body Image Disturbance and Knowledge Deficit can be treated only after the patient's pain level is at an acceptable level. Both diagnoses require teaching, during which the patient needs to concentrate. A person's ability to concentrate is affected by the pain level.
9. The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient's bed b. Administering oxygen by nasal cannula c. Assessing the patient's oxygen saturation d. Evaluating the patient's peripheral circulation
Answer: b Before a nurse can legally administer oxygen to a patient, the method of delivery and amount must be ordered by the primary care provider. Elevating the head of the bed and assessing a patient's oxygen saturation and peripheral circulation are all independent nursing interventions.
4. Which activity by the nurse best demonstrates part of the working phase of a patient interview? a. Summarizing previously discussed key topics b. Including selected family members in care planning c. Transferring care responsibilities to the home health nurse d. Verifying the name by which a patient prefers to be addressed
Answer: b Care planning takes place during the working phase of the nurse-patient interview. When a patient needs care assistance, it is important for family members who will be helping with the patient's care to be involved in the process. Verifying the name that a patient prefers to be called takes place during the orientation or introductory phase. Summarizing key topics covered in the interview and transferring care responsibilities take place in the termination phase.
4. What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice
Answer: b Each nursing diagnosis label identifies either a patient problem or need, which is its purpose. Resolving patient confusion, meeting accreditation requirements, and articulating the nurse's scope of practice are not related to the purpose of the nursing diagnostic process.
10. A patient is seeking information about leading indicators that show the importance of health promotion and illness prevention in the United States. To which government-sponsored program would the nurse refer the patient for the best source of information? a. The American Cancer Society website b. The Healthy People 2020 website c. The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report d. The American Association of Hospitals home page
Answer: b Healthy People 2020 is the most up-to-date site for health indicators in the United States, and it is presented in a client-friendly format. The CDC Morbidity and Mortality Weekly Report does not cover all of the indicators, and it may be overly technical for the client. The same holds true for the American Cancer Society website and the American Association of Hospitals home page.
7. The nurse is completing an assessment on a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient's abdominal pain? a. Evaluation b. Interpretation c. Reflection d. Inference
Answer: b Nurses use interpretation to understand and explain the meaning of data. In this case, the nurse must first interpret the assessment data before reflecting on its meaning, evaluating its reliability or credibility, and making inferences that will have an impact on treatment options.
2. In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking? a. "What do I know about this situation?" b. "What additional details do I need to gather?" c. "Does the clinical presentation correlate with the diagnosis?" d. "Are the treatments appropriate for the diagnosis?"
Answer: b Precision relates to providing sufficient detail to lead to an exact understanding of the situation. What do I know about this situation? is focused on self-reflection about what is known about the situation. Does the clinical presentation correlate with the diagnosis? relates to relevance. Are the treatments appropriate for the diagnosis? relates to logic.
4. An active, older patient has been frequently evaluated for minor problems at the clinic since the death of her husband 3 months earlier. During one of her visits, she states that she has no energy to get through the day and no desire to keep up with her Tuesday night bridge club. Which type of holistic health model intervention should the nurse employ to help the patient cope with the loss of her husband? a. Encouraging use as needed of a drug for anxiety ordered by her provider b. Teaching the value of music therapy to address anxiety about her loss c. Explaining that she will be over the loss of her husband in a few months d. Encouraging a gradual reentry into social interaction and activities with friends
Answer: b Teaching the patient to use music therapy when she feels anxious about her loss is the most appropriate intervention listed. This type of distraction is a holistic technique that works well in the form of music, painting, and expressive dance. Instructing the patient to use drugs is not part of the holistic approach. The patient may not be ready to re-engage in a full activity schedule, and it is unlikely that her feelings of loss will ever totally resolve.
3. Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. Always position patients in a comfortable reclined position to ensure their comfort during questioning. b. Ask which name a patient prefers to be called during care to show respect and build trust. c. Quickly conduct a review of systems to determine the need for a complete or focused assessment. d. Begin with questions about intimacy and sexuality to address sensitive issues first.
Answer: b The nurse should provide a personal introduction and establish the name by which the patient wants to be called at the very beginning of the interview as part of the orientation phase. In most cases, the patient and the nurse should be seated at eye level during the interview portion of the assessment. Questions about intimacy and sexuality should be reserved for later in the interview to establish rapport before exploring potentially sensitive issues. A review of systems takes place during the working phase of the nurse-patient interview, just before initiation of the physical assessment.
1.The nurse receives change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse's action? a. Problem solving b. Decision making c. Judgment d. Reasoning
Answer: b The nurse used decision making to guide which patients to see first, based on an analysis of patient data and care needs. Problem solving is used when the nurse is faced with a situation that requires analysis and a solution. Judgment is used in the decision-making process but does not result in the actual decision. Reasoning is logical thinking that may be used in decision making but, again, is not the actual result. Decision making culminates in a definitive action.
9. The nurse enters a patient's room to deliver a dinner tray and notices that the patient has not been out of bed since the previous day. The patient states that his condition has made him bed-ridden, although the nurse knows that he is capable of independent ambulation. Which type of reaction is the patient exhibiting? a. Ambivalence to symptoms b. Illness behavior c. Diminished functional ability d. Overreaction to illness
Answer: b The patient is defining and interpreting his disease symptoms according to his beliefs about illness and how to respond to it. The patient's ability to ambulate is intact. Overreaction to illness is a subjective anomaly, and the patient is not ambivalent about his diagnosis.
9. A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition. c. Seek physician input related to updating the nursing diagnosis statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.
Answer: b The patient's condition requires immediate performance of the lifesaving steps of the nursing process. All other answers are secondary actions. The nurse later resumes all interventions for previously identified nursing diagnoses and evaluates the success of the acute care plan for management of the cardiac arrest. Nurses do not seek the input of the physician for creation of nursing diagnoses.
5. Knowledge gained from research in the 1970s about placing infants on their backs to prevent sudden infant death syndrome was not recommended to parents until the 1990s. This is an example of what barrier to evidence-based practice? a. Proliferation of research b. Implementation delay c. Information needs not being met d. Lack of readily available resources
Answer: b There is an implementation delay of approximately 17 years from clinical research to integration into practice. Proliferation of research is the large amount of research that is conducted. Lack of resources refers to a reduced number of databases that provide the information being sought, and information needs not being met refer to the inability to readily find the answers to questions.
3. Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient's ability to swallow the medication. b. Double-check the patient's allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration.
Answer: b Verifying patient allergies before administering medication is the most important intervention listed to ensure patient safety. Providing water may or may not be necessary, depending on the type of medication being administered. Although it is okay to ask a patient about having taken a medication previously, it is not routinely done or most important. It is preferable to have patients sit up while taking medication unless contraindicated.
8. Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages
Answer: b, c, d Auscultating lung sounds and monitoring skin integrity are both important aspects of basic patient assessment that require independent nursing actions. Ordering and applying heel protectors is done independently by nurses to prevent skin breakdown on patient's confined to the bed. Ordering blood transfusions and adjusting antibiotic dosages are the responsibility of the patient's primary health care provider.
2. Which nursing diagnosis is appropriately written? (Select all that apply.) a. Risk for Infection related to elevated temperature and white blood count b. Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication c. Noncompliance related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Bleeding with the risk factor of prolonged clotting time e. Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort.
Answer: b, c, d Readiness for Enhanced Relationship is a heath-promotion nursing diagnosis and is written with two sections: the label and the defining characteristics. Noncompliance is a nursing diagnosis that requires a related factor and defining characteristics. Risk for Bleeding requires at least one risk factor, which it has as it is written. Use of related factors in a risk nursing diagnosis is not the accepted NANDA-I format. The nursing diagnosis of Chronic Pain is incorrectly written because it includes a medical diagnosis and a related factor that is supportive of acute rather than chronic pain.
9. When initiating a physical examination, which action should the nurse take first? a. Review of the patient's prior medical records b. Gather admission health history forms c. Assess the patient's vital signs d. Perform light and deep palpation for fluid
Answer: c Assessment of the patient's vital signs begins the physical examination aspect of the assessment process. This provides the nurse with baseline information about cardiac and respiratory function, pain level, and temperature. The nurse should review the patient's prior medical records before the interview or after the patient interaction to fill in gaps. Admission health history forms need to be gathered before initiating the interview, and abdominal palpation takes place about halfway through the head-to-toe physical examination.
3. Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data? a. Do these findings make sense? b. How can this information be verified? c. What are the most significant factors in the problem? d. What is the relationship of this information to other data?
Answer: c Determining relationships is effective in establishing the relevance of data. Verification of information is related to accuracy, making "sense" relates to logic, and significance more closely related to depth. The routine use of the intellectual standards helps improve critical thinking.
8. Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient's short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before shift change c. Documenting patient assessment findings in the patient's chart d. Checking with the pharmacist regarding possible drug interactions
Answer: c Documentation of assessment findings is the only objective form of data listed as an option that can support the night nurse in evaluating whether the patient achieved short-term goals. Patient observations are subjective in nature. Leaving a message with the charge nurse produces secondary subjective data, and checking for drug interactions is unrelated to the evaluation process.
5. An 8-year-old girl is newly diagnosed with type 1 diabetes. The nurse may expect fear and crying when teaching the child how to self-administer insulin injections due to which influencing factor? a. Self-concept b. Self-esteem c. Developmental level d. Hierarchy of needs
Answer: c Even when the child understands about having the disease, she is less likely to understand the need for insulin therapy due to her emotional and comprehension level of development. A child's self-concept is not well established at this point, and self-esteem is not a major factor. Hierarchy of needs is not yet fully developed because the child depends on her parents for the basic level of needs.
4. The nurse feels that the results of a recent literature search and analysis about handwashing should be implemented in the entire hospital system. With whom would the nurse be required to collaborate? a. Colleagues caring for patients in her unit b. Colleagues in the community c. Administrators at the hospital d. Others in her department
Answer: c Implementation would require collaboration with hospital administrators to influence the larger practice environment of the entire hospital. Collaboration with colleagues in the community would have no effect on the hospital system. Collaboration with the department or colleagues in the unit would not allow for hospital-wide implementation.
7. Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient's social worker to determine resources c. Listening to the patient's concerns and beliefs about proposed treatment d. Engaging the patient's family, friends, or care providers in conversation
Answer: c It is most important to involve the patient in developing realistic, attainable, patient-centered plans of care. Involving others in care planning is secondary to involving the patient, unless the patient is cognitively impaired.
2. Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC)
Answer: c Maslow's hierarchy of needs and the airway, breathing, circulation (ABCs) of life support are the most helpful tools in identifying priorities of care. Functional health patterns is one method of organizing assessment data. NOC and NIC are resources for identifying outcomes and interventions to include in a patient's care plan after priorities have been established.
5. On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses
Answer: c Nursing diagnoses emerge from groupings of clustered data collected during the assessment phase of the nursing process. The nurse documents the patient's medical diagnosis as one piece of data, which may be clustered with others to support a nursing diagnosis. Data collected from a nurse's intuition and first impressions may also be listed in the patient's assessment findings as long as they are objectively recorded without prejudice and are not judgmental in nature.
5. Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. Complaining of chest pain b. Apical pulse 110 c. Comatose d. Difficulty swallowing
Answer: c Primary data are obtained from the patient directly. A patient who is comatose is unable to speak and therefore unable to share subjective, primary data. A patient complaining of chest pain has already shared primary, subjective data. A patient with an apical pulse of 110 who is alert or one who has difficulty swallowing may still be able to contribute subjective information to the data collection.
3. Which phrase best represents a related factor in an actual nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness
Answer: c Related factors are broad statements that indicate the cause for the defining characteristics, which are signs or symptoms identified from collecting the patient's data. Redness and swelling, unsteady gait, and complaint of restlessness are specific defining characteristics that would be clustered with other data to support the existence of an actual or health-promotion nursing diagnosis.
8. A patient diagnosed with an aggressive cancer is estimated to have 6 months to live. Two months later, the patient's wife calls the nurse's office because she is upset that her husband has taken up motorcycle racing and has already been injured twice. The nurse knows that the patient is experiencing a behavioral change in which factor due to the prognosis of his illness? a. Spirituality b. Physical attributes c. Self-concept d. Personal affect
Answer: c Self-concept is profoundly affected by the diagnosis of a terminal disease. The individual often tries to reinvent himself or herself and behaves in an uncharacteristic manner.
10. What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.
Answer: c The nurse should evaluate the need to continue or discontinue a plan of care if a patient has met a short-term goal. It is unnecessary to consult the surgeon unless there is a concern. Discontinuing the care plan may be premature, and the decision needs to be evaluated before taking action. The patient's intake and output will continue to be monitored throughout hospitalization, not just for 1 hour after surgery.
1. What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team
Answer: c The nursing process is the methodology used to "think like a nurse." Providing patient-centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care.
4. The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first? a. Ask the patient to describe the chief complaint b. Request that another nurse be assigned to this patient c. Review data about the medical diagnosis and routine management d. Complete a physical assessment of the patient
Answer: c The priority action is to find the necessary information/data needed to guide the nursing care. The nurse cannot apply critical thinking about something that is unknown. If the nurse asks the patient to describe the chief complaint or completes the physical assessment with limited knowledge of the disease process, the nurse has nothing to corroborate or compare. Requesting another nurse to care for the patient does not address the lack of knowledge.
6. Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. Ambulating a patient with ataxia and new right sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications
Answer: c Transporting the stable patient for discharge can be delegated immediately to UAP. A patient with new neurologic symptoms needs to be assessed before being ambulated. Patients who have recently choked need to be evaluated for their ability to swallow before being fed. Administering medication is not within the UAP's scope of practice and can never be delegated to UAP.
2. Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously b. Discourage the patient from bathing while hospitalized c. Encourage the patient to rest between bathing activities d. Ask the patient's spouse to assist with all bathing
Answer: c When patients are unable to complete their personal care without fatigue, it is best to encourage them to rest between activities. All patients should be encouraged to wash during hospitalization and to complete as much of their personal care as independently as possible. Patients who tire easily should not be encouraged to shower and shave simultaneously but should space out personal care while seated.
10. What is the primary purpose of quality improvement? a. Recognizing the need to discipline employees violating policies b. Preventing patient injury that may contributor to the death of others c. Increasing institutional profits to support further scientific research d. Enhancing current practices to improve patient outcomes and care
Answer: d
8. Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.
Answer: d
10. If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid c. Perform passive range of motion to promote flexibility d. Inspect the patient's left elbow to compare its appearance
Answer: d A major aspect of assessment is checking for symmetry. If an abnormality is observed on one side of a patient's body, the next step in the assessment is to compare that area with the other side. Applying ice is premature until the assessment is complete and an underlying cause of the swelling and pain is understood. Percussion is not indicated for assessment of a swollen elbow. Performing passive range of motion is not appropriate before identifying an injury or disease and determining its extent.
7. A 65-year-old male patient has been a one-pack-per-day smoker for 40 years. He was recently diagnosed with early-stage chronic obstructive pulmonary disease (COPD) and would like to attend a smoking cessation class. The nurse recognizes smoking cessation as which level of prevention for this patient? a. Primary prevention b. Secondary prevention c. Statutory prevention d. Tertiary prevention
Answer: d According to the stages for disease prevention, primary prevention is implemented for the absence of disease, secondary prevention applies to the early stages of disease or recently diagnosed risk factors, and tertiary preventive care is offered for permanent and irreversible disease.
6. Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer, high blood pressure, or stroke?" c. "When was your last annual physical? What immunizations did you receive at that time?" d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?"
Answer: d During a review of systems, the patient is asked questions about each body system to determine the level of functioning. Asking about work-related information, family history, and immunizations is accomplished during the collection of health history data before initiating the review of systems.
4. Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy d. Encouraging the patient to explore options for care
Answer: d Encouraging the patient to explore options for care empowers the patient to have some control over the situation and to be actively involved in care planning. It is a form of informal counseling. Reassessment and teaching are not immediately indicated at this time. Although referring a patient with a new cancer diagnosis may be helpful, it is an indirect care intervention.
2. A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting
Answer: d In an emergent situation, the nurse initially focuses on the patient's chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.
8. A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. Body systems model b. Physical assessment model c. Head-to-toe assessment model d. Functional health patterns model
Answer: d Job stress and family relationships data will only be recorded extensively when using the Functional health patterns model. The functional health patterns model is holistic in its approach. The body systems model and head-to-toe assessment model focus on physical rather than psychological or emotional concerns. All three models listed are ways to organize physical assessment findings.
4. Which statement illustrates a characteristic of goals within the care planning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient's progress.
Answer: d Long-term goals are very useful in determining patient progress. Both short-term and long-term goals need to be measurable. Goal attainment is based on patient actions, not nursing actions.
1. Which of the listed basic needs identified by Maslow must be addressed first when providing nursing care? a. Self-esteem b. Love and belonging c. Self-actualization d. Nutrition and elimination
Answer: d Nutrition and elimination must be addressed first before concerns about self-esteem, love and belonging, and self-actualization, according to Maslow's hierarchy of needs. According to Maslow, the lower-level needs must be fulfilled and maintained before the higher-level needs can be met.
9. Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB.
Answer: d Option d is the only notation that indicates whether the goal was met and how all of the outcome criteria were attained.
1. Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. List possible treatment options b. Identify realistic outcome indicators c. Consult with health care team members d. Rank patient concerns from assessment data
Answer: d Prioritizing or ranking patient needs precedes the identification of outcome indicators, consulting with team members, or consulting with interdisciplinary team members.
1. What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I? a. Insurance documentation b. Professional autonomy c. Role delineation d. Patient safety
Answer: d Safety is the most important reason for using standardized language to communicate patient's needs and information. Using the same definitions of terms helps nurses and other health care professionals interpret the information. Helping with insurance documentation, supporting professional autonomy, and clarifying the nursing role in patient care are uses for NANDA-I taxonomy, but they are not the most important.
6. What is the most important action for a nurse take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy? a. Share concerns with the nurse manager on the nursing unit b. Offer alternative care for a patient and family members c. Discuss how to address patient needs with physicians d. Provide evidence-based research to support nursing care
Answer: d Supporting a suggestion for a new nursing diagnostic label with research is required for consideration by NANDA-I. Sharing concerns, providing alternative care, and advocating for patients are all a part of the nursing role, but are not the most important part of having a diagnosis considered for inclusion in the NANDA-I taxonomy.
1. A nursing student is taking care of a patient with possible appendicitis and is curious about the best method of diagnosing this disorder. What does the nursing student have to consider in formulating a question using the PICO format (patient, population, or problem; intervention; comparison intervention; outcomes) to determine evidence-based practice? a. Problem: appendicitis; interventions: ultrasound versus CT scan; outcome: diagnosis of appendicitis b. Problem: pain; interventions: meperidine versus morphine; outcome: pain free c. Problem: fever; interventions: cooling measures versus antipyretics; outcome: normal temperature d. Problem: appendicitis; Interventions: complete blood count versus chemistry panel tests; outcome: painless
Answer: d The PICO format asks for the patient's problem, the two possible interventions for comparison (i.e., diagnostics), and the desired outcome from the interventions.
5. The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply. ) a. Assessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated d. Allowing the patient to be alone to rest more comfortably e. Discussing adaptations needed for daily activities with the patient
Answers: a, b, c Analysis involves assessing a situation and determining what should be done based on an appropriate rationale. In this case, assessing the patient for symptoms of hypoxia, providing oxygen as ordered, and elevating the head of the bed help determine the extent of air hunger, promote increased gas exchange, and ease the effort of breathing. Leaving a patient who has a low pulse oximetry reading alone is potentially dangerous. Discussing nonemergent information with a patient experiencing air hunger requires increased oxygen consumption and is inappropriate.
4. Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Thoroughly review the patient's medical history b. Analyze the nursing assessment data to determine whether information is complete c. Outline an individualized plan of care to address each concern d. Consider potential complications to which the patient is susceptible e. Evaluate how the patient has responded to treatment
Answers: a, b, d Before determining the types of nursing diagnoses that are appropriate for a patient, the nurse must review and analyze all of the patient's data, including the medical history, for completeness and accuracy. Considering the vulnerability of a patient to potential complications permits the nurse to identify the need for risk nursing diagnoses. Outlining an individualized plan of care takes place during the planning stage of the nursing process after the nursing diagnoses have been identified. Evaluation of a patient's response to treatment is part of the evaluation stage of the nursing process.
6. If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections
Answers: a, b, d Sharing a desire to eat, reporting that food smells good, and preparing meals are indications of an increased appetite. Although relaxation techniques may decrease anxiety associated with eating, they do not indicate an increase in appetite. Reading nutrition labels is unlikely to increase a person's appetite.
8. Which entity or document specifically addresses the role of the nurse in research? (Select all that apply.) a. American Nurses Association standards of practice b. Institutional review board c. Hospital Magnet status d. Joint Commission e. MD Consult
Answers: a, c The American Nurses Association (ANA) standards of professional performance support the nurse's role in research, and hospital Magnet status includes the nurse using evidence to improve quality of care. The Joint Commission does not address nursing research, institutional review boards approve all research involving human subjects if it is funded by the federal government, and MD Consult is a background resource for research. None of these three entities specifically address the role of the nurse in research.
8.The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.) a. Teamwork b. Intuition c. Judgment d. Conflict management e. Advocacy f. Reasoning
Answers: a, d, e Interpersonal skills such as teamwork, conflict management, and advocacy engage others in the process of critical thinking. Intuition, judgment, and reasoning are intrapersonal aspects of critical thinking that the nurse may use personally to better understand a situation.
9. Which of the following factors contributes to the nurse having difficulty keeping up with the latest patient care information? (Select all that apply.) a. Implementation delays b. Proliferation of research c. Volume of health care literature d. Hours spent in direct patient care e. The need to read 3 articles every day of the week
Answers: b, c, d The proliferation of research has led to huge volume of literature, which would require the nurse to read approximately 17 articles every day to remain current. Hours spent in direct patient care make it nearly impossible to keep up with current practices. Implementation delays affect putting alternative interventions into practice, not a nurse's ability to keep up with research findings.
3. What specific aspect of a profession does the development of theories provide? a. Altruism b. Body of knowledge c. Autonomy d. Accountability
B.
5. What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.) a. Patient's treatment preferences b. Cultural and ethnic influences c. Professional level of expertise d. Current evidence-based research e. Convenience to the nursing staff
a b c d
1. In comparing the American Nurses Association (ANA) and the International Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA's definition and is indicative of a more global focus? a. Advocacy b. Health promotion c. Shaping health policy d. Prevention of illness
C.
4. Health care 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. Autocratic leadership
C.
5.A nurse makes a medication error, immediately assesses the patient, 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. The nurse is demonstrating accountability by taking responsibility for the error and reporting it after an initial assessment of the patient. Criteria of a profession include altruism (public service over personal gain), autonomy (independence), accountability, and diversity; however, in this case, the nurse is demonstrating accountability. Although collaboration is important for the health care team, it is not a criterion for a profession.
3. Roles of the Nurse:
Care Provider: using the nursing process Educator: using discharge planning and health promotion Advocate: Speaks for patients in time of inability Leader: Builds communication and direction Change Agent: Change in health policy issue or patient care Manager: CNL or Unit Nurse Management role Researcher: Evidence based practice to validate nursing process Collaborator: Interpersonal collab with other healthcare colleagues Delegator: "5 Rights of Delegation, see Delegation section.
7. Which core competency of advanced practice nursing is the Master of Science in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques? a. Leadership b. Ethical decision making c. Direct clinical practice d. Expert coaching
D.
Orem's Theory: Dependent care
Dependent care: the continuing care responsible by adults caring for people with disabling conditions. This is provided when one is unable to meet needs on their own.
Magnesium: Cardiac Functioning 1.3-2.3
Facts: ICF cation -Decreases respiration muscle contraction. Patient may have respiratory depression. -Used to tx toxemia in pregnant women.
Calcium 8.4-10.6 Function:
Function: Calcium is the major cation in bones and teeth. Plays a role in blood clotting and nerve impulses, muscle contractions and heart conduction. -A decreased PH (acidosis) will decrease calcium's ability to bind to albumin Parathyroid hormone and calcitonin regulate calcium levels. Low serum calcium levels signal the thyroid glands to release PTH. PTH then signals the bones to release calcium into the blood and increasing GI absorption of calcium. Calcitonin has the opposite effect and will lower levels of Calcium by increasing renal excretion of calcium, decreasing GI absorption of calcium. Vit. D helps in absorption.
Phosphorus 2.5-4.5:
Inverse levels with Calcium* Helps diagnose kidney, bone and endocrine conditions Hypophosphatemia: Resp/heart failure, muscle weakness Hyperphosphatemia:
Hypervolemia Excess Fluid Volume FVE Nurse Interventions:
Nurse Interventions: Remove excess fluid w/o changing electrolytes imbalance, Give diuretics (careful about electrolyte status and check Potassium Levels). Restrict fluid and limit to a set amount of fluid for intake Restriction of sodium
Orem's theory: SCR, Self Care Requisites:
SCR, Self Care Requisites: formulated ideas about the actions to be performed by individuals that are known to be a necessary part in the regulation for health.
Hyperkalemia: Excess Serum Potassium >5.0
Signs: Cardiac dysrhythmias, cramping in legs, paralysis, GI hypermobility. Tall peaked T Wave. Wide QRS *High Potassium will lead to- Acidosis Causes: Too much K in diet/supplements, medications (ACE/ARB drugs, diuretics), renal disease, Nurse Interventions: Insulin, Diuretics, treat underlying condition,
Hypokalemia: Low Serum Potassium <3.5
Signs: Dysthymia- heart is not beating properly, muscle and respiratory muscle weakness, decrease GI motility and hyperglycemia. Shallow Respirations, Slightly peaked P Wave, Prominent U Wave. *Low Potassium will lead to Alkalosis Causes: GI Loss (vomiting diarrhea, anorexia), excess insulin therapy, NPO, diuretics Tx: POT: Potato, Oranges and Tomato, SLOW K+ infusion with IV Fluids
Hypervolemia Excess Fluid Volume FVE -Fluid shifts to ECF/ ICF space -Decreased urinary output from kidney disease s/s
Signs: Edema, pulmonary congestion (fluid in the lungs), elevated BP, neck veins will show JVD and protruding neck vein. Neurological changes- confusion- becomes priority. Causes weight gain.
Hypercalcemia: High serum calcium >2.3
Signs: Faturgue, lethargy and confusions lead to seizures and coma. Cardiac dysrhythmia and heart block, tachycardia Causes: primarily caused by hyperparathyroidism, breast and lung cancers, prolonged immobilization. *Too much calcium will cause acidosis* Nurse Interventions: start a diet low in calcium, encourage low weight bearing activity, fluids to prevent renal stones, administer calcitonin and saline for severe cases.
Hypermagnesemia: more than 2.3
Signs: Metabolic Alkalosis, Lethargy, Diminished deep tendon reflexes, flushed warm skin, decreases pulse and decreased BP, urine retention Causes: Rare but from OD of antacids/laxatives. Renal failure/chronic kidney disease Nurse Intervention:
Sodium: Hypernatremia Function: major role in maintaining water distribution between ECF and ICF, nerve and muscle conduction and regulation of acid base balance. The kidneys primarily regulate sodium by ADH. Aldosterone also regulates sodium by allowing reabsorption from the kidney.
Signs: high thirst, agitation, restlessness, seizuress, coma. Confusion and restless are affecting your brain and TAKE PRIORITY in diagnosis. Causes: Inadequate water intake, sodium excess, Hypertonic tube feedings, patients unable to detect thirst, Hyperaldosteronism *(reabsorbing too much sodium) Nurse Interventions: Immediate intervention needs to take place. D not leave the told lady that begins to have agitation, confusion and neuro changes. Catch this quick and intervene. Do not want Aspiration!
Hypomagnesemia: <1.3
Signs: symptomatic and deep tendon reflexes and cramps but the priority is seizures and cardiac dysrhythmias, Increased pulse and BP, urinary output Causes: NG suctioning, GI loss, Malnutrition, alcoholism, resembles hypocalcemia. Nurse Intervention: Oral supplements, IV mag if severe, Monitor vitals and cardia response.
Sodium: Hyponatremia Function: major role in maintaining water distribution between ECF and ICF, nerve and muscle conduction and regulation of acid base balance. The kidneys primarily regulate sodium by ADH. Aldosterone also regulates sodium by allowing reabsorption from the kidney.
Signs:Mild- headache, irritability, diff concentrating Severe- confusion, seizures and coma Causes: GI loss (vomiting, diarrhea, NG suctioning), hypotonic solutions, SIADH (abnormal retention of water) Nursing Interventions: replace fluids with isotonic fluid with sodium, withhold diertrics and encourage oral intake. Monitor risk for head injury and neuro changes. IF serious, hypertonic solution may be given 3% NS.
Orem's Theory: Dependent Care Agency
The ability of an individual to meet the needs for the person show can meet their own needs
Hypocalcemia: less than 8.4
Trousseus and Chvostek's (Chin twitch when tapped face) Signs. Signs: Laryngeal Stridor (Airways come first and is a priority), tingling mouth and extremities, cardiac dysrhythmias. Prolonged QT interval Causes: PTH deficiency, Thyroidectomy (removal of thyroid gland), Radiation, Chronic alcoholism, Loop Diuretics, Elevated Phosphorus, Vitamin D deficiency, Renal insufficiency. Nurse Intervention: Asses tetany and seizure precaution, check and monitor serum levels, increase calcium in diet, Vit D supplements, monitor surgery patients, IV calcium gluconate, Paper bag to treat alkalosis symptoms.
3. The nurse researcher provides participants with informed consent so that what ethical principle is upheld? a. Respect for persons b. Beneficence c. Justice d. Ethics
a
2. Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient e. Music preference of the patient
a b c d
8. The nurse is analyzing the intake and output record for a patient being treated for dehydration. The patient weighs 176 lbs. and had a 24-hour intake of 250 mL and urine output of 500 mL. Based on this data, which conclusion by the nurse is most appropriate? A. Treatment is not effective, should include intravenous fluids. B. Treatment needs to include a diuretic. C. Treatment is effective. D. Treatment has been effective and should end.
a. Rational: Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Patients whose intake substantially exceeds output are at risk for fluid volume excess; however, the patient is dehydrated. The extra fluid intake is being used to improve body fluid balance
10.A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the patient's chart. The nurse is performing which specific nursing function? a. Diagnosis b. Assessment c. Education d. Advocacy
b
2. The nurse decides to access a systematic review database to determine evidence-based practice related to the patient's treatment plan for a diagnosis of otitis media (i.e., ear infection). What database can provide that type of resource? a. Cumulative Index of Nursing and Allied Health Literature (CINAHL) b. Cochrane c. PubMed d. MD Consult
b
2. Which action taken by a nurse would reflect application of an appropriate generalization in a patient care setting? a. Assigning same-gender nurses to all patients admitted to the unit b. Sharing with unlicensed assistive personnel that Muslim patients typically do not eat pork c. Telling the radiology technician that every Latino family is late for appointments d. Assuming that Asians share financial responsibility for medical bills
b.
4. A patient presents with the following electrolyte levels of Sodium 160 mEq/L, TOTAL Calcium of 13 mEq/L, and Potassium of 2.5 mEq/L. The nurse interprets that this patient has: A. Hypernatremia, hypocalcemia and hyperkalemia B. Hypernatremia, hypercalcemia and hypokalemia C. Hyponatremia, hypocalcemia, and hyperkalemia D. Hyponatremia, hypercalcemia and hyperkalemia
b.
5. How best can a nurse evaluate goal attainment for a patient with a culturally diverse background? a. Assume that gender roles will be a challenge to overcome regardless of the patient's ethnicity. b. Base decisions on feedback from the patient and the nurse's professional judgment. c. Collaborate with future community care providers to determine patient strengths. d. Seek input from members of the patient's support system to avoid biased patient responses.
b.
8. If a patient's primary language differs from that of the health care professionals providing care, which action is most appropriate for the nurse to take? a. Use colorful pictures, white boards, and gestures to communicate all important information. b. Recognize that continuous affirmative answers by the patient require verification of understanding. c. Arrange for a professional language translator to sit with the patient throughout the hospitalization. d. Decrease interaction with the patient and family to avoid making them uncomfortable for not understanding.
b.
8. The nurse expects the long-term treatment of a patient with hyperphosphatemia secondary to renal failure will include a. Fluid restriction b. Calcium supplements c. Magnesium supplements d. Increased dairy supplements
b.
10. After reading various research articles and reviews on a subject, the nurse designs a practice change based on the literature. What stage of evidence-based practice is this? a. Maintaining the change b. Implementing the change c. Evaluating and critically appraising d. Synthesizing the evidence and developing a plan
d
10. The patient has PH 7.52, C02 30 and HC03 24 a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
d
1. During postoperative care of a 76 year old patient, the nurse monitors Input and output carefully- knowing that the patient is at risk for fluid and electrolytes imbalances primarily because of: a. Older adults have an impaired thirst mechanism and need reminding to drink fluids b. Water accounts for a greater percentage of body weight in older adults than in younger adults c. Older adults are more lily to lose fluids than younger adults during surgical procedures d. Small fluid losses are significant because body fluids account for 45% to 50% of body weight in older adults.
d.
1. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient's input. The patient states, "How is this different from what the doctor does?" Which response would be most appropriate for the nurse to make? A. "The role of the nurse is to administer medications and other treatments prescribed by your doctor." B. "The nurse's job is to help the doctor by collecting information and communicating any problems that occur." C. "Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor." D. "In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.
d.
10. The nurse is caring for a patient experiencing fluid volume deficit determines that the priority is which action? A. Provide education on the importance of increasing fluid intake. B. Start an IV per physician orders. C. Delegate foley catheter insertion to the UC. D. Assess patient intake and output for the last 24 hours.
d.
10. What is the best method for the nurse to ensure that a Croatian patient's nutritional needs are met during hospitalization? a. Preorder a diet that is consistent with the typical Croatian patient's dietary preferences. b. Ask a Croatian coworker for ideas on what would be best to order for the patient's meals. c. Request that a variety of dietary entrees be provided to the patient to provide options. d. Check with the patient on admission to determine dietary limitations and preferences.
d.
12. The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention is: a. Apply warm compress to site b. Attempt to force 10ml of NS c. Place the patient on left side with head down d. Instruct patient to change positions and raise arm, and cough.
d.
7.A patient is being cared for in the hospital with wound care dressing changes. The nurse completes a dry sterile dressing change every 8 hours. The nurse is using which component of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation
d.
Health Disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups. These disparities are often exacerbated by: a. Bias b. Stereotyping c. Prejudice d. All of the above
d.
