Which of the follow is an example of fidelity?

Returning to explain results after stating your intent

What statement by a client with Paget's Dz indicates good understanding of causative factors?

I may have a genetic predisposition

What are age related changes in the immune system*?

Failure of immune system to differ self from non-self, Altered nutritional intake, Increased hematuria

Patient begins to hyperventilate w/ news of breast cancer. Complains of tingling fingers/lips

Have the patient breath into a paper bag

Why would a senile dementia pt be incontinent of urine*?

Mental inability of voluntary control, Loss of sphincter control

Strategies a nurse can teach a patient to help reduce symptoms of fibromyalgia

Establish a regular sleep pattern

During pre-op client states takes NSAID regularly. What question is most important to ask?

When was the last time you took your NSAID?

What statement by pt indicates need for additional teaching for pre-op patient

I will go to the bathroom right after I take my pre-op meds

Things to do when using a piggyback IV

check compatibility of meds, flush before and after with incompatibility, change flow rate to administer antibiotic

Pt being d/c after spleenectomy. What info on immune fxn in education plan?

Basic infection control techniques

Post abd. Sx pt going home. RN knows teaching effective if pt does which of the following*

Completes regiment of antibiotics, Performs the dressing change as prescribed, Restates signs and symptoms of infection

Priority Nsg action in pt with urinary retention who has an indwelling catheter

Provide catheter care every shift

What should a patient expect after Sx for ulcerative colitis

Placement of stoma with collection bag attached at all times

What indicates a positive Mantoux test?

patient has been infected and has a T-cell response

What are the risks for a baby who had recent thymectomy*?

increased inflammation, infections, increased age related chronic disease, Autoimmune response

Which instruction by RN help client/family meet expected outcome for functional incontinence

Buy pants with elastic waistbands that are easy to pull down

Primary instructions for patients with difficulty passing stool

Increase fluid and fiber intake

What effects does the aging process have on thermoregulation*?

Average body temp is 96.8, More likely to develop adverse effects from extreme temps, Loss of fat, lower body temp, feeling cold

The nurse must consider this when encouraging a fitness plan for older adults

Activities should incorporate improving balance

What is the reason for culturing the exudate of a wound

To determine the type of pathogen causing the infection

Immunosupression patient teaching for new kidney transplant

meds are used to decrease chance of attack on new kidney

Appropriate interventions for pt with Hypovolemia*

Encourage fluid intake, I&O daily, Monitor electrolytes

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Nursing 1 Final Review

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Answers

1
Which of the follow is an example of fidelity?
Holding the hand of a scared teen until they fall asleep
Report abuse witnessed by a CNA to a patient
Respecting pt wish to cancel Sx to get a 2nd opionion
Returning to explain results after stating your intent
2
RN suspects a pt who abuses which medication is at risk for metabolic alkalosis
Senna
Tums
Milk of magnesia
Alchohol
3
Pt education when given Rx for trimethoprim-suflamethoxazole (Bactrim)
Do not take with antacids
Decrease fluid intake while taking medication
Avoid tyramine rich foods
Stop taking when symptoms improve
4
What statement by a client with Paget's Dz indicates good understanding of causative factors?
I bet I got this from a blood transfusion
I may have a genetic predisposition
This is a bacteria that can be cure with antibiotics
I must have contracted this when I traveled overseas
5
What are age related changes in the immune system*?
Failure of immune system to differ self from non-self
Increased response to immunogens
Altered nutritional intake
Increased hematuria
6
Patient begins to hyperventilate w/ news of breast cancer. Complains of tingling fingers/lips
Tell the patient to calm down, it could be worse
Have the patient breath into a paper bag
Sing to the patient to help her relax
Have the patient jog in place
7
Which if the following assessments with the complete first for a pt that had general anesthesia
Circulation
Apical pulse
Ascultate bowel
Patent airway
8
Why would a senile dementia pt be incontinent of urine*?
Mental inability of voluntary control
It's a normal part of the aging process
Forgets where they are headed when going to the restroom
Loss of sphincter control
9
Strategies a nurse can teach a patient to help reduce symptoms of fibromyalgia
Take NSAIDs round the clock
Eat a low carb, high protein diet
combine alcohol with opiates to help forget you have pain
Establish a regular sleep pattern
10
A patient who smokes will receive what Rx post-op?
Rx for nicorette after they are discharged
Rx to reduce nicotine cravings
Rx to decrease alcohol cravings
Rx to reduce anxiety
11
During pre-op client states takes NSAID regularly. What question is most important to ask?
Which brand of NSAID do you take?
When was the last time you took your NSAID?
Do you buy those over the counter or are they prescribed?
Tell me why you take NSAIDs?
12
What statement by pt indicates need for additional teaching for pre-op patient
I will leave my valuable jewelry at home
I will go to the bathroom right after I take my pre-op meds
I will not eat anything for 6-8 hours before my surgery
I will remove my nail polish before arriving
13
Things to do when using a piggyback IV
check compatibility of meds
flush before and after with incompatibility
change flow rate to administer antibiotic
Administer at same flow rate as fluid
14
Dc pulse, RR, & BP; shivering, pale, cool, shiny skin, dc urine output, disoriented, dizzy ...
Hypothermia
Hypocalcemia
Hyperthermia
Hypercalcemia
15
Pt being d/c after spleenectomy. What info on immune fxn in education plan?
Proper diet main impact
Immune is what it is, can't be altered
Basic infection control techniques
Antibiotics serve as shield of protection
16
Principle site for regulation of fluid and electrolyte balance
hepatic
endocrine
renal
cardiac
17
Post abd. Sx pt going home. RN knows teaching effective if pt does which of the following*
Completes regiment of antibiotics
States she will remain on bedrest until her doctor appt.
Performs the dressing change as prescribed
Restates signs and symptoms of infection
18
Priority Nsg action in pt with urinary retention who has an indwelling catheter
Monitor I & O
Provide catheter care every shift
Irrigate the catheter
Replace catheter
19
RN primary concern re: psychological adaptation for a toddler post-op
depression
separation from security blanket
separation from parents
anxiety
20
What are the signs of inflammatory response?
Edema, heat, erythema, pain
Pain, turgor, cyanosis, heat
dry, cool, diaphoretic, pain
BP, RR, Pulse, Temp
21
Exposure to what molecules illicit an immune response?
pathogens
Immunogens
parasites
mold spores
22
What is an appropriate nursing goal for a 2 year old after tonsilectomy?
increased appetite
decreased level of pain
decreased separation anxiety
increased social interaction with nurse
23
Pt with NURSING Dx excess fluid volume, nurse alter to which sign or symptom?
Migraines
Hypertension
Fever
Hypotension
24
physiological changes assoc. w/ aging place older adults at risk for which nursing Dx?
Risk for being placed in a home by ungrateful children
Risk for cognitive impairment
Risk for falls
Risk for infection
25
High caffeine intake can increase the risk of which condition?
Irritable bowel syndrome
Osteomyelitis
Osteoporosis
Osteomalcia
26
What should a patient expect after Sx for ulcerative colitis
Going home the same day
Placement of stoma with collection bag attached at all times
Staying in bed for 48 hours following surgery
Pain and only pain
27
Positive sign of response to injury and host defense
thermoregulation
fever
rash
malaise
28
What manifestation nurse expects to find during physical assessment of a pt w/ osteoarthritis?
strong bones
calculi
Apathy
Atrophy
29
Pressure ulcers form primarily as a result of
Being too thin
Improperly turning a patient
too much pressure
Tissue ischemia
30
What is the inability to stop urine flow long enough to get to the toilet?
Stress incontinence
Nina-waits-to-go syndrome
Urge incontinence
functional incontinence
31
How long should a nurse wait after pt drinking, eating, or smoking to obtain a temperature?
20-30 minutes
No need to wait
10-15 minutes
45-60 minutes
32
What indicates a positive Mantoux test?
IgA increased
patient has been infected and has a T-cell response
fever
hives
33
What are the risks for a baby who had recent thymectomy*?
increased inflammation
infections
increased age related chronic disease
Autoimmune response
34
Which instruction by RN help client/family meet expected outcome for functional incontinence
Have the pt wear depends whenever leaving the house
Remind patient to perform kegel exercises 4 times a day
Restrict fluid intake to minimize restroom needs
Buy pants with elastic waistbands that are easy to pull down
35
What's the #1 goal for Rheumatoid Arthritis?
Increase physical activity
improve fine motor skill function
Find a cure
Control inflammation
36
What diet information is important to collect for a pt after abdominal surgery
Monitor food intake
Monitor if they prefer pudding or jello
Monitor fluid intake
Monitor bowel sounds
37
Primary instructions for patients with difficulty passing stool
Increase fluid and fiber intake
Increase exercise
Administer a stool softener
Drink Dunkin Donuts coffee
38
What effects does the aging process have on thermoregulation*?
Average body temp is 96.8
More likely to develop adverse effects from extreme temps
Feel warmer than those of younger ages
Loss of fat, lower body temp, feeling cold
39
Pt presents with skeletal pain and tenderness w/o Hx of injury and has a waddling gait
hypokyphosis
osteomalacia
osteoporosis
osteoarthritis
40
causes fluids to move out of vessels...0.45%NS, 0.25%NS...caution for cellular edema
Hypotonic
Isotonic
Hypertonic
41
treats intravascular dehydration...e.g. 0.9% NS, LR D5W
Hypertonic
Hypotonic
Isontonic
42
Which is part of the primary prevention for systemic disorders
Transfusions of globulins
Vaccinations
Exposure to virus
cell mediated activity
43
Which is a description of Kussmal respirations
shallow and rapid
gasping for air
deep and rapid
Normal breathing with gaps in respirations
44
The nurse must consider this when encouraging a fitness plan for older adults
Walk a minimum of 5 miles a day
Orange theory is a good option to promote
Activities should incorporate improving balance
Whether they wear velcro or laced shoes
45
What is the reason for culturing the exudate of a wound
To determine the source of the infection
To make the patient have to stay in the hosital longer
Because the lab needs practice identifying pathogens
To determine the type of pathogen causing the infection
46
When applying cold therapy, the cold should be applied for how long a period of time?
20 minutes at a time
30 minutes at a time
45 minutes at a time
15 minutes at a time
47
Immunosupression patient teaching for new kidney transplant
meds are used to decrease chance of attack on new kidney
Alteration to Ig status common
May experience personality changes with new organ
48
What is the primary prevention tool for Colon Cancer Screening?
Digital rectal exam
Colonoscopy
Occult Blood testing
Genetic screening for Lynch syndrome
49
Which age group do nurses make car crashes a priority teaching topic when it comes to safety
13-19
41-65
65 and older
20-40
50
What increases chance of allergy to IVP (intravenous pyelogram)
Taking blood thinners
Test anxiety
Allergy to tetracyclines
Allergy to shellfish
51
Appropriate interventions for pt with Hypovolemia*
Encourage fluid intake
I&O daily
Monitor electrolytes
Push potassium rich foods
52
Sodium 142, K 2.5, Ca 8.5, chloride 98. Electrolyte disturbance?
Hypokalemia
Hyperkalemia
Hypocalcemia
Hypernatremia
53
What does serous exudate leaking from a wound indicate?
It contains materials from the initial inflammation response
The infection is spreading and needs to be irrigated
The bandage isn't placed correctly
The wound is healing
54
Medications given for a fever*
Ibuprofen
acetaminophen
antiemetic
Aspirin
55
A client on prolonged bed rest, nurse observing for signs assoc. w/ immobility. Nurse alert to*
positive mental attitude
decreased peristalsis
skin breakdown
muscle weakness
56
Inspection - Auscultation - Percussion - Palpation when assessing what part of the body?
Kidneys
Heart
Abdomen
Lungs
57
What is the nursing care goal for a client who is at risk for injury?
The patient will acknowledge their risk for injury
The patient will identify factors increasing injury risk
The patient will do their best to avoid injury
The patient will remain free from injury
58
Dressing to use for deep wound with tunneling, seroussanguenous fluid & 100% red-beefy tissue
Optifoam dressing
Wet to dry dressing
Hydrogel dressing
Alginate dressing
59
In surgery, when will scripts be given on an "on-call basis"?
Meds to be given when the RN feels the patient needs them
Meds to be given when the family member asks for them
Meds to be given when the patient requests them
Meds to be given when OR staff notifies RN to do so
60
for intravascular dehydration with cellular fluid overload...e.g. D5LR, D51/2NS, D5NS
Hypertonic
Isontonic
Hypotonic
61
How should the nurse evaluate the effectiveness of home care teaching on wound care*
Document the caregiver's statement "OK, we'll manage"
Have the pt or caregiver demonstrate the procedure
Have the pt or caregiver verbalize the procedure
Have the pr read the written instructions provided outloud
62
What is the cancer mnemonic?
C H E M O
F A T A L
C A N C E R
C A U T I O N
63
When should the nurse initiate the education/discharge plan for a patient?
When the patient states they want to go home
Upon Admission
When the doctor tells you to
After surgery is successful
64
Client has a serum sodium level of 129. Which solution to adminster
Lactated ringers
D2.5w
Normal Saline
D10w
65
What are the signs of IV site infiltration
swollen, pain, cool, pale
swollen, pain, warm, blanchable
swollen, no pain, weeping, red
swollen, pain, warm, red
66
Appropriate method to assess pain in an adolescent
Numbered pain scale
Ask the parent(s)
Wong-Baker face scale
Watch their reaction as you trigger pain response
67
(Do I really need to ask this?!?) Abnormal urine output is ...
Less than 1500mL/day
Around 30mL/hr
Below 30mL/hr
Above 30mL/hr
68
What intervention should be encouraged for respiratory function of an immobile client
Breath into a paper bag
deep breathing and coughing
remain supine as much as possible to keep lungs expanded
Use an inhaler to improve respiratory function
69
Pt is CAOx3 and wants off vent. RN SUPPORTS decision, stays to SUPPORT him. Moral principle?
Veracity
Beneficience
Fidelity
Autonomy
70
What is the primary advantage to using conscious (minimal) sedation?
The patient can tell you if something is going wrong
It's more cost effective than general anesthesia
Respiratory support is not needed
The patient can drive themselves home
71
Which client at greatest risk for compromised immunity
Client who works in a daycare setting
Client who eats a healthy diet and exercises
Client who just had surgery
Client who travels extensively for work
72
Pt with poor healing infected leg ulcers. Why is patient's nutritional history important?
To meet his dietary needs while admitted to hospital
poor nutrition negatively affect healing & infection control
good nutrition rules out weakened immune system
Food is always a good discussion topic during orientation
73
Convulsions, flushed skin, tachycardia, tachypnea, and warm to the touch are symptoms of what?
Hyperthermia
Hypernatremia
Hyponatremia
Hypothermia
74
What are nursing interventions for hyperthermia
Limit exposed skin surface
Provide, fluid, rest, and reduce activity, change damp linen
Use of antipyretics and antibiotics
Blood cultures, count, sed rate, and electrolytes
75
What is the device used to prevent atelectasis?
N95 respirator
refridgerator
Incentive spirometer
Atelectater
76
What are the concerns with NSAIDs to treat the patient with arthritis*?
Patient has increased risk of bleeding
Risk of GI toxicity
NSAIDs have addictive properties
They have to be taken for prolonged period of time to work
77
Pt's lab = severe hypokalemia, RN tells MD. Assess shows heart rhythm normal. Next priority?
Administer potassium
Seizure precautions
Increase fluids and change meals to potassium rich foods
fall precautions d/t potential OTHN & weak leg muscles
78
Can person w/ h/o Chicken pox concerned with getting shingles visit a kid with pox outbreak?
Yes, the virus lies dormant and visit will not increase risk
No, the patient is susceptible to developing shingles
79
What is the best response when asked to explain palliative care?
It's a nice way of saying the pt is terminal
Surgery will relieve symptoms but not cure the disease
Its all about pain management at this point
Its the only option at this point
80
What is the RN's first step to determine best practice to prevent pneumonia after heart Sx?
Search for evidence via case studies
Ask the other nurses what works best
have the pt use an incentive spirometer 1 hour after Sx
Keep patient supine for full lung expansion
81
What's the best indicator for fluid status?
Monitoring I&O
electrolyte levels
daily weight
ask the patient if they are thirsty
82
Major problem associated with severe diarrhea in the very young
weight loss
May cause abuse of laxatives in the future
Can't tell you that they are in pain
electrolyte and fluid loss
83
Finds indicative of Systemic manifestations of inflammation*
Discharge
elevated WBCs
Fever
Fatigue
84
Outcome of the post-surgical elderly patient
Depends on severity of illness
Still breathing
Palliative care
Improved cognitive function
85
What is the stage of infection when a person might be contagious?
Prodromal
Incubation
Convalescence
Infection
86
Mom of newborn worried baby will get sick being around others. RN says baby has what immunity
Altered
Active
Compromised
Innate
87
What dietary adjustments should RN recommend to older adult to prevent/manage constipation*?
More fruit and fiber
More lean protein and dairy
Add a multivitamin
Drink more juice and water
88
RN assessed 4 pts at start of shift. which most urgent to report to MD?
Positive Chvostek's sign in pt with acute pancreatitis
Chronic hypertensive pt with c/o headache
Patient is mad that he can't have beer with dinner
Post op with no BM in 2 days
89
Which activities would RN perform post-op to decrease risk of complications*
Monitor vitals on a regular basis
Assess the drainage from the surgical site
Restrict the number of visitors during the first 24 hours
Assist the pt to turn, breath deeply and cough every 2 hours
90
Pt w/ risk of injury r/t decreased vision. The client will benefit MOST from ...
have a friend or family member move in to the home
having a seeing eye dog
sell his house and move to assisted living
become oriented to the position of the furniture and stairs
91
RN assess no bowel sounds w/ occasional splashing sounds over large intestines suggests what?
Diverticulitis
Testanxietyitis
Ulcerative colitis
bowel obstruction
92
RN priority action for pt with reduced immune function?
Use disposable items as much as possible
Place contact precautions on pt's door
Have housekeeping use bleach to clean the room
Wash hands before entering the room
93
RN forgot to admin. a med that causes an adverse incident to the patient. Why is it negligence
Because harm was caused to the patient
Bitch, please. "Forgot"?!? yeah right
She failed to perform a necessary procedure
Battery means it was intentional
94
What type of Immunity is provided via IV administration of IgG?
Passive
Altered
Innate
Active
95
What is the nursing priority for a pt in anaphylactic shock?
Place oxygen on patient
Call MD
Position pt's head to maintain open airway
Administer epinephrine
96
What causes Nociceptive pain*?
broken bone
nerve injury
Burn
cut
97
What helps to prevent acid-base imbalances*?
staying hydrated
Dialysis
place aspirin away from child's reach
take insulin as prescribed
98
What are nursing interventions for hypothermia
Use warm blankets, limit exposed skin surface, warm lavage
Humidify airway
Place the patient in a hot shower
Adjust room temp, monitor pt temp
99
Pt headed to knee Sx states "Dr. didn't mark my knee". What is the priority action?
Stop and call the surgeon to mark site before moving to OR
mention it to the surgeon during the timeout
Tell the patient to tell the anesthesiologist in the OR
Pull out your sharpie and mark the knee the pt states to
100
What supplement should A RN be concerned about a pt taking during a pre-op assessment?
Vitamin D
Vitamin K
Vitamin E
Vitamin A

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