As a patient ages, the nursing plan of care

Needs to be individualized to the patient’s unique needs.

All of the following are signs of a wound infection EXCEPT for.....

Itchiness, bleeding, granulation tissue

absence of insulin, Occurs in young people

Signs and symptoms of Right sided heart failure are

JVD , edema or ascites , increase HR

The nurse is aware that the purpose of theraputic communication is to

Focus on the pt and the pt needs to facilitate interaction

Why are patients in atrial fibrillation often prescribed warfarin?

It prevents clot formation in the atria

A nurse has a client with thrombocytopenia. A nurse should:

Avoid an unnecessary venipuncture

Decreased Pedal pulses, cool legs, loss of hair/legs, thick toenails, intermittent claudiction

Peripheral Artery Disease (PAD)

You are the RN caring for a heart failure patient complaining of worsening shortness of breath. What do you do 1st?

Assist the patient into high-Fowler's position

Why do we need to titrate oxygen to Sp02 in COPD patients?

To avoid C02 retention & potential subsequent apnoea.

What are the warning signs of cancer ?

"CAUTION", Change in bowel bladder habits, Unusual bleeding or discharge

What are symptoms of heart failure that you might see in a patient? Select all that apply.

Nausea/Loss of Appetite, edema, lung crackles

Which one is NOT a way to prevent Pressure Ulcers?

Massage areas that have started to become red to relive

Situation, Background, Assessment, recommendation

What are sign and symptoms of a stroke?

Slurred Speech, Extremity weakness, Facial Droop, Sudden Severe headache

Which statement demonstrates the RN's understanding of enteral feedings?

The HOB should be kept at 30 degrees or higher.

What can be done to help manage congestive heart failure? (Select All That Apply)

Stop smoking, Keep a healthy weight, Limit salt and fat in your diet

What causes Pressure Ulcers?

Frictions between around the bone and skin

Pain assessment can include:

PQRST, Faces, scale, self report

Stress incontinence is

urine leaks when you laugh, cough or excercise

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NUR 350 Fundamentals & Chronic

87 termsStudBud Administration282 plays

Fall semester 2019

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Questions 87

Answers

1
Neutropenia
Providing optimal nutrition
Washing hands meticulously
Restricting the presence of live flowers and plants
Initiating broad spectrum antibiotic use
2
As a patient ages, the nursing plan of care
Should be standardized; all older pts have the same needs.
Should be based on chronological age alone.
Focuses on the disabilities that all aging persons face.
Needs to be individualized to the patient’s unique needs.
3
All of the following are signs of a wound infection EXCEPT for.....
Redness, swelling, heat
Pus, pain, fever
Itchiness, bleeding, granulation tissue
Odor, incresed WBC on CBC
4
Type I diabetes
absence of insulin
also occurs in people over 40.
insulin production is normal
Occurs in young people
5
What is the major symptom of Peripheral Arterial Disease?
drop in blood pressure
swelling in the upper extremities
intermittent claudication
shortness of breath
6
Which one is not a sign of dehydration?
Dry mouth
Dizziness
Thirst
Sweating
7
Which is not a symptom of osteoarthritis
Problems moving joints
Migraines
Pain
Stiffness
8
Which wave indicates atrial depolarization? Why?
P wave
S wave
Q wave
U wave
9
The evaluation step of the nursing process involves
Setting goals and creating a care plan
Deciding if goals were met
Putting the care plan into action
Identifying the health problems and resident needs
10
People with urinary incontinence should
restrict salt intake
increase salt intake
restrict fluid intake
drink regular fluids
11
Deep Venous Thrombosis (DVT) leads to all of the following except:
Hypotension
Increased pressure in the vein behind the clot causing edema
Obstruction of venous flow causing increased venous pressure
Risk of pulmonary embolism
12
Which of the following is NOT a manifestion of anemia?
bradycardia
paleness
fatigue
dyspnea
13
Signs and symptoms of Right sided heart failure are
anasarca , decreased HR , increased wt
murmur, no edema or ascites, hepatomegaly
JVD , edema or ascites , increase HR
14
Insulin should be injected into:
Fatty tissue
Given orally
Bone
Muscle
15
Signs/Symptoms of Hypoglycemia
low blood pressure
hair loss, cramping
Muscle weakness, pot belly
Cold, clammy, needs some candy
16
The nurse is aware that the purpose of theraputic communication is to
Gather aas much info as possible about the patient's problem
Focus on the pt and the pt needs to facilitate interaction
Direct the patient to communicate about his deepest concerns
Gain specific medical information and history of illnesss
17
Thrombocytopenia places the patient at risk for_________?
bleeding
infection
inflammation
anemia
18
Why are patients in atrial fibrillation often prescribed warfarin?
Most clients with atrial fibrillation don't receive warfarin
It prevents lethal arythmias
It prevents clot formation in the atria
Warfarin controls heart rate
19
Why is this so important to patient safety?
prevents spread of infection
keeps hands smelling good
keeps hand looking clean
prevents hands from drying out
20
A nurse has a client with thrombocytopenia. A nurse should:
Allow no fresh plants into patient's room.
Put the client on isolation percautions
Avoid an unnecessary venipuncture
Monitor the patient's cardiac rhythm for murmurs
21
How would you diagnose someone with anemia?
CBC
ANA
BMP
H&H
22
What tool is utilized to identify a patient at risk for falls?
Incontinence checks
Turn and Positions
Morse Scale
Braden Scale
23
A primary cause of confusion in an older adult can be due to
Their age
Multiple caregivers
Urinary tract infection
Bronchitis
24
Which of the following is NOT a sign of congestive heart failure?
Hypotension
Urticaria
Tachycardia
Pulmonary edema
25
Which insulin is long-acting?
Humulin
NPH
Glargine
Lispro
26
Atrial fibrillation is;
rapid & regular heart beat
slow & regular heart beat
slow & irregular heart beat
rapid & irregular heart beat
27
Decreased Pedal pulses, cool legs, loss of hair/legs, thick toenails, intermittent claudiction
Deep Vein Thrombosis
Peripheral Artery Disease (PAD)
Raynaud's syndrome
Chronic Venous Insufficiency (CVI)
28
A resident has clostridium difficile, to prevent it from spreading what are appropriate actions
Wash hands with soap and water on entering and exiting room
Use alcohol foam to wash hands when providing care to client
A and B
Place patient in contract isolation
29
drug class for enoxaprin
anticoagulant
calcium channel blocker
cardio-combo
alpha/beta blokcer
30
You are the RN caring for a heart failure patient complaining of worsening shortness of breath. What do you do 1st?
Obtain the patient's weight
Auscultate lung sounds
Check oxygen saturation with pulse oximeter
Assist the patient into high-Fowler's position
31
Why do we need to titrate oxygen to Sp02 in COPD patients?
Sp02 is always accurate and we should rely on it 100%.
They usually don't need much oxygen anyway.
To avoid C02 retention & potential subsequent apnoea.
Because we should always titrate our medications.
32
What are the warning signs of cancer ?
"CAUTION"
Change in bowel bladder habits
"LIFE"
Unusual bleeding or discharge
33
Nursing assessment of the skin includes
all of the above
any recent skin color changes
recent changes in moles
recent skin lesions or rashes
34
What are symptoms of heart failure that you might see in a patient? Select all that apply.
Nausea/Loss of Appetite, edema, lung crackles
Slurred speech
Diarrhea
Fever
35
The lower a colostomy is placed
the more solid the output
the more liquid the output
the more fluid the output
the more problems with the output
36
What is the culprit for painful ambulation in the patient with Intermittent Claudication?
Venous Insufficiency
Insufficient Blood Supply
Arterial Insufficiency
Varicosed Veins
37
Which one is NOT a way to prevent Pressure Ulcers?
Keeping linens clean and dry
Use padded heel protectors for the feet
Massage areas that have started to become red to relive
Change positions frequently
38
Opiod medications
causes diarrhea
give pain relief, increased breathing
increases breathing rate
cause respiratory depression
39
NEVER mix with other insulins
Isophone
Regular
Glargine
Lispro
40
What does SBAR mean?
Situation, Background, Assessment, recommendation
Situation, Background, Recommendation, Assessment
Situation, Assessment, background, Recommendation
Situation, Assessment, Recommendation, Background
41
What are sign and symptoms of a stroke?
Slurred Speech
Extremity weakness
Facial Droop
Sudden Severe headache
42
Which statement demonstrates the RN's understanding of enteral feedings?
The HOB should be kept at 30 degrees or higher.
Tubing requires a filter.
Residuals should be thrown away.
I flush the NGT with 100 mL of water q4 hours.
43
What can be done to help manage congestive heart failure? (Select All That Apply)
Stop smoking
Keep a healthy weight
Begin training for a marathon
Limit salt and fat in your diet
44
What causes Pressure Ulcers?
Derp
A fungal infection
Frictions between around the bone and skin
Friction between the skin and skin
45
A patient with COPD has target oxygen saturations of...
90%-94%
88% - 92%
88% - 96%
86% - 88%
46
Nursing care for neutropenia may include all except:
Notify the provider if there is a fever.
Maximize exposure to illness.
Wearing a mask when in public.
Have the patient use a soft bristled toothbrush.
47
Which of the following is not a symptom of osteoarthritis?
aching
stridor
limited ROM
stiffness
48
Pain assessment can include:
The Blyman-Scott pain assessment
ADPIE, spirometry, obs, patient centred care
PQRST, Faces, scale, self report
AVPU, pinch test, scale, Nursing assessment
49
Name rhythm in image.
Ventricular fibrillation
Sinus rhythm with a first degree block
Sinus rhythm with a bundle branch block
Atrial fibrillation
50
Stress incontinence is
urine leaks when the bladder is hypersensitive
urine leaks when the bladder overflows
urine leaks when you laugh, cough or excercise
urine leaks when you can't get to a toilet urgently
51
How long should a person remain upright after g-tube feedings?
No more than 10-15 minutes
At least 60-90 minutes, preferably 4 hours
At least 30-60 minutes
Until they fall over and start saying weird things.
52
Since Parkinson's Disease patients often experience difficulty chewing and swallowing, which diet is recommended?
Soft diet with mainly thick liquid
Keto diet
Paleo diet
Liquid calories diet
53
Intermittent clarification is a classic sign of:
Arterial embolism
Hypertension
PVD
DVT
54
In a teaching plan for a patient with peripheral arterial disease, which will you include?
No walking
Elevate Legs
Keep the environment warm, wear socks
Wear Ted stockings
55
which of the following would be a good nursing diagnosis?
impaired mobility related to incisional pain
Risk for falls related to the stupid wires on the floor
anxiety related to CT of the brain
impaired gas exchange related to COPD
56
You’re assessing the stoma of a patient with a healthy well-healed colostomy. You expect to see
pale, pink and moist
dry and black
dark or purple colored
red and moist
57
What is Dehydration?
When your tongue is dry
When fluid gained is greater than fluid lost
When fluid loss is greater than fluid gained
The body has lost over 50% of its water
58
What are some symptoms of anemia?
Nausea and skin/eye yellowing
Fatigue, shortness of breath, and headaches
There are no visible symptoms of anemia
Fainting, heavy loss of blood, and irregular heatbeat
59
Which assessment finding might indicate that a patient is experiencing pain?
Heart rate 80 beats/min
Blood pressure 160/82 mm Hg
Oxygen saturation 95%
Temperature 100.6°F
60
To prevent medication errors, I must:
Ask questions if unsure
Carefully read the label
All of the above
Triple check the order, medication, and patient ID
61
Best practice pain assessment includes an objective score & PQRST. To assess for "P" (provokes)
ALL of these
Ask what were you doing when the pain started
Ask if anything makes it better or worse
Ask does anything change the pain?(deep breath, cough, move)
62
A patient who smokes and has COPD complains of shortness of breath. The nurse should
use caution when administering O2
give him a paper bag to breathe into
give him CO2
give him O2
63
Pain assessment consists of?
Doing a set of vital signs.
Assessing the wound.
Asking the patient where it is painful?
Intensity, Quality, location, Duration, Aggravators?
64
Health teaching pt. on opiods
Avoid alcohol & CNS depressants
SE: sedn, N/v/const/urin retention/itchy/decr. R, BP
all of above
Potential dependance
65
Which nursing diagnosis is of high priority
Self-care deficit
Risk for aspiration
Functional urinary incontinence
Impaired physical mobility
66
10. Acute confusion (Delirium) in elderly patients is commonly caused by
pneumonia
ageing
neurological degeneration
urinary incontinence
67
The most common concentration of insulin
U40 insulin
U100 insulin
U35 insulin
U80 insulin
68
What factors can cause a stroke
Anorexia
Smoking
Eating too much sugar
Obesity
69
what are the stages of grief
alarm, anger, depression, acceptance
denial, anger, bargaining, depression, acceptance
denial, bargaining, depression, anger
anger, denial, acceptance
70
When mixing two types of insulins into one syringe what is the correct order of drawing up?
Draw up the NPH insulin first, then regular
Draw up regular first, then NPH
Cloudy before clear
Drawing up two insulins into one syringe should not be done
71
What do you do if you notice someone is experiencing signs and symptoms of a stroke in hospital
call primary nurse
call 911
ask your supervisor
call a code s
72
Which of the following can occur as a result of polypharmacy in geriatric patients?
Decreased medication costs
Increased adverse effects
Decreased drug interactions
Decreased health care costs
73
Important interventions to avoid pressure ulcers are
Prompt Incontinence care and keeping the patient dry
All of the above
Nutrition & Hydration and education
Early and Ongoing Head to toe assessment and frequent assess
74
Which choice depicts the way a nursing diagnoses should be written?
Pain r/t patient stating "I have pain" aeb surgical wound
None are correct
Pain aeb patient stating "I have pain" r/t surgical wound
Pain r/t surgical wound aeb patient stating "I have pain"
75
ur caring for a postop pt with a new colostomy. Which would be a priority to report (stoma)
dusky colour
slight bleeding
round shape
mucous drainage
76
S & S of left sided heart failure
Peripheral, gastric, perineal edema
Coccyx and periorbital edema
Liver enlargement and JVD
Crackles in the lungs and SOB
77
A RN prioritizing nursing diagnoses would select which nursing diagnosis as highest priority?
Risk for imbalanced body temperature
Impaired adjustment
Ineffective airway clearance
Acute pain
78
Insulin lispro (humalog) action?
Rapid
Long
Intermediate
Short
79
Which patient with COPD would the nurse assess first?
A 74-year-old with a chronic cough and thick, tenacious secretions
A 46-year-old with a 30-pack-year history of smoking
A 52-year-old in a tripod position using accessory muscles to breathe
A 68-year-old who has dependent edema and clubbed fingers
80
What do you do if you notice someone with stroke symptoms out of hospital?
call ghostbusters
call code s
phone a friend
call 911
81
When mixing NPH and Regular insulins, the nurse draws up:
NPH and Regular insulin cannot be mixed together
The Regular insulin first
The order of draw does not matter
The NPH insulin first
82
A Stroke is caused when......
there is a blockage in the coronary artery to the brain.
there is a ischaemic or haemorrhagic reaction in the brain.
the brain is starved of blood and therefore oxygen.
there is either a blockage or burst in the cerebral artery.
83
what is Parkinson's disease?
a sleeping disorder
a progressive motor disease
an idiopathic neurodegenerative disease
an idiapathic neurodegenerative disease
84
Diuretics work to lower blood pressure by
promoting vasodilation
increasing potassium retention
decreasing blood volume
inhibiting the RAAS
85
What Precautions are appropriate for Neutropenia?
Contact
Droplet
Reverse Isolation
Isolation
86
Which statement about incontinence is incorrect?
Affects a person emotionally
Skin care is needed
A catheter is needed
Dry garments are needed
87
How is insulin typically measured?
milliliters
cubic centimeters
grams
units

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