The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. injections; and a 25G needle, for I.M. Interventions: Chapter 01 - Fundamentals of Nursing 9th edition - test bank Fundamentals of Nursing 9th edition - test bank University Rowan College of South Jersey Course Nursing I (NUR 131) 54 Documents Academic year:2017/2018 Uploaded byTimothy Robert Helpful? A patient who develops hives after receiving an antibiotic is exhibiting drug: Which of the following will probably result in a break in sterile technique for respiratory isolation? Interventions: What interventions would you provide to promote adequate nutrition? Please wait while the activity loads. - It is a simple chemical test of a stool sample that involves about five minutes of preparation time. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. Abnormal: 49. or added to a solution and given I.V. - process of moving gases into and out of the lungs The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area. Exam Mode Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. injections; and a 25G needle, for subcutaneous insulin injections. Vaginal instillation of conjugated estrogen - irregular breathing - Clients must consume a diet high in fiber and be adequately hydrated to promote proper bowel elimination, Describe what is included in each step of the nursing process for patients with alterations in urinary and/or bowel elimination (UTI, constipation, etc.). The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove. 10. If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.Question 27The purpose of increasing urine acidity through dietary means is to:AInhibit the growth of microorganisms BChange the urines concentrationCChange the urines colorDDecrease burning sensationsQuestion 27 Explanation: Microorganisms usually do not grow in an acidic environment.Question 28The nurse explains to a patient that a cough:AIs a protective response to clear the respiratory tract of irritantsBIs induced by the administration of an antitussive drugCCan be inhibited by splinting the abdomen DIs primarily a voluntary actionQuestion 28 Explanation: Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. Attempted Questions Correct - medications that decrease respiratory rate - Allows for clients to gain control of their bowel movement schedule to avoided unexpected accidents and the embarrassment associated with such events The back of the gown is considered clean, the front is contaminated. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. - anxiety Hot water may lead to skin irritation or burns.Question 21When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:AInside of the gown BWaist tie and neck tie at the back of the gownCCuffs of the gownDWaist tie in front of the gownQuestion 21 Explanation: The back of the gown is considered clean, the front is contaminated. ; beets turn stool red. All of the following are common signs and symptoms of phlebitis except: After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of pathogen transmission. These symptoms probably indicate that the patient is experiencing: The consent submitted will only be used for data processing originating from this website. med surg II final. Choose the letter of the correct answer. - the primary goal is to help patients and families achieve the best quality of life Eating, drinking, and medications are allowed before this test, Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist. - let your genuine "caring" self show through All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. A. Attempted Questions Wrong Describe and differentiate between urine collection methods (clean catch vs. indwelling catheter). A 20G needle is usually used for I.M. If you leave this page, your progress will be lost. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. - smoking When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated.Question 39The most appropriate time for the nurse to obtain a sputum specimen for culture is:AAfter aerosol therapyBAfter chest physiotherapy CAfter the patient eats a light breakfastDEarly in the morningQuestion 39 Explanation: Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication.Question 40A natural body defense that plays an active role in preventing infection is:ARapid eye movements BHiccuppingCYawningDBody hairQuestion 40 Explanation: Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Treatment: 20. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Any oral medications In this reaction, antibodies in the recipients plasma combine rapidly with donor RBCs; the cells are hemolyzed in either circulatory or reticuloendothelial system. injection. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.Question 3In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?AAssessmentBEvaluation CPlanningDAnalysisQuestion 3 Explanation: In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.Question 4A patient who develops hives after receiving an antibiotic is exhibiting drug:ASynergismBToleranceCAllergy DIdiosyncrasyQuestion 4 Explanation: A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. Answer Choice(s) Selected - removes stomach contents/secretions and gas from the stomach via wall suction - allow the family to participate in post-mortem care A. Start EXAMPLES: plain cake, fruit juices, tender cuts of beef, creamy nut butters, cooked fruit Soap or detergent to promote emulsification The nurse explains to a patient that a cough: Screen blood donors for antibodies to human immunodeficiency virus (HIV) - pregnancy and lactation Exam Mode None of the other situations would put the patient at risk for contracting an infection; taking broad-spectrum antibiotics might actually reduce the infection risk. Learn how your comment data is processed. What educational setting would be most appropriate for this process? Question 9 Explanation: Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Constipation is characterized by small, hard masses. - headache - trauma This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. - Question content is constantly updated for FREE, so you don't have to worry about outdated questions.This app is a practice test on the fundamentals of nursing that can help you think critically and complete your NCLEX review. Hyperkalemia The most appropriate nursing action would be to: Ongoing Monitoring: In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. - patients accepted into hospice usually have less than 6-12 months to live Application features: Mode "Preparation" Mode "Exam" 46. - agitated All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! The first glove should be picked up by grasping the inside of the cuff. Because of this, limiting the patients intake of oral and I.V. - low levels of protein in urine are normal Enteric precautions prevent the transfer of pathogens via feces. Why are these interventions effective? Immobility impairs bladder elimination, resulting in such disorders as. It cannot be administered subcutaneously or intradermally. The reaction can range from a rash or hives to anaphylactic shock. 8. - decreased LOC; coma The Z-track method is an I.M. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis. IV or an intradermal injection 22G The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove. Hot water may lead to skin irritation or burns. Interpret the features of normal vs. abnormal stool and urine. NPO: A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. fluids may be necessary. Describe the assessment, diagnosis, intervention, and evaluation of clients with alterations in oxygenation (pneumonia, COPD, etc). If you want to check your ability to succeed as a nurse, try to excel in these trivia questions and answers. All of the following statement are true about donning sterile gloves except: 39. An impaired or traumatized blood vessel wall - psychological factors injections; and a 25G needle, for subcutaneous insulin injections.Question 18All of the following are common signs and symptoms of phlebitis except:APain or discomfort at the IV insertion siteBFrank bleeding at the insertion site CA red streak exiting the IV insertion siteDEdema and warmth at the IV insertion siteQuestion 18 Explanation: Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. You have not finished your quiz. Correct The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. When administering the medication, the nurse observes a fine rash on the patients skin. - diet of foods that do not require chewing - perform every 3 days or when the ostomy appliance is leaking or accidentally Administer the medication and notify the physician Effective hand washing requires the use of: Soap or detergent to promote emulsification, A disinfectant to increase surface tension. A clinical nurse specialist must have completed a masters degree in a clinical specialty and be a registered professional nurse. These symptoms probably indicate that the patient is experiencing:AHyperkalemiaBHypokalemiaCDysphagia DAnorexiaQuestion 42 Explanation: Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. CReceived credentials from the Philippine Nurses AssociationDGraduated from an associate degree program and is a registered professional nurseQuestion 23 Explanation: A clinical nurse specialist must have completed a masters degree in a clinical specialty and be a registered professional nurse. - decreased inspired oxygen concentrations (high altitude) Assess a vital signs every 15 minutes for 2 hours Effective skin disinfection before a surgical procedure includes which of the following methods? UPDATED ACTUAL EXAM MATERIALUpdated questions with answers.Actual exam questions and answers for self-study.Our app is a source of accurate exam questions and answers to help you pass your exam easily and quickly! We have made considerable efforts to provide you with the most informative rationale, so be sure to read them. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.Question 48All of the following measures are recommended to prevent pressure ulcers except:AMassaging the reddened are with lotionBAdhering to a schedule for positioning and turningCUsing a water or air mattressDProviding meticulous skin care Question 48 Explanation: Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. Tub bathing might transfer organisms to another body site rather than rinse them away.Question 8The correct method for determining the vastus lateralis site for I.M. - checks appearance, concentration, and content of urine Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. - intended to decrease strain on the digestive system while keeping the body hydrated Final Score on Quiz Acute pulsus paradoxus Ask the patient if he/she has used ear drops before Ketones: D. In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase. She has worked in Medical-Surgical, Telemetry, ICU and the ER. The appropriate needle gauge for intradermal injection is: Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. Urine - dyspnea 3) Young/Middle Adults: Dysphagia means difficulty swallowing. Which of the following blood tests should be performed before a blood transfusion? C. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. A 22G, 1 needle is usually used for adult I.M. Return Chegg Prep has millions of flashcards to help students learn faster with an interactive card flipper and scoring to measure your progress. 4) Older Adults: These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. The physician orders gr 10 of aspirin for a patient. injection. Please wait while the activity loads. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.Question 30The physician orders gr 10 of aspirin for a patient. 40. 5 gtt/minute Insertion: - decreased ventilation Terminal disinfection is performed A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. An 18G, 1 needle is usually used for I.M. Which of the following types of medications can be administered via gastrostomy tube? Partial-Credit Pain or discomfort at the IV insertion site Irrigate the patient with 1% Neosporin solution three times a daily Muscles of the abdomen, back, and upper arms may be easily injured.Question 15Which of the following statements about chest X-ray is false?AEating, drinking, and medications are allowed before this test BA signed consent is not requiredCNo contradictions exist for this testDBefore the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waistQuestion 15 Explanation: Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. Placing a sterile object on the edge of the sterile field Purpose: - urinary incontinence Maintaing the drainage tubing and collection bag level with the patients bladder could result in reflux of urine into the kidney. The nurse does not need to wear gloves for respiratoryisolation, but good hand washing is important for all types of isolation. Which of the following nursing interventions is considered the most effective form or universal precautions? 0 cards. - maintain underwater seal - decreased O2 capacity (anemia) Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place? Normal WBC counts range from 5,000 to 100,000/mm3. Question 38 Explanation: The edges of a sterile field are considered contaminated. Adhering to a schedule for positioning and turning Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as: Kussmails respirations and hypoventilation, Appneustic breathing, atypical pneumonia and respiratory alkalosis, Cheyne-Strokes respirations and spontaneous pneumothorax, Respiratory acidosis, ateclectasis, and hypostatic pneumonia. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding. Make sure to include whether its an upper or lower airway issue, its cause, and its treatment. The inside of the glove is considered sterile Yawning The most appropriate nursing action would be to:AWithhold the moderation and notify the physicianBApply corn starch soaks to the rash After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Which of the following will probably result in a break in sterile technique for respiratory isolation? - personal habits Once you are finished, click the button below. LearnMore. Potential for clot formation injections; and a 25G needle, for I.M. Fundamentals of Nursing Exam 3 Overview of Exam 3: - 40 Questions - 60 minutes to take - multiple choice, select all that apply, fill in the blank - on Canvas Click the card to flip . Subclavian and jugular veins Results Fundamentals of nursing include basic nursing skills, caring for the perioperative patient, positioning patients, medication administration, patient safety, and more. Describe the risk factors for alterations in nutrition. - normally, a bladder can hold up to 2 cups of urine. Differentiate between wheezing, crackles, and rhonchi. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.Question 5After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. - anxiety attacks The nurse does not need to wear gloves for respiratoryisolation, but good hand washing is important for all types of isolation.Question 38Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?AChest painBHemoglobinuriaCDistended neck veins DUrticariaQuestion 38 Explanation: Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donors and recipients blood). All of the following measures are recommended to prevent pressure ulcers except: Adhering to a schedule for positioning and turning. The equivalent dose in milligrams is:A600 mg B60 mgC10 mgD0.6 mgQuestion 30 Explanation: gr 10 x 60mg/gr 1 = 600 mgQuestion 31Which element in the circular chain of infection can be eliminated by preserving skin integrity? Strictisolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls.Question 12The appropriate needle size for insulin injection is:A22G, 1 longB18G, 1 longC25G, 5/8 long D22G, 1 longQuestion 12 Explanation: A 25G, 5/8 needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. Tub bathing might transfer organisms to another body site rather than rinse them away. - anorexia Abdominal muscles All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. Ventilation: - pneumonia or infection Not Attempted EXAMPLES: ice cream, juices, pudding, milkshakes, tea, strained soups, protein shakes, gelatin Which of the following patients is at greater risk for contracting an infection? Describe the structure and function of the cardiopulmonary system. Which of the following conditions may require fluid restriction? Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam. Chest pain and urticaria may be symptoms of impending anaphylaxis. 10) Change catheters drainage bags based on clinical indication such as infection, obstruction, or when the closed system is compromised All of the following are good sources of vitamin A except: 43. D. The Z-track method is an I.M. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? Assessment: How would you assess a patient's elimination. - dizziness . D. The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). Many medications and foods will discolor stool for example, drugs containing iron turn stool black. - always assess for placement Enteric-coated tablets that are thoroughly dissolved in water How do you interpret a urinalysis (S.G, protein, glucose, nitrates, ketones). Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions. Many medications and foods will discolor stool for example, drugs containing iron turn stool black. There are 50 questions to complete. A signed consent is not required because a chest X-ray is not an invasive examination. Which of the following conditions may require fluid restriction? The correct method for determining the vastus lateralis site for I.M. Attempted Questions Correct Change the urines color - any detection of sugar on this test usually calls for follow-up testing for diabetes - widespread availability of unhealthy/fast food Wearing gloves is not always necessary when administering an I.M. The back of the gown is considered clean, the front is contaminated. A. Parenteral penicillin can be administered I.M. Which of the following procedures always requires surgical asepsis? - education on breathing techniques Pureed Diet: The two blood vessels most commonly used for TPN infusion are the: Also, this page requires javascript. Answers and Rationales Strictisolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged. Questions Not Attempted Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.Question 20Effective hand washing requires the use of:ASoap or detergent to promote emulsificationBHot water to destroy bacteriaCAll of the above DA disinfectant to increase surface tensionQuestion 20 Explanation: Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
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