Normal: Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls. Received credentials from the Philippine Nurses Association Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. 48. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. Fundamentals of Nursing. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. After routine patient contact, hand washing should last at least: Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. Inside of the gown Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Specific Gravity (SG): Chest pain and urticaria may be symptoms of impending anaphylaxis. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. injections; and a 25G needle, for subcutaneous insulin injections. The primary purpose of a platelet count is to evaluate the: 16. Ethics. - medication The appropriate needle size for insulin injection is: Reservoir 9) Use standard precautions (gloves and gown) Correct 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. Increased urine acidity and relaxation of the perineal muscles, causing incontinence Environmental Factors: Massaging the reddened are with lotion Effective skin disinfection before a surgical procedure includes which of the following methods? Thrombophlebitis typically develops in patients with which of the following conditions? However, the patients room should be well ventilated, so opening the window or turning on the ventricular is desirable. Revise data in the assessment column to reflect the patient's current status, revise the nursing diagnosis, goals and outcomes, select or revise specific interventions that correspond to the new nursing diagnoses or that are necessary for existing diagnoses, choose methods of evaluation that will be used to determine whether the patient . Text Mode Text version of the exam Fundamentals of Nursing (NUR100) Foundational Literacy Skills and Phonics (ELM-305) multidimensional care 3 (NUR2502) Nursing Process IV: Medical-Surgical Nursing (NUR 411) biology (bio 111) Intermed Algebra (MTH 101) Physics II (PHY 220) Principles of Marketing (proctored course) (BUS 2201) Maternal-Child Nursing (NR-327) Nursing LVN (VN 200) If this activity does not load, try refreshing your browser. All of the following are appropriate nursing interventions except: 36. 8. - soft, but formed stool that is easy to pass without straining Click the card to flip 1 / 54 Flashcards Learn Test Match Created by graciejung622 Terms in this set (54) Overview of Exam 3: - 40 Questions For more information, see the developers privacy policy. All of the above - infused into the bowel exert osmotic pressure that pulls fluids out of the interstitial spaces Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? Thus, a count of 25,000/mm3 indicates leukocytosis.Question 19All of the following nursing interventions are correct when using the Z-track method of drug injection except:APrepare the injection site with alcoholBUse a needle thats a least 1 longCRub the site vigorously after the injection to promote absorption DAspirate for blood before injectionQuestion 19 Explanation: The Z-track method is an I.M. Waist tie and neck tie at the back of the gown 3) full liquid The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve). - focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of a illness, including the care of the dying and bereavement follow-up for the family Test your knowledge by answering the questions from our nursing test bank about the fundamentals of nursing (located under each . Why? Assessment: How would you assess a patient's elimination. - irregular breathing - airway management. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.Question 15The mid-deltoid injection site is seldom used for I.M. If loading fails, click here to try again injections of oil-based medications; a 22G needle for I.M. - supplemental oxygenation. The middle third of the muscle is recommended as the injection site. - hospital bundle Constipation is characterized by small, hard masses. 20. - therapeutic diets, Describe what is included in each step of the nursing process for clients with impaired nutrition (dysphagia, malnutrition, etc.). Administering an antihistamine is a dependent nursing intervention that requires a written physicians order. - may be prescribed for clients recovering from surgery, clients with swallowing difficulty due to medications, dysphagia, etc. Also, this page requires javascript. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Full Liquid Diet: - diagnostic tests. Diagnosis: The patient can be in a supine or sitting position for an injection into this site.Question 9A patient with no known allergies is to receive penicillin every 6 hours. Protein: The factors, known as Virchows triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Initial vasoconstriction may cause skin to feel cold to the touch. A. 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. 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). It cannot be administered subcutaneously or intradermally.Question 7Effective skin disinfection before a surgical procedure includes which of the following methods?AShaving the site on the day before surgeryBHaving the patient take a tub bath on the morning of surgeryCApplying a topical antiseptic to the skin on the evening before surgeryDHaving the patient shower with an antiseptic soap on the evening v=before and the morning of surgery Question 7 Explanation: Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Enteric precautions prevent the transfer of pathogens via feces. The physician orders gr 10 of aspirin for a patient. A. Platelets are disk-shaped cells that are essential for blood coagulation. D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. - education on breathing techniques Which of the following procedures always requires surgical asepsis? - neurological disorders EXAMPLES: broth, gelatin, water, tea, fruit juices, sports drunks Start Hot water may lead to skin irritation or burns. Choose the letter of the correct answer. - maintain skin integrity around stoma Central Nervous System: The normal count ranges from 150,000 to 350,000/mm3. Ask the patient to demonstrate the procedure Apricots - dehydration Which of the following procedures always requires surgical asepsis? Discuss the significance of carbohydrates. A. 44. You have not finished your quiz. Why are these interventions effective? Prothrombin and coagulation time The most appropriate nursing action would be to:AWithhold the moderation and notify the physicianBApply corn starch soaks to the rash 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. 30 seconds Score - medications (barbiturates, narcotics, benzodiazepines) The equivalent dose in milligrams is:A0.6 mgB10 mgC600 mg D60 mgQuestion 31 Explanation: gr 10 x 60mg/gr 1 = 600 mgQuestion 32A patient with no known allergies is to receive penicillin every 6 hours. - position during defecation Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again.Question 8In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:AKussmails respirations and hypoventilation BCheyne-Strokes respirations and spontaneous pneumothoraxCRespiratory acidosis, ateclectasis, and hypostatic pneumoniaDAppneustic breathing, atypical pneumonia and respiratory alkalosisQuestion 8 Explanation: 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.Question 9The two blood vessels most commonly used for TPN infusion are the:ASubclavian and jugular veinsBBrachial and subclavian veinsCFemoral and subclavian veinsDBrachial and femoral veins Question 9 Explanation: Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. - breastfeeding and formula A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS). When administering the medication, the nurse observes a fine rash on the patients skin. What would the flow rate be if the drop factor is 15 gtt = 1 ml?A50 gtt/minute B5 gtt/minuteC25 gtt/minuteD13 gtt/minuteQuestion 16 Explanation: 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minuteQuestion 17The appropriate needle gauge for intradermal injection is:A22GB20GC26G D25GQuestion 17 Explanation: Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. Initial vasoconstriction may cause skin to feel cold to the touch. In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain? This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Please visit using a browser with javascript enabled. In this reaction, antibodies in the recipients plasma combine rapidly with donor RBCs; the cells are hemolyzed in either circulatory or reticuloendothelial system. - mottling. Many medications and foods will discolor stool for example, drugs containing iron turn stool black. 2. is administered to a collection of individuals who have in common one or more personal or enviromental characteristics. - relief from anxiety and pain is essential Aspirate for blood before injection - promotes cardiovascualr health though controlling portions, eating a varied diet, and watching sodium intake Effective hand washing requires the use of: 5. Insertion: 8. Administer the medication with an antihistamine Date Constipation is characterized by small, hard masses. Touching the outside wrapper of sterilized material without sterile gloves, Using sterile forceps, rather than sterile gloves, to handle a sterile item, Placing a sterile object on the edge of the sterile field, Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container. - from the kidneys, urine is transported to the bladder by the ureters Time allowed The mid-deltoid injection site is seldom used for I.M. - age TOP: Communication and Documentation MSC: Management of Care 3. - a catheter places through the thorax to remove air and fluids from the pleural space Administer the medication and notify the physician - stomach pH is normally <3.5 Synergism - measure the tube from the tip of the nose, to the earlobe, to the xiphoid process or added to a solution and given I.V. A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)Question 43Which of the following types of medications can be administered via gastrostomy tube?ACapsules whole contents are dissolve in waterBAny oral medicationsCMost tablets designed for oral use, except for extended-duration compounds DEnteric-coated tablets that are thoroughly dissolved in waterQuestion 43 Explanation: Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. IM injection or an IV solution fluids may be necessary. Interpret the features of normal vs. abnormal stool and urine. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Test blood to be used for transfusion for HIV antibodies The urinary system is normally free of microorganisms except at the urinary meatus. Discard all used uncapped needles and syringes in an impenetrable protective container - fad diets/risk of eating disorders Which of the following blood tests should be performed before a blood transfusion? Mode of transmission 25. You Selected 25G, 5/8 long 25 gtt/minute - Cheyenne-Stokes respirations - position the patient upright or elevate the head of the bed a minimum of 30 (preferably 45) degrees - usually ordered in addition to a urinalysis Respiratory isolation, like strict isolation, requires that the door to the door patients room remain closed. 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Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.Question 25Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?A25,000/mm B4,500/mmC7,000/mmD10,000/mmQuestion 25 Explanation: Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Complete blood count (CBC) and electrolyte levels. Enteric precautions prevent the transfer of pathogens via feces.Question 27In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?AAnalysisBEvaluation CAssessmentDPlanningQuestion 27 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 28Clay colored stools indicate:AImpending constipationBUpper GI bleedingCAn effect of medicationDBile obstruction Question 28 Explanation: Bile colors the stool brown. Opening the door of the patients room leading into the hospital corridor, Opening the patients window to the outside environment, Failing to wear gloves when administering a bed bath. 23. - trauma - a higher than normal concentration often is a result of not drinking enough fluids - carry oxygen and carbon dioxide Rapid eye movement marks the stage of sleep during which dreaming occurs. Effective hand washing requires the use of: insertion site. Complete blood count (CBC) and electrolyte levels. Protective isolation is necessary Identify the clinical outcomes as a result of hyperventilation. Normal Saline Enema: - weakness The nurse should seek an alternate physicians order when an ordered medication is inappropriate for delivery by tube. Attempted Questions Wrong Effective skin disinfection before a surgical procedure includes which of the following methods? However, the patients room should be well ventilated, so opening the window or turning on the ventricular is desirable. An 18G, 1 needle is usually used for I.M. - patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume Vaginal instillation of conjugated estrogen. 26G The patient can be in a supine or sitting position for an injection into this site.Question 23A clinical nurse specialist is a nurse who has:ABeen certified by the National League for NursingBCompleted a masters degree in the prescribed clinical area and is a registered professional nurse. Start - psychological factors The developer, Andrey Andreyev, indicated that the apps privacy practices may include handling of data as described below. D. Microorganisms usually do not grow in an acidic environment. It also is used to evaluate the patients potential for bleeding; however, this is not its primary purpose. Hot water may lead to skin irritation or burns.Question 36Which of the following conditions may require fluid restriction?ARenal FailureBDehydration CChronic Obstructive Pulmonary DiseaseDFeverQuestion 36 Explanation: In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. injections because it: 24. - provided for patients who cant swallow and have a functioning GI tract - foods that are soft and smooth C. The factors, known as Virchows triad, collectively predispose a patient to thromboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. What educational setting would be most appropriate for this process? Choose the letter of the correct answer. Is primarily a voluntary action - 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.). Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity Distended neck veins are an indication of hypervolemia.Question 25The ELISA test is used to:AScreen blood donors for antibodies to human immunodeficiency virus (HIV)BTest blood to be used for transfusion for HIV antibodiesCAll of the above DAid in diagnosing a patient with AIDSQuestion 25 Explanation: The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). - decreased diffusion 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. 2) Ensure that only properly trained persons who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility Final Score on Quiz - diet of foods that do not require chewing Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician. 2) to prevent air and fluids from re-entering the pleural space - high altitudes These symptoms probably indicate that the patient is experiencing: 18. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. 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.Question 41All of the following are good sources of vitamin A except:AApricotsBWhite potatoesCCarrotsDEgg yolks Question 41 Explanation: The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Answers and Rationales PDF Lippincott Fundamentals Of Nursing Test Bank Pdf , (PDF) However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove. Fundamentals Exam 3 study guide - A group of nurses talking are We have made considerable efforts to provide you with the most informative rationale, so be sure to read them. injection technique in which the patients skin is pulled in such a way that the needle track is sealed off after the injection. Application features: Mode "Preparation" Mode "Exam" Results Treatment: Total Questions on Quiz - brain injury Bruises too easily Femoral and subclavian veins The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? A 22G, 1 needle is usually used for adult I.M. Idiosyncrasy DPotential for clot formationQuestion 4 Explanation: Platelets are disk-shaped cells that are essential for blood coagulation. Urinalysis: Chest Tubes: All doneNeed more practice!Keep trying!Not bad!Good work!Perfect! - checks appearance, concentration, and content of urine Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin. The two blood vessels most commonly used for TPN infusion are the: Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. 4,500/mm So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.Question 34Clay colored stools indicate:AUpper GI bleedingBAn effect of medicationCImpending constipationDBile obstruction Question 34 Explanation: Bile colors the stool brown. Anorexia C. In an infected patient, shivering results from the bodys attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. - educate client about their stoma and how to care for it - place clean gown or clothes and cover with clean sheet An Enema is the instillation of a liquid solution through the anus to relieve constipation or cleanse the bowel in preparation for diagnostic test, procedure, or surgery 5) Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma 7) Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions Impending constipation injection. Normal WBC counts range from 5,000 to 10,000/mm3. Idiosyncrasy is an individuals unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. S & S: All of the following statement are true about donning sterile gloves except: This test bank for nurses has over 595 NCLEX-style practice questions divided into four sets. - patient should initially extend the neck, then flex the neck forward once the tube is in the back of the throat - offer silence 8) Following aseptic insertion of the urinary catheter, maintain a closed drainage system - lack of access to safe places to play/exercise D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. A. 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. Thrombophlebitis typically develops in patients with which of the following conditions? Increases partial thromboplastin time 25G - poor tissue perfusion 22G, 1 long injection technique in which the patients skin is pulled in such a way that the needle track is sealed off after the injection.
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