She must successfully complete the licensing examination to become a registered professional nurse.Question 24Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?AIrrigate the patient with 1% Neosporin solution three times a dailyBMaintain the drainage tubing and collection bag level with the patients bladderCMaintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity DClamp the catheter for 1 hour every 4 hours to maintain the bladders elasticityQuestion 24 Explanation: Maintaing the drainage tubing and collection bag level with the patients bladder could result in reflux of urine into the kidney. A. 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). - perform dressing changes per agency policy. Hypoxia: lack of oxygen at the cellular level The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. All of the following are good sources of vitamin A except: Strict isolation is required Normal WBC counts range from 5,000 to 100,000/mm3. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.Question 14An infected patient has chills and begins shivering. Tub bathing might transfer organisms to another body site rather than rinse them away. Results 34. Egg yolks 3) to re-establish normal intra-pleural and intra-pulmonary pressures A red streak exiting the IV insertion site 4) pureed Many medications and foods will discolor stool for example, drugs containing iron turn stool black. 10) Change catheters drainage bags based on clinical indication such as infection, obstruction, or when the closed system is compromised Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls. 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. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated.Question 22The correct method for determining the vastus lateralis site for I.M. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. - heard on exhalation These symptoms probably indicate that the patient is experiencing:AAnorexiaBHypokalemiaCDysphagia DHyperkalemiaQuestion 5 Explanation: Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. Attempted Questions Correct Administer the medication and notify the physician Tub bathing might transfer organisms to another body site rather than rinse them away.Question 11Thrombophlebitis typically develops in patients with which of the following conditions?AChronic Obstructive Pulmonary Disease (COPD) BIncreases partial thromboplastin timeCAcute pulsus paradoxusDAn impaired or traumatized blood vessel wallQuestion 11 Explanation: 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. Splinting the abdomen supports the abdominal muscles when a patient coughs.Question 29The primary purpose of a platelet count is to evaluate the:APotential for bleedingBPresence of an antigen-antibody responseCPotential for clot formationDPresence of cardiac enzymes Crackles: insertion site. 3) Young/Middle Adults: The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms.Question 7When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:ACuffs of the gownBInside of the gown CWaist tie and neck tie at the back of the gownDWaist tie in front of the gownQuestion 7 Explanation: The back of the gown is considered clean, the front is contaminated. Choose the letter of the correct answer. - normally, a bladder can hold up to 2 cups of urine. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool. 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 . These symptoms probably indicate that the patient is experiencing: 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. - exercise A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. The best nursing intervention is to: Diagnosis: The nurse should seek an alternate physicians order when an ordered medication is inappropriate for delivery by tube. Describe the risk factors for alterations in nutrition. 33. Wearing gloves is not always necessary when administering an I.M. questions Rapid eye movements Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. A signed consent is not required because a chest X-ray is not an invasive examination. - urine travels through the urinary system or urinary tract, which consists of kidneys, ureters, bladder, and urethra The mid-deltoid injection site is seldom used for I.M. 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. Normal Saline Enema: The middle third of the muscle is recommended as the injection site. - allow the family to participate in post-mortem care - from the kidneys, urine is transported to the bladder by the ureters document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. 0 cards. injections, which are typically administered in the vastus lateralis or ventrogluteal site. - hospice services are available in home, hospital, extended care, or nursing home settings - as with sugar, any amount of ketones detected in your urine could be a sign of diabetes and requires follow-up testing. A clinical nurse specialist is a nurse who has: 39. Bile colors the stool brown. White potatoes Change the urines color Been certified by the National League for Nursing Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. 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. -trauma Be sure to include color, odor, and clarity. Diffusion: - education on breathing techniques Enteric-coated tablets that are thoroughly dissolved in water This is done by blood typing (a test that determines a persons blood type) and cross-matching (a procedure that determines the compatibility of the donors and recipients blood after the blood types has been matched). - dyspnea Inhibit the growth of microorganisms D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. Rapid eye movement marks the stage of sleep during which dreaming occurs. - poor meal choices You got 50 minutes to finish the exam .Good luck! Which of the following nursing interventions is considered the most effective form or universal precautions? Is primarily a voluntary action - record output The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms. 20. Dysphagia means difficulty swallowing. Average Cardiac Output (CO) = 5-8 L/min Cap all used needles before removing them from their syringes, Discard all used uncapped needles and syringes in an impenetrable protective container, Wear gloves when administering IM injections. Start 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. You have completed Which of the following patients is at greater risk for contracting an infection? 22G Increased urine acidity and relaxation of the perineal muscles, causing incontinence Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Yawning 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. Upper GI bleeding Having the patient take a tub bath on the morning of surgery Immobility impairs bladder elimination, resulting in such disorders as. 11 cards. 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. - assist client with dressing changes and troubleshooting issues that clients commonly have as they adjust, - Assists clients with gaining control of their elimination schedule Hospice: Assessment: How would you assess for alterations in oxygenation? After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. The reaction can range from a rash or hives to anaphylactic shock. The appropriate needle size for insulin injection is: In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain? The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography. Waist tie and neck tie at the back of the gown Date - medications that decrease respiratory rate The urinary system is normally free of microorganisms except at the urinary meatus. Edema and warmth at the IV insertion site 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 . A patient with no known allergies is to receive penicillin every 6 hours. 1,2, and 3 Flashcards | Quizlet Fundamentals of Nursing Ch. - checks appearance, concentration, and content of urine We have made considerable efforts to provide you with the most informative rationale, so be sure to read them. Developmental Factors: The respiratory system is comprised of the nose, oropharynx, larynx, trachea, bronchi, bronchioles, and lungs insertion site, and a red streak going up the arm or leg from the I.V. A patient receiving broad-spectrum antibiotics Why? Effective skin disinfection before a surgical procedure includes which of the following methods? D. The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). The patient can be in a supine or sitting position for an injection into this site. 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. Applying additional bed clothes helps to equalize the body temperature and stop the chills. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis.Question 10Effective skin disinfection before a surgical procedure includes which of the following methods?AApplying a topical antiseptic to the skin on the evening before surgeryBHaving the patient shower with an antiseptic soap on the evening v=before and the morning of surgery CHaving the patient take a tub bath on the morning of surgeryDShaving the site on the day before surgeryQuestion 10 Explanation: Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Idiosyncrasy is an individuals unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Clamp the catheter for 1 hour every 4 hours to maintain the bladders elasticity - does not create the danger of excess fluid absorption - educate client about their stoma and how to care for it D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. Screen blood donors for antibodies to human immunodeficiency virus (HIV), Test blood to be used for transfusion for HIV antibodies, The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). injections; and a 25G needle, for I.M. 40. Compare and contrast the different types of enemas (water, hypertonic, saline, soapsud). These symptoms probably indicate that the patient is experiencing: Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. - securement device - the specimen needs to be a clean collected specimen, - A fecal occult blood test checks stool samples for traces of blood that cannot be seen with the naked eye Thus, a count of 25,000/mm3 indicates leukocytosis.Question 26Which of the following nursing interventions is considered the most effective form or universal precautions?ADiscard all used uncapped needles and syringes in an impenetrable protective containerBFollow enteric precautions CWear gloves when administering IM injectionsDCap all used needles before removing them from their syringesQuestion 26 Explanation: 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. An effect of medication 10. Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams). All of the following are common signs and symptoms of phlebitis except: A red streak exiting the IV insertion site, Edema and warmth at the IV insertion site, Pain or discomfort at the IV insertion site. Which of the following types of medications can be administered via gastrostomy tube? These symptoms probably indicate that the patient is experiencing: 18. All of the following are appropriate nursing interventions except: 36. A 20G needle is usually used for I.M. Enhancing my Professional Caregiving course to Nursing Aid Course, To achieve more knowledge in general nursing, This is very helpful to students academia. - diarrhea. Chegg Prep has millions of flashcards to help students learn faster with an interactive card flipper and scoring to measure your progress. B. Muscles of the abdomen, back, and upper arms may be easily injured. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. All of the following are appropriate nursing interventions except:AAssess femoral, popliteal, and pedal pulses every 15 minutes for 2 hoursBCheck the pressure dressing for sanguineous drainageCOrder a hemoglobin and hematocrit count 1 hour after the arteriography DAssess a vital signs every 15 minutes for 2 hoursQuestion 49 Explanation: A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. 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. 1 minute Blood typing and cross-matching The mid-deltoid injection site is seldom used for I.M. All of the following measures are recommended to prevent pressure ulcers except: 14. Which of the following nursing interventions is considered the most effective form or universal precautions? - allow for time with loved ones 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. or added to a solution and given I.V. Anorexia is another symptom of hypokalemia. - significant cause of illness, death, and excessive cost Palpate a 1 circular area anterior to the umbilicus Although applying corn starch to the rash may relieve discomfort, it is not the nurses top priority in such a potentially life-threatening situation. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? Synergism, is a drug interaction in which the sum of the drugs combined effects is greater than that of their separate effects.Question 40Which of the following patients is at greater risk for contracting an infection?AA patient with leukopeniaBA newly diagnosed diabetic patient CA patient receiving broad-spectrum antibioticsDA postoperative patient who has undergone orthopedic surgeryQuestion 40 Explanation: Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. Screen blood donors for antibodies to human immunodeficiency virus (HIV) Fundamentals of nursing include basic nursing skills, caring for the perioperative patient, positioning patients, medication administration, patient safety, and more. Abnormal: 3 minutes - psychological factors Assess a vital signs every 15 minutes for 2 hours Study Fundamentals Of Nursing Flashcards for Free. - can be maintained for short or long term A postoperative patient who has undergone orthopedic surgery Shaving the site on the day before surgery, Having the patient take a tub bath on the morning of surgery, Applying a topical antiseptic to the skin on the evening before surgery, Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery. Describe the structure and function of the cardiopulmonary system. - amount and frequency depends on fluid intake The normal count ranges from 150,000 to 350,000/mm3. - pain All of the following are appropriate nursing interventions except: . 2. It also is used to evaluate the patients potential for bleeding; however, this is not its primary purpose. 100 cards Kiki V. Emergency equipment. - lung disease (COPD, asthma) - symptom control and management is very important in the end of life process - 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. Get paid to shop at over 2,500 stores! 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. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region. 4. - initial check (gold standard): confirm placement by x-ray Applying additional bed clothes helps to equalize the body temperature and stop the chills. It cannot be administered subcutaneously or intradermally.Question 45Which element in the circular chain of infection can be eliminated by preserving skin integrity? 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Idiosyncrasy A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. The purpose of protective (reverse)isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms. What would the flow rate be if the drop factor is 15 gtt = 1 ml? Which of the following will probably result in a break in sterile technique for respiratory isolation? Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician. Urine Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged. injection. D. 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. injections, which are typically administered in the vastus lateralis or ventrogluteal site.Question 13The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:AAsk the patient to demonstrate the procedure BAsk the patient if he/she has used ear drops beforeCDemonstrate the procedure to the patient and encourage to ask questionsDHave the patient repeat the nurses instructions using her own wordsQuestion 13 Explanation: Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.Question 14When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?ALeg musclesBBack musclesCUpper arm muscles DAbdominal musclesQuestion 14 Explanation: The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Cerebral Aneurysm Nursing Diagnosis and Nursing Care Plan. The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. - increased HR Pain The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.Question 50Which of the following procedures always requires surgical asepsis?ANasogastric tube insertionBVaginal instillation of conjugated estrogenCColostomy irrigation DUrinary catheterizationQuestion 50 Explanation: The urinary system is normally free of microorganisms except at the urinary meatus. A 22G, 1 needle is usually used for adult I.M. injections of oil-based medications; a 22G needle for I.M. You Selected An 18G, 1 needle is usually used for I.M. 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. Tolerance 48. Your answers are highlighted below. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? 39. - provided for patients who cant swallow and have a functioning GI tract 17. In this reaction, antibodies in the recipients plasma combine rapidly with donor RBCs; the cells are hemolyzed in either circulatory or reticuloendothelial system. or added to a solution and given I.V. D. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. An 18G, 1 needle is usually used for I.M. Total Questions on Quiz Apply iced alcohol sponges - patient should initially extend the neck, then flex the neck forward once the tube is in the back of the throat Pureed Diet: - process of moving gases into and out of the lungs Pain or discomfort at the IV insertion site The Urinary Tract the ability to read and understand food labels nutritional values allows nurses to help their clients make better food choices, ea;Differentiate between different types of hospital diets (clear liquid, full liquid, soft, pureed, heart healthy, renal, NPO). BBeen certified by the National League for NursingCReceived credentials from the Philippine Nurses AssociationDGraduated from an associate degree program and is a registered professional nurseQuestion 44 Explanation: A clinical nurse specialist must have completed a masters degree in a clinical specialty and be a registered professional nurse. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not be worn above the waist. The appropriate needle gauge for intradermal injection is: 26. minutes Discuss how psychological and physiological factors may alter after the elimination process. Which element in the circular chain of infection can be eliminated by preserving skin integrity? Discuss the significance of carbohydrates. All of the following are appropriate nursing interventions except: Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours, Check the pressure dressing for sanguineous drainage, Order a hemoglobin and hematocrit count 1 hour after the arteriography, Assess a vital signs every 15 minutes for 2 hours. injections because it: Can accommodate only 1 ml or less of medication, Can be used only when the patient is lying down. Lippincott Fundamentals Of Nursing Test Bank Pdf Eventually, you will very discover a further experience and endowment by spending more cash. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Shaving the site on the day before surgery - the primary goal is to help patients and families achieve the best quality of life Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place? 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). In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Wrong Assessment: How would you assess a patient's elimination. Choose the letter of the correct answer. Animal sources include liver, kidneys, cream, butter, and egg yolks. 13 gtt/minute Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy. 7,000/mm The middle third of the muscle is recommended as the injection site. Frank bleeding at the insertion site Question Text D. Microorganisms usually do not grow in an acidic environment. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. injections because it has relatively few major nerves and blood vessels. 4. Make sure to include insertion, placement, checks, feedings, decompression, and ongoing monitoring. 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. - hypovolemia (dehydration and hemorrhage) This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. - infections (pneumonia) Assessment - smoke inhalation All of the following nursing interventions are correct when using the Z-track method of drug injection except: Rub the site vigorously after the injection to promote absorption. injections, which are typically administered in the vastus lateralis or ventrogluteal site.Question 13All of the following nursing interventions are correct when using the Z-track method of drug injection except:AUse a needle thats a least 1 longBAspirate for blood before injectionCPrepare the injection site with alcoholDRub the site vigorously after the injection to promote absorption Question 13 Explanation: The Z-track method is an I.M.
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