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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

Medical Surgical Practice Test 2

Situation 1: A nurse who is assigned in a medical ward took time to be prepared with her task and give quality nursing care.

1. If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:

a. Flexion of both upper and lower extremities
b. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
c. Flexion of elbows, extension of the knees, and plantar flexion of the feet
d. Extension of upper extremities, flexion of lower extremities

2.The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:

a. Act as a vasoconstrictor
b. Act as a vasodilator
c. Block beta stimulation in the heart
d. Increase the heart rate

3. A client with alcoholic cirrhosis with ascites and portal hypertension is to receive neomydn. The desired effect of this drug is to;

a. Sterilize the bowel
b. Reduce abdominal distention
c. Decrease the serum ammonia
d. Prevent infection

4. A retention catheter for a male client is correctly taped if it is:

a. On the lower abdomen
b. On the umbilicus
c. Under the thigh
d. On the inner thigh

5. When assessing a client for Cournadin therapy, the condition that will eyclude this client from Coumadin therapy is:


a. Diabetes
b. Arthritis
c. Pregnancy
d. Peptic ulcer disease


6. Preparing for an intravenous pyelosram (IVP), the nurse instructs a 25-year-old male client to restrict her:

a. Fluid intake
b. Physical activity
c. Use of stimulants such as tobacco
d. Use of any medications

7. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?

a. Serosanguimeous drainage from the puncture site
b increased temperature and blood pressure
c. increased pulse and pallor
d. Hypotension and hypothermia

8. The nurse is collecting a urine specimen from a client who has been catheterized. When the urine begins to flow through ths catheter, the next action is to:

a. Inflate the catheter balloon with sterile water
b. Place the catheter tip into the specimen container
c. Connect the catheter into the drainage tubing
c. Place the catheter tip into the urine collection receptacle

9. During a retention catheter insertion or bladder irrigation, the nurse must use:

a. Sterils equipment and wear sterile gloves
b. Clean equipment and maintain surgical asepsis
c. Sterile equipment and maintain medical asepsis
d. Clean equipment and technique

10. If a client continues to hypoventilate, the nurse will continually assess for a complication of this condition;

a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

Situation 2: Diabetes Meilitus is a common disease among Filipinos. Caring for these patients require meticulous assessment and follow-up.

11. The nurse will know a diabetic client understands exercise and its relation to glucose when he says that he eats bread and milk before, or juice or fruit during exercise activity because

a. Exercise enhances the passage of glucose Into muscle celts
b. Exercise stimulates pancreatic insulin production
c. A diabetic's muscle require more glucose during exercise
d. The pancreas utilizes more glucose during exercise

12. The ADA exchange diet is compiled of lists of foods. The statement that indicates the diabetic has an understanding of the purpose of these food lists is:

a. Exchanges are allowed within groups
b. Exchanges are allowed between groups
c. Only meat and fat exchanges can be interchanged
d. Vegetables and fruit exchanges can be Interchanged

13. The non-insulin-dependent diabetic who is obese is best controlled by weight
loss because obesity

a. Reduces the number of insulin receptors
b. Cause pancreatic islet cell exhaustion
c. Reduces insulin binding at receptor cites
d. Reduces pancreatic insulin production

14. A person with a diagnosis of adult diabetes (NIDDM) should understand the symptoms of a hyperglycemic reaction. The nurse wiiS know tills client understands if she says these symptoms are:

a. Thirst, poiyuria and decreased appetite
b. Flushed cheeks, acetone breath, and increased thirst
c. Nausea, vomiting and diarrhea
d. Weight gain, normal breath, and thirst

15. The diabetic client the nurse is counseling is a young man who occasionally goes drinking with his buddies. The nurse will know the client understands the diet when he says that when he consumes alcohol, he includes il as part of:

a. Protein
b. Simple carbohydrates
c. Complex carbohydrates
d. Fats

16. The nurse is teaching a Type 1 diabetic client about her diet, which is based on the exchange system. The nurse wiil know the dient has learned correctiy when she says that she can have as much as she wants of:

a. Lettuce
b. Tomato
c. Grapefruit juice
d. Skim milk

17. The nurse should evpiain to a dient with diabetes meliitus that self-monitoring of blood glucose is preferred to urine glucose testing because it is:

a. More accurate .
b. Easier to perform
c. Done by the cient
d. Not influenced by drugs

18.A client is diagnosed as having non-insulin-dependent diabetes mellitus how to
provide self-care to prevent infections of the feet. The nurse recognizes that the
teaching was effective when the client says, I should:

a. "Massage my feet and feet with oil or lotion."
b. "Apply heat intermittently to my feet and legs."
c. "Eat foods high in kilocalories of protein and carbohydrates."
d. "Control my diabetes through diet, exercise, and medication."

19. A client is admitted to the hospital with diabetic ketoadosis. The nurse understands that the elevated ketone level present with this disorder is caused by the incomplete oxidation of:

a. Fats
b. Protein
c. Potassium
d. Carbohydrates

20. A client with insulin-dependent diabetes is pjaced on an insulin pump. The most appropriate short-term goal in teaching this client to control the diabetes: " The client will:

a. Adhere to the medical regimen."
b. Remain normogtycemic for 3 weeks."
c. Demonstrate the correct use of the insulin pump."
d. List three self-care activities necessary to control the diabetes."

Situation 3: In the CCU, the nurse has a patient who needs to be,watched out.

21. To determine the status of a clients carotid pulse, the nurse should palpate:

a. In the lateral neck region
b. Immediately below the mandible
c. At the anterior necK, lateral to the trachea
d. At the base of the neck", along the clavicle

22. To help reduce a client's risk factors for a heart disease, the nurse, in discussing dietary guidelines, should teach the client to:

a. Avoid eating between meals
b. Decrease the amount of uhsaturated fat
c. Decrease the amount of fat-binding fiber
d. Increase the ratio of complex carbohydrates

23. The nurse would expect a client diagnosed as having hypertension to report
experiencing the most common symptom associated with this disorder, which is:

a. Fatigue
b. Headache
c. Nosebleeds
d. Flushed face

24. A client with a history of hypertension develops pedal edema and demonstrates dyspnea on exertion. The nurse recognizes that the client's dyspnea on exertion is probably;

a. Caused by cor pulmonale
b. A result of left ventricular failure
c. A result of right ventricular failure
d. Associated with wheezing and coughing

25. A client who has been admitted to the cardiac care unit with myocardial infarction complains of chest pain. The nursing intervention that would be most effective in relieving the client's pain would be to administer the ordered:

a. Morphine sulfate 2 mg IV
b. Oxygen per nasal cannula
c. Nitroglycerine sublingually
d. Lidocaine hydrochloride 50 mg IV bolus

26. The nurse admitting a client with a myocardial Infarction to ICU understands that the pain the client is experiencing is a result of:

a. Compression of the heart muscle
b. Release of myocardia! isoenzymes
c. Inadequate perfusion of the myocardium
d. Rapid vasodilation of the coronary arteries

27. A male client who is hospitalized following a myocardial infarction asks the nurse why he is receiving morphine. The nurse replies that morphine;

a. Dilates coronary blood vessels
b. Relieve pain and prevents shock
c. Helps prevent fibrillation of the heart
d. Decreases anxiety and restlessness

28. Several days following surgery a client develops pyrexia. The nurse should monitor the client for other adaptations related to the pyrexia including:

a. Dyspnea
b. Chest pain
c. Increased pulse rate
d. Elevated blood pressure

29. The nurse recognizes that a pacemaker is indicated when a client is
experiencing;

a. Angina
b. Chest pain
c. Heart block
d. Tachycardia

30. When assessing a client with a diagnosis of left ventricular failure (congestive heart failure), the nurse should expect to find:

a. Crushing chest pain
b. Dyspnea on exertion
c. Jugular vein distention
d. Extensive peripheral edema


Situation 4: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.

31. After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:

a. 3150ml
b. 3200 ml
c. 3650 ml
d. 3750ml

32. The dietary practice that will help a client reduce the dietary intake of sodium is

a. Increasing the use of dairy products
b. Using an artificial sweetener in coffee
c. Avoiding the use of carbonated beverages
d. Using catsup for cooking and flavoring foods

33. When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;

a. Urinary output of 30 ml in an hour
b. Central venous pressure reading of 2 cm H20
c. Pulse rates of 120 and 110 in a 15- minute period
d. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes

34. When monitoring for hypernatremia, the nurse should assess the client for:

a. Dry skin
b. Confusion
c. Tachycardia
d. Pale coloring

35. Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:

a. Urinary output
b. Abdominal girth
c. Serum ammonia level
d. Hepatic encephalopathy

36. A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;

a. A glass of water every hour until hydrated
b. Small frequent intake of juices, broth, or milk
c. Short-term NG replacement of fluids and nutrients
d. A rapid IV infusion of an electrolyte and glucose solution

37.The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full-thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording

a. Weights every day .
b. Urinary output every hour
c. Blood pressure every 15 minutes
d. Extent of peripheral edema every 4 hours

38. A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:

a. A rapid, thready pulse
b. Decreased peristalsis .
c. Respiratory congestion
d. An increased in temperature

39. The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:

a. Filtration
b. Diffusion
c. Osmosis
d. Active Transport

40. A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;

a. 13 gtt/min
b. 16 gtt/min
c. 29 gtt/min
d. 32 gtt/min

Situation 5: Protection of self and patient can be done by supporting the body's immunity.

41. Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:

a. Obtain vita! signs
b. Stop the transfusion
c. Assess the pain further
d. Increase the flow of normal saline

42.A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask:

a. "Have you bee sexually active lately?"
b, "Do you have a sore throat at the present time?"
c. "Have you been exposed recently to anyone with an infection?"
d. "When did you first notice that your temperature had gone up?"

43. The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;

a. Has intercourse with just the spouse
b. Makes a donation of a pint of whole blood
c. Limits sexual contact to those without HIV antibodies
d. Uses a'condom each time there is a sexual intercourse

44. The knows that a positive diagnosis for HIV infection is made based on;

a. A history of high-risk sexual behaviors
b. Positive ELISA and Western blot tests
c. Evidence of extreme weight loss and high fever
d. Identification of an associated opportunistic infection

45. When taking the blood pressure of a client who has AIDS the nurse must;

a. Wear dean gloves
b. Use barrier techniques
c. Wear a mask and gown
d. Wash the hands thoroughly


46. The nurse should plan to teach the client with pancytopenia caused by a
chemotherapy to;

a. Begin a program of aggressive, strict mouth care
b. Avoid traumatic injuries and exposure to any infection
c. increase oral fluid intake to a minimum of 3000 ml daily
d. Report any unusual muscle cramps or tingling sensations in the extremities

47. An elderly client develops severe bone barrow depression from chemotheraphy for cancer of the prostate. The nurse should;

a. Monitor for signs of alopecia
b. Increase dally intake of fluids
c. Monitor Intake and output of fluids
d. Use a soft toothbrush for oral hygiene

48. A tuberculin skin test with purified protein derivative (PP!) tuberculin is performed as part of a routine physical examination. The nurse should instruct the client to make an appointment so the test can be read in:

a. 3 days
b. 5 days
c. 7 days
d. 10 days

49.A client is admitted with cellulites of the left teg a temperature of 103°F. The physician orders IV antibiotics. Before instituting this therapy, the nurse should;

a. Determine whether the client has allergies
b. Apply a warm, moist dressing over the area
c. Measure the amount of swelling in the client's leg
d. Obtain the results of the culture and sensitivity tests

50. Following multiple bee stings, a client has an anaphylactic reaction. The nurse is aware that the symptoms the client is experiencing are caused by;

a. Respiratory depression and cardiac standstill
b. bronchial constriction and decreased peripheral resistance
c. Decreased cardiac out and dilation of major biood vessels
d. Constriction of capillaries and decreased peripheral circulation

Situation 6: Following these diagnostic tests, Mr. Mangoni's physical discussed possible therapies with him. It was decided that a partial gastrectomy, vagotomy, and gastrojejunostomy would be performed.

51. Mr. Mangoni asks why the vagotomy is being done. You explain that a vagotomy is done in conjunction with a subtotal gastrectomy because the vagus nerve:

a. Stimulates increased gastric motility.
b. Decreases gastric motiiity, thereby preventing the movement of HCl out of the stomach.
c. Stimulates both increased gastric secretion and gastric motiiity.
d. Stimulates decreased gastric secretion, thereby increasing nausea and vomiting.

52. Which of the following nursing interventions would be included. in the preoperative period for Mr. Mangoni?

a. Insertion of a nasogastric tube on the morning of surgery.
b. Administration of Vallum 4 mg with 4 oz water 1 hour before surgery.
c. Detailed description of the possible complications that could happen postoperatively
d. Instructions to avoid taking pain medication too frequently in the first 2 postoperative days to avoid drug dependency.

53. Which of the following complications, would you primarily anticipate in Mr. Mangoni's postoperative period?

a. Thrombophlebitis from decreased mobility.
b. Abdominal distention due to air swallowing
c. Atelectasis due to shallow breathing
d. Urinary retention due to prolonged use of antichoiinergic medications.

54. The nurse would recognize drainage from the nasogastric tube after surgery as abnormal If:

a. It after 6 hours
b. It continued for a period greater than 12 hours.
c. ft turned greenish yeiiow in less than 24 hours.
d. It was dark red in the immediate postoperative period.

55. Which of the following statements would the nurse include in teaching regarding nasogastric tubes?

a. Nasogastric tubes should be irrigated with sterile water.
b. Client should be in sitting position with head slightly flexed for tube Insertion
c. When resistance is met while irrigating a nasogastric tube, pressure should be increased to complete that irrigation, and the physician should be notified at the completion. d. Ice chips- can be taken as often as desired to promote comfort in the
throat.

56. The nurse must observe for which of the following imbalances to occur with prolonged nasogastric suctioning?

a. Hypernatremia
b. Hyperkalemia
c. Metabolic alkalosis
d. Hypoproteinemia

57. Of the following mouth care measures by the nurse, which one should be used with caution when a client has a nasogastric tube?

a. Regularly brushing teeth and tongue with soft brush.
b. Sucking on ice chips to relieve dryness.
c. Occasionally rinsing mouth with a nonastringent substance and massaging gums.
d. Application of lemon juice and glycerine swabs to the lips.

58. The nurse tells Mr. Mangoni that the nasogastric tube will be removed:

a. Standardly on the fourth postoperative day.
b. When bowel sounds are established and the client has passed flatus or Stool
c. Thirty-six hours after the cessation of bloody drainage.
d. After 2 days of alternate clamping and unclamping of the tube.

59. Following surgery the nurse must observe for signs of pernicious anemia, which may be a problem after gastrectomy because:

a. The extrinsic factor is produced In the stomach.
b. The extrinsic factor is absorbed in the antral portion of the stomach.
c. The intrinsic factor Is produced in the stomach.
d. Decreased hydrochloric acid production Inhibits vitamin B12 reabsorption.

60.The nurse will usually ambulate the post gastrectomy patient beginning;

a. The day after surgery
b. Three to four days after surgery
c. After 4 days bedrest
d. immediately upon awakening .

Situation 7: Donald Lee, a 70-year-old retired businessman, went .to his ophthalmologist wilt's complaints of decreasing peripheral vision. Tonometry revealed increased intraocular pressures. Mr. Lee was admitted to the hospital with a diagnosis of open-angle glaucoma.

61. The signs and symptoms of open-angle glaucoma are related to:

a. An imbalance between the rats of secretion of intraocular fluids and the rate of absorption of aqueous humor.
b. A degenerative disease characterized by narrowing of the arterioles of the retina and areas of ischemia.
c. An infectious process that causes clouding and scarring of the cornea.
d. A dysfunction of aging in which the retina of the eye buckles from inadequate fluid pressures. .

62. Assessment of the intraocular pressure as measured by tonometry would be normal if the value is in the range;

a. 5-10 mm Hg
b. 12-22 mm Hg
c. 10-20 cm H20
d. 20-30 mm Hg

63. While taking Mr. Lee's history, the nurse would be alerted to a sudden increase in intraocular pressure if he complained of;

a. Generalized decrease in peripheral vision over the past year.
b. Difficulty with close vision.
c. increasing discomfort in the left eye with radiation to his forehead and left
temple.
d. Halos around lights.

64. Client teaching about glaucoma should include a comparison of the two types. Open-angle, or chronic, glaucoma differs from close-angle, or acute, glaucoma in, that

a. Open-angle glaucoma occurs less frequently than closed-angle glaucoma.
b. Open-angle glaucoma's symptomatology Includes pain, severe headache, nausea, and vomiting; whereas closed-angle glaucoma has a slow, silent, and generally painless onset.
c. The obstruction to aqueous flow In open-angle glaucoma generally occurs somewhere in Schlemm's canal or aqueous veins. It does not narrow or close the angle of the anterior chamber, as in closed-angle glaucoma.
d. Open-angle glaucoma rarely occurs in families; however, there is a heredity predisposition for closed-angle glaucoma.

65. Piiocarpine is the drug of choice in the treatment of open-angle glaucoma. The expected outcome following administration would be:

a. Blocked action of cholinesterase at the cholinergic nerve endings, and therefore increased pupil size.
b. Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid.
c. Impaired vision from decreased aqueous humor production.
d. Constriction of aqueous veins and therefore decreased venous pooling in the eye.

66. Bedrest is ordered for Mr, Lee because activity tends to increase intraocular pressure. Which of the following activities of daily living should he be instructed to avoid?

a. Watching television
b. Brushing teeth and hair
c. Seif-feeding
d. Passive range-of-motion exercises

67. To correctly instill pilocarpine in Mr. Lee's eyes, the nurse should gently pull down the lower lid of the eye and instill the drop:

a. Dirediy on the central surface of the cornea
b. On the inner canthus of the eye
c. into the conjunctive sac
d. Directly on the dilated pupil

68. Which of the following aspects of open angle glaucoma and its medical treatment is the most frequent cause of client noncompliance?

a. Loss of mobility due to severe-driving restrictions
b. The painful insidious progression of this type of glaucoma.
c. Decreased light and near-vision accommodation due to miotic effects of pilocarpine.
d. The frequent nausea and vomiting accompanying use of miotic drugs.

Situation 8: Gladys Meeker is a 30-year-oid advertising executive with a history of ulcerative colitis since age 22. Her chief complaint is severe abdominal cramping and 18- 20 stools per day for four days.

69. Blood and fluid loss from frequent diarrhea may cause hypovolemia. You can quickly assess volume depletion In Miss Meeker by;

a. Measuring the quantity and speciflc gravity of her urine output
b. Taking her blood pressure first supine, then sitting, noting any changes.
c. Comparing the client's present weight with her weight on her last admission.
d. Administering the oral water test.

70. The nurse would recognize other signs of hypovolemia, which include:

a. Dry mucous membranes and soft eyeballs.
b. Decreased hematocrit and hemoglobin
c. Decreased pulse rate and widened pulse pressure.
d, Dyspnea and crackles.

71. With severe diarrhea, electrolytes as well as fluid are lost. The nurse would conclude that the client is experiencing hypokalemia if which of the following were observed?

a. Spasms, diarrhea, irregular pulse.
b. Kussmaul breathing, thirst, furrowed tongue.
c. Apathy, weakness, GI disturbance

72. Three days after admission Ms. Meeker continued to have frequent stools. Her oral intake of both fluids and solids was poor. Her physician ordered parenteral hyperalimentation. While administering the ordered solution, It is important to remember that hyperalimentation solutions are:

a. Hypotonic solutions used primarily for hydration when hemoconcentration is present.
b. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma.
c. Alkalizing solutions used to treat metabolic acidosis, thus reducing cellular swelling.
d. Hyperosmoiar solutions used primarily to reverse negative nitrogen balance.

73.Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects from too rapid an infusion rate would the nurse expect Ms. Meeker to demonstrate?

a. Cellular dehydration and potassium depletion
b. Circulatory overload and hypoglycemia.
c. Hypoglycemia and hypovolemia.
d. Potassium excess and congestive heart failure.

74.Which of the following statements is correct regarding nursing care of Ms. Meeker while she is receiving hyperlimentation?

a. The client's urine should be tested for glucoseacetone every 8-12 hours.
b. The hyperlimentation subclavian line may be utilized for CVP readings and/or blood withdrawal.
c. Occlusive dressings at the catheter insertion site are changed every 48 hours using the clean technique.
d. Records of intake and output and daily weights should be kept. .

Situation 9: After 10 days of therapy, Ms. Meeker's physician decided to perform an iieostomy. For 3 days prior to surgery she was given neomycin. On the morning of surgery she catheterized and nasogastric tube was inserted.

75. Neomycin was administered by the nurse prior to surgery:

a. To decrease the incidence of postoperative atelectasis due to decreased depth of respirations.
b. To increase the effectiveness of the body's immunologic response following surgical trauma.
c. To reduce the incidence of wound infections by decreasing the number of intestinal organisms.
d. To prevent postoperative bladder atony due to catheterization.

76. Following iieostomy, the nurse would expect the drainage appliance to be applied to the stoma;

a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begins to function.
d. When the client is able to begin self-care procedures.

77.Which of the goals would be described to Ms. Meeker as the highest postoperative nursing priority?

a. Relief of pain to promote rest and relaxation.
b. Assisting the client with self-care activities.
c. Maintenance of fluid, electrolyte, and nutritional balances.
d. Skin care and control of odors.

78. During the early postoperative period, the nurse initiates ileostomy teaching with Ms. Meeker. The primary objective of this procedure is;

a. To facilitate maintenance of intake and output records
b. To control unpleasant odors.
c. To prevent excoriation of the skin around the stoma.
d. To reduce [he risk of postoperative wound infection.

79. After discharge, Ms. Meeker calls you at the hospital to report the sudden onset of abdominal cramps, vomiting, and watery discharge from her iieostomy. What would you advise?

a. Call the physician if symptoms persist for 24 hours.
b, Take 30 cc of m.o.m. (milk of magnesia).
c. NPO until vomiting stops.
d. Call the physician immediately.

Situation 10: Joseph Clifford, age 38, has extensive bums over much of his trunk and arms. He complains of intense pain during wound cleansing, dressing change, debridement, and physical therapy.

80. This pain most likely is related to:

a. Thermal stimulation
b. Menta! stimulation
c. Mechanical stimulation
d. Chemical stimulation

81. Mr. Clifford dreads physical therapy and resists activity; he has difficulty sleeping due to pain and fatigue after the treatments. He lacks appetite for food or fluid. Based on this information, his priority nursing diagnosis would be:

a. Activity Intolerance related to pain secondary to bums.
b. Altered Nutrition; Less Than Body Requirements related to pain secondary to bums.
c. Sleep Pattern Disturbance reiated to pain secondary to bums.
d. Pain related to bums.

82. Mr. Clifford continues to experience significant pain after his expensive bum wounds have healed - 6 months after his injury. He also expresses concern over possible loss of job and disfigurement. At this; stage, the nurse can most effectively intervene for his pain by:

a. Referring him for his counseling and occupational therapy.
b. Staying with him as much as possible and building trust
c. Providing cutaneous stimulation and pharmacoiogic therapy.
d. Providing distraction and guided imagery.

83. Eventually, Mr- Clifford's chronic pain and anxiety about his appearance did contribute to his losing his job and disrupting his plans for marriage.

He finally heeded the nurse's recommendation and sought treatment at a pain center, after which his pain subsided and he permitted his former fiancee to participate in his rehabilitation process, including looking for a new job.

Evaluation criteria for Mr. Clifford's successful rehabilitation should include which of the following:

a. The patient has no aftermath phase of his pain experience.
b. The patient experiences decreased frequency of acute pain episodes.
c. The patient continues normal growth and development with his support systems intact.
d. The patient develops increased tolerance for severe pain in the future.

84. Which of the following statements regarding pain is incorrect?

a. intractable pain may not be relieved by treatment.
b. Pain is an objective sign of a more serious problem.
c. Psychologic factors can contribute to a patient's pain perception.
d. Pain sensation is affected by a patient's anticipation of pain.

85. Billy Bragg, aged 5, received a small paper cut on his finger. His mother left him wash it and apply a smail amount of bacitracin and a Band-aid. She then let him watch TV and eat an apple Her intervention for pain are examples of:

a. Providing pharmacologic therapy
b. Providing control and distraction
c. Altering Billy's environment
d. Providing cutaneous stimulation

Situation 11: Mrs. Smith, age 64, has been diagnosed with COPD. Although she was hospitalized several times in the last year for acute respiratory failure, she is presently in stable condition.

86. The primary focus of care in the long-term nursing care for Mrs. Smith would be to:

a. Decrease activity to conserve functional Sung tissue.
b. Increase the frequency of postural drainage to every 2 hours he awake.
c. Increase the RV.
d. improve and maintain pulmonary ventilation and gas exchange.

87. Mrs. Smith's condition has changed over a period of days,, and her arterial blood studies now indicate she is again in acute respiratory failure. The primary nursing intervention most commonly required .in the care of patient with COPD who are in acute respiratory failure is to:

a. Establish initial stage of activity.
b. Discourage patient from sitting in Fowler's position in order to reduce work of heart.
c. Remove bronchia! secretions, and manage oxygen therapy.
d. Plan with family for home care.

88. Mrs. Smith has been treated aggressively for acute respiratory failure and has improved over the past four weeks. She experienced anxiety about being prepared for discharge. The nurse who cares for her should help her develop ways to cope with her chronic obstructive lung disease by:

a. Encouraging the family to take increased responsibility for the patients care.
b. Discouraging the patient from performing activities of daily living if they make her tired.
c. Teaching the patient relaxation techniques and breathing refraining exercises.
d. Protecting the patient from knowing the prognosis of her disease.

Situation 12: Mrs. Lippett, age 66, is experiencing sensory and perceptual problems that affect her right visual field (right homonymous hemianopia).

89. When placing a meal tray in front of Mrs. Lippett, the nurse should;

a. Place all the food on the right side of the tray.
b. Before leaving the room, remind the patient to look over all the tray.
c. Place food and utensils within the patient's left visual field.
d. Stay with the patient & periodically draw her attention of the food on the right side of the tray to prevent unilateral neglect

90. The nurse should include which of the following in preprocedure teaching for a patient scheduled for carotid angiography?

a. "You will be put to sleep before the needle Is inserted."
b. "The test will take several hours."
c. "You may fee! a burning sensation when the dye is injected."
d. "There will be no complications."

91.What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?

a. Expressive aphasia and paralysis on the right side of the body.
b. Expressive aphasia and paralysis on the left side of the body. .
c. Dysarthria and paralysis on the right side of the body.
d. Mixed aphasia and paralysis on the right side of the body.

92. What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?

a. Wait for the patient to complete the sentence.
b. Immediately begin showing the patient various objects In the environment.
c. Leave the room and come back later.
d. Begin naming various objects that the patient could be referring to.

93. Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?

a. "What would you like to do first, brush your teeth?"
b. "Where is y our toothbrush?"
c. "When would you like to have your bath?"
d. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."

94. Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?

a. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
b. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
c. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
d. On the back with no pillows used, with trochanter rolls and a footboard.

95.To prevent infection in a patient with a subdura! intracranial pressure monitoring system in place, the nurse should;

a. Use aseptic technique for the insertion site.
b. Use clean technique for cleansing connections and aseptic technique for the insertion site.
c. Use sterile technique when cleansing the insertion site
d. Close any leaks in the tubing with tape.

Situation 13: Mrs. Taylor, age 74, suffers from degenerative joint disease due to osteoarthritis and is admitted for a total joint replacement of the right hip.

96. During the preoperative period, the nurse should focus assessment primarily on:

a. Local and systemic infections
b. Self-care ability
c. Response to pain medications
d. Range of motion in the affected joint

97. Following arthroplasty, the nurse should maintain correct position of Mrs, Taylor's operative leg by:

a. Placing an abductor wedge or pillows between the legs.
b. Placing sandbags or pillows to Keep leg abducted.
c. Elevating the affected leg on two pillows or supports.
d. Positioning her supine and on the operative side.

98. When discussing physical activities with Mrs. Tayior, the nurse should instruct her to;

a. Avoid weight bearing until the hip is completely heated.
b. Intermittently cross and uncross legs several times daily.
c. Maintain hip flexion at 90 degrees when sitting.
d. Limit hip flexion to only 45 to 50 degrees.

99. Before discharge, the nurse reviews the signs and symptoms of joint dislocation with Mrs. Tayior. The nurse would determine that Mrs. Taylor understands the instructions by her identification of which of the following symptoms?

a. Positive Homan's sign and Inability to bear weight.
b. Painiess, sudden deformity of the affected hip joint.
c. Severe hip pain with shortening of the extremity.
d. Severe pain and swelling of the affected hip joint.

100. As part of treatment of gouty arthritis for Mrs. Martin, age 66, the physician orders antiuric acid medication to be given in large doses until the maximum safe dosage can be determined. The nurse would determine the maximum dosage and the need for dosage reduction by asking Mrs. Martin to report which of the following symptoms?

a. Bleeding gums and bruising
b. Nausea, vomiting, and diarrhea
c. Gastric irritation and heartburn
d. Blurred vision and nausea

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