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Nursing Fundamentals I Final Exam Review
Typology: Exams
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that this is related to which sensory deficit?
sensory impairment?
deficit?
assessment of the patient would indicate an adaptation to the sensory deficit?
conversation.
arm, the child says, "Ow, that was sharp!" The nurse knows that the ability to recognize and interpret stimuli is known as:
interventions, the most appropriate recommendation would be:
assessment when administering med- ications because this patient may experience problems with:
assesses that the patient's respirations are depressed. The effects of the morphine sulfate can be classified as:
loss. Although she's familiar with her apart- ment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next two weeks. Which of the following approaches will teach the children to assist ambulation: Have her grasp your arm just above the elbow and have her walk at a comfortable place; stand next to your mom at the top and the bottom of the stairs
eyepatch over the left eye and poor vision in the right eye. What is the correct order of steps to help the pt safely walk down the hall and sit in a chair.: 1. Guide pt's hand to nurse's arm resting above the elbow. 2 position yourself one half step ahead of the patient. 3 Walk at a relaxed pace. 4 Tell pt when you're approaching the chair. 5 Position pt's hand on back of chair
intervention is to teach parents and chil- dren to:: Take precautions when involved in activities associated with high- intensity noises.
statements made by the pt indicates that additional teaching is needed: "I have right sided partial paralysis and reduced sensation so i should dress the left side of my body first"
aphasia: Use a dry erase board or paper and pen for writing messages
the medical clinic for a routine checkup/ he is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness: Sharing info about senior transportation services; providing information about local social groups in the pt's neighborhood; recommending that the patient consider making living arrangements that will put him closer to family and friends
department for severe bilateral eye trauma. During pt admission the nurse's priority interventions include which of the following: Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching; orienting the patient to the environment to reduce anxiety and prevent further injury to the eye; placing signage on the pt's room door and over the bed to alert healthcare providers about pt's visual status
medical record reveals that he had a stroke affecting the right hemisphere of the brain six months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find: I attention and neglect, especially to the left side; visual spatial alterations such as loss of half of a visual field
my hearing aid is broken. I cant hear any- thing" which of the following teaching strategies does the nurse implement- : Demonstrate hearing aid battery replacement; review method to check volume on hearing aid; discuss the importance of having wax buildup in the ear canal removed
a reddened area blanches on finger tip touch: Sensitive skin that requires special bed linen
wound surface
wound: Providing support to abdominal tissues when coughing or walking; reductions of stress on the abdominal incision
improve blood flow to an injured part
depth
adherent to the wound edge. What is the correct category/stage for the patient's pressure ulcer: Unstageable
: Use a transfer device; have head of bed flat when repositioning pt; raise head of bed 30 degrees when pt positioned supine
position the pt on the bedpan, elevate the head of the bed to a 45 degree angle
abdomen. On the basis of these findings, what do you suspect is wrong with the pt?*: An intestinal obstruction
he rates a 6 out of 10. What is your priority nursing intervention: Stop the instillation
in the diet; exercise for 30 min every day; schedule time to use bathroom at same time every day
apply.): How to change the pouch, how to empty the pouch; how to open and close the pouch; how to determine if the ostomy is healing appropriately
antibiotics
peristomal skin. 3 assess the stoma and skin around it. 4 measure the stoma. 5 trace the correct measurement onto back of
provider: Light pink urine
bifurcation of the drainage and balloon ports
condom catheter: Washing with soap and water before applying the condom-type catheter
indwelling urinary catheter removed that day: Report the time and amount of first voided
lower abd pain and distensión. What should be the nurses initial intervention: Assess intake and output from system
has not been seen toileting independently. What is the best nursing intervention for this patient?: Start a scheduled toilet- ing program.
preventions: Keep the bowels regular; wear cotton underwear; cleanse the perineum from front to back
prostate enlargement may not be emptying his bladder adequately: Do you dribble urine constantly
with sterile square and fenestrated drapes
four hours. What is the priority nursing intervention: Assess the catheter and drainage tubing for obvious occlusion
an adult pt: Allow the balloon to drain into the syringe by gravity; initiate voiding record or bladder diary
bladder
next?: Leave the catheter there and start over with a new catheter
because of the nutritional status, the pt is at increased risk for: Sepsis; pleural effusion; cardiac arrhythmias
action: Do not reinstall aspirate and hold the feeding until you talk to the PCP
monitoring every 6 hours on a pt; documenting PO intake on a pt who is on a calorie count for 72 hours
record to see if there is a medication order for abnormal glucose levels
formula with whole milk starting next month
should be included in the program for older adults: Avoid grapefruit and grapefruit juice which impair drug absorption; take a multivitamin that includes vitamin D for bone health, cheese and eggs are good sources of protein
continuous enteral feedings. Which action would require immediate attention: Placing pt supine while giving bath
prevent a central line infection: Clean the central line port through which the TPN is infusing with antiseptic
her gluten free diet; the 25 -year-old pt with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements
assessing the pt 1 hr after administering an opiod: Difficulty arousing the pt
operating room following a total hip replacement; "fentanyl patch 100mcg, change every 3 days." On the basis of this order, the nurse takes the following action: Calls the health provider and questions the order
nurse anticipates an order for which class of medications: Stool softeners
order does the nurse question?: time interval
acetaminophen, two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most: The amount of daily acetaminophen
stop the medication for frenar of addiction. He is now experiencing shaking, chills, abdominal cramps, and joint pain. The nurse recognizes the this pt is experiencing symptoms of: Opioid withdrawal
about to be started on a patient controlled analgesia of morphine: Only the pt should push the button; the PCA system can set limits to prevent overdoses from occurring; do not push the button to go to sleep
sleeping for 30 min. Which is the most accurate resource for assessing the pain: Patient's self report
skin; apply ice for 5 min or until numbness occurs; use a slow, circular steady massage
TENS electrodes are applied near or directly on the site of pain
him sleep but it is stil necessary to assess pain
hospitalized patient?: Avoid awakening patient for nonessential tasks