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Terms in this set (42)
normal temperature in celsius
normal temperature in farenheit
pulse older adult
respirations older adult
systolic constantly between 85-110
oxygen life threatening
young adulthood psychosocial
intamacy vs. isolation, occupation, multiple roles
young adults cognitive
young adults moral/spiritual
personal principles, conformity, gender differences, reflective
progressive loss of function
acute and reversible syndrom of progressive loss of cognitive function
the prevention of the initial occurence of disease or injury, directed toward well people,
early detection and treatment of disease or injury to limit disability
maximizes recovery after an injury or illness
chain of command for nurse on drugs
charge nurse, manager, chief nurse investigator
a client comes to the walk in clinic with reports of abdominal pain and diarrhea. while taking the clients vital signs the nurse is implementing which phase of the nursing process?
The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone."
Which nurse is demonstrating the assessment phase of the nursing process?
A.The nurse who observes that the client's pain was relieved with pain medication
B. The nurse who turns the client to a more comfortable position
C. The nurse who ask the client how much lunch he or she ate
D. The nurse who works with the client to set desired outcome goals
The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source
Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)?
A. Taking vital signs of clients on the nursing unit
B. Assisting the physician with an invasive procedure
C. Adjusting the rate on an infusion pump
D. Evaluating achievement of client outcome goals
prior to taking the health history, the nurse should do which of the following?
a. establishing a rapport with the client
b. offer the client a beverage of choice
c. establish that insurance coverage exists
d. ask the client to disrobe and put on a gown
which of the following best describes jean watsons basis for the delivery of nursing practice?
a. systems theory
b.hierarchy of needs
d.self care functioning
the primary purpose of the nursing assessment is to
a.diagnose medical problems
c.treat health problems
d. collect health data
to be considered normal, bowel sounds need to be hear in
a. one quadrant
when preparing a patient for a physical exam, the nurse should
a. ensure the consent has been signed
b. have the patient drink water in order to fill bladder
c.remove drapes in order to have the entire body visible
d. explain the purpose of the exam and what to expect
objective recording of patient data is an important aspect of the nursing process. which statement below would meet the criteria for objective?
a. mrs.jay is depressed today
b. patients behavior is weird
c. sara selected her lunch deliberately avoiding the more nutritious food
d. jerry refused lunch today, did not engage in conversation, and was frequently observed staring out the window
while performing a physical assessment of mrs.jay you hear crackles in the base of both lungs. which of the folowing would be the correct recording of this finding?
a.friction rub heard bilateraly on auscultation
b.rales present in base of lung bilaterale
c.rhonchi heard on ausculatation of base of lungs
d. wheezing heard at base of lungs without sthethoscope
ryan is admitted to the hospital with the diagnosis of uti. his vital signs are T 101, P 82, R 34, BP 126/84. which of the following are abnormal
a.temperature, pulse, and bp
b.temperature, pulse, respirations and bp
c.temp and resp
d. bp, pulse and resp
the primary stimulus for normal breathing is a
a. alteration in blood ph
b. decrease in teh oxygen level in the blood
c. increase in teh carbon dioxide level in the blood
d. reflex action initiated by stretch receptors in the alveoli
as you take mrs.e pulse, you notice it is irregular, for what length of time would you count her pulse
a. 15 seconds
b. 30 seconds
c. 60 seconds
d. 120 seconds
how shoudl the nurse determine the proper cuff size to use in taking mr. smiths blood pressure?
a.wrap the cuff around the limb, the uninflated bladder should cover at least two thirds of the limb circumfrence
b. measure the arm one inch above the antecubital space
c. wrap the cuff around the limb, the uninflated bladder should cover about one third of the limb circumfrence
d. use a bladder six inches long
the proper technique for auscultating lung sounds includes listening for __
A. inspiration and expiration in each area
b. inspiration in each area
c. expiration in each area
d. 2 full breaths in each area
the most efficient order in which to asculate the heart is
a. aortic, pulmonic, erbs, tricuspid, mitral
b. pulmonic, aortic, tricuspid, erbs, mitral
c.erbs, tricuspid, mitral, aortic, pulmonic
d. aortics, apex, pulmonic, erbs, base
which of the following behaviors by the nurse demonstrates that the nurse is participating in crital thinking?
a. admiting not knowing how to do a procedure and requesting help
b. using clever and persuasive remarks to support an opinion or position
b. utilize a lifting device when moving the patient
d. finding a quick and logical answer, even to complex questions
e. fathering 3 assistants to help transfer the client to a stretcher after noting the client weights 300 lbs
a female night charge nurse in the icu has cared for critically ill clients for over 20 years, she is widely recognied, according to benners model of skill acquisition, this nurse is practicing which level?
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