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Foundations of Nursing Chapters 42-45, 49
Terms in this set (50)
Impaired immune function
Many kinds of noise are generated during the delivery of health care in a variety of settings. What may be the effects of these noises on the patient?
Ask the patient to describe the purpose of the PCA device.
Emphasize that the patient controls medication delivery.
Explain that the pump prevents the risk of overdose.
The nurse is teaching a patient the use of patient-controlled analgesia (PCA). Which interventions should the nurse perform?
Excessive daytime sleepiness
What is the most common complaint by patients who have narcolepsy?
A patient develops a mild allergic reaction during a blood transfusion. Which should the nurse administer to manage this allergic reaction?
The patient's report of pain is the best method for assessing the pain.
The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain, because he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain?
Ensuring that the drip chamber is at least half full
Preparing for changing the solution when 50 mL of fluid remains in the container
Which nursing intervention should be carried out to prevent the vein from clotting during intravenous infusions?
Temporarily slowing the infusion rate to 10 gtt/minute
While caring for a patient on intravenous (IV) therapy, the nurse observes symptoms of dyspnea and crackles in lungs due to sudden infusion of a large volume of solution. What should be the immediate nursing intervention?
Deficient fluid volume related to vomiting
While caring for a patient with gastroenteritis, the nurse finds a supine blood pressure of 90/58 mm Hg and a heart rate of 102 bpm. What condition does the nurse suspect?
How long before bedtime should a patient take melatonin? Record your answer using a whole number.
At which stage of human development does sleep duration at night begin to decline?
Administration of diuretics
A patient has acute intravascular hemolysis as an adverse effect of transfusion reaction. Which nursing intervention will be beneficial?
"I should monitor the IV infusion site every 3 hours."
The registered nurse is teaching a nursing student regarding regulation of the intravenous (IV) flow rate. Which statement if made by the nursing student indicates a need for further learning?
"I must use a distal site first, then a proximal site."
"I must refrain from using hand veins in ambulatory patients."
The registered nurse is discussing with a nursing student the nursing interventions performed while initiating an intravenous (IV) line. Which actions taken by the nurse indicate effective understanding?
The route of administration of the analgesic is not correct.
A patient who is in the terminal stages of liver cancer reports continuous vomiting after taking oral opioid analgesics. The patient's weight is 85 pounds. The nurse applies a transdermal fentanyl patch to the patient. The next day, the patient informs the nurse that the pain is not alleviated. What could be the possible reason for this?
A patient with chronic diarrhea shows Chvostek's sign. What might be the reason behind the patient's condition?
Inspect intravenous site and check for patient complaints.
Review the type and amount of intravenous fluid ordered.
Perform hand hygiene when handling intravenous devices.
The nurse is caring for a patient who is undergoing intravenous (IV) fluid therapy to correct dehydration. Which measures should the nurse take to prevent complications related to IV lines?
Severe facial swelling
What are the potential adverse effects of sleep medications?
Kneading downward along one side of the spine from the shoulders to the buttocks.
The registered nurse is evaluating the performance of a student nurse who is performing a back massage for a patient with back pain. Which action by the student nurse needs correction?
Human immunodeficiency virus (HIV)
The nurse works at a blood bank. For which diseases should the nurse screen in blood donors?
Offering fluid frequently in large amounts as tolerated.
A patient with gastroenteritis is experiencing dehydration due to vomiting and diarrhea. Which nursing intervention requires correction?
"Intensity of the pain does not accurately indicate the tissue damage."
The nurse is evaluating the statements made by the nursing student about pain. Which statement made by the nursing student is true?
The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate should the nurse program into the infusion pump?
The child has moderate pain.
After assessing pain in a 9-year-old child using a numeric rating scale (NRS), the nurse documents the score as 5. What does the nurse interpret from this score?
Massaging the patient's legs and calf muscles.
The nursing student is massaging the patient who has peripheral vascular disease to provide relaxation by reducing pain. Which action if performed by the nursing student indicates a need for correction?
By pretreating with antipyretics
By considering leukocyte-poor blood products
How can the nurse prevent the development of febrile nonhemolytic reactions in the patient during blood transfusions?
Positioning the patient during insertion
Which skill should the nurse delegate to nursing assistive personnel when providing care to a patient receiving enteral feedings?
Presbyopia and the need for glasses for reading
When assessing a 45-year-old patient's sensory status, which assessment findings does the nurse consider a normal part of aging?
When assessing a patient prior to insertion of an enteral feeding tube, which finding should alert the nurse to poor nutrition?
Promote the use of safety equipment.
Avoid the use of toys with pointed projections.
Instruct the children not to run while carrying pointed objects.
The community health nurse is educating a group of parents on ways to avoid eye trauma. What instructions should the nurse include in her teachings?
Decreased nutritional status
The nurse is caring for a patient with dysphagia. Of what complications of dysphagia should the nurse be aware?
During which phase of the nursing process does the nurse consult other health care professionals to adopt the best nursing intervention for a patient diagnosed with nutritional disturbances?
Plan menus a week in advance.
Avoid grocery shopping when hungry.
Use evaporated milk for cooking.
The nurse is consulting with a patient about meal planning on an allocated budget. What advice should the nurse provide to help ensure good nutrition on a budget?
Placing the patient in reverse Trendelenburg's position
The nurse is administering an enteral feeding to a patient who must remain in a supine position. Which nursing action is appropriate?
Both are antioxidants.
How are selenium and beta-carotene similar?
Providing information about local social groups in the patient's neighborhood.
Recommending that the patient consider making living arrangements that will put him closer to family or friends.
Introducing the idea of bringing a pet into the home.
A patient with a history of a hearing deficit comes to the medical clinic for a routine checkup. His wife died 2 years ago, and he admits to feeling lonely much of the time. What are some interventions the nurse uses to reduce loneliness?
Both are mechanisms for intestinal absorption of nutrients.
Both involve movement of particles from an area of higher concentration to one of lower concentration.
How are active transport and passive diffusion similar?
Calculate the energy provided by a slice of bread containing 2 g of protein, 1 g of fat, and 20 g of carbohydrate. Record your answer using whole number.
Vitamin A is stored in the body.
Vitamin A is a fat-soluble vitamin.
How is vitamin A different from vitamin C?
Carpal tunnel syndrome
In which condition does alteration of tactile sensation occur due to the pressure on the median nerve?
A 70-year-old patient is admitted to the hospital post stroke. The patient suffers from right-sided hemiplegia and dysphagia. Which complication of dysphagia might the nurse observe in the patient?
Observe the patient's behavior in a group.
Use the tuning fork test.
Use the spoken word test.
The nurse is planning to conduct a hearing acuity test on a patient. What are the different activities through which the nurse may assess this sensory function?
Decreased folic acid absorption
What drug-nutrient interaction do aspirin and sodium bicarbonate have in common?
Which term refers to the process in which biochemical substances break down into simpler substances during physiological states of negative nitrogen balance?
Provide constant reorientation.
Control excessive stimuli.
A junior nurse is caring for a patient in the intensive care unit (ICU). She finds that the patient is restless, anxious, and inattentive. The nurse understands that the patient is experiencing sensory overload. What measures should the nurse take to make the patient comfortable?
Discarding gastric contents
Which nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding?
Food rich in fiber relieves constipation.
Fluid and fiber intake should be increased.
Fruits and vegetables relieve constipation.
The nurse is caring for a patient diagnosed with hemorrhoids. While taking the patient's clinical history and vitals, the nurse finds that the patient has chronic constipation. What should the nurse teach the patient about the diet?
By providing touch therapy to the patient
Following an assessment, the nurse finds that a patient has reduced tactile sensation. How does the nurse improve the patient's tactile sensation?
Fear of becoming fat despite being significantly underweight
Upon assessing a patient, the nurse suspects anorexia nervosa. What behavioral finding may have led the nurse to this suspicion?
Increased difficulty with balance
Which proprioceptive change is observed in older adults?
Infusing a bolus of formula over 20 to 30 minutes
Which nursing action is appropriate when advancing the rate of an intermittent tube feeding?
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