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Foundations Nursing
Foundations Nursing set 6
| Question | Answer |
|---|---|
| Which person would be expected to have the lowest body temperature? | An 80-year-old who walked half a mile. |
| The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? | Ask the patient not to eat, drink, or smoke for 20mins and then assess the patient's oral temperature |
| For which patient would a tympanic thermometer be the preferred thermometer to use? | A tachypneic patient who is receiving oxygen by nasal cannula |
| Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) | a patient receiving a blood transfusion for chronic anemia, an adult female in the recovery room following a hysterectomy, and a young adult with a white blood count of 15,000/mm |
| The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) | Remove the patient's blankets and administer an antipyretic to the patient as ordered |
| Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? | The NAP inserts the red tipped electronic thermometer probe into the patient's mouth after applying a probe cover and the NAP wipes the single use chemical dot thermometer and places in back in the patient's drawer for future use |
| Identify the factors that may have an effect on an elderly patient's temperature: | Drinking a cold glass of water, participation in physical therapy exercises, infection, and room temperature |
| If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? | 96.8-100.4F |
| A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? | Temporal artery |
| The task of pulse assessment could be delegated to the NAP for which of the following patients? | A radial pulse on a patient with a 1200 ml fluid restriction and the temporal pulse of a child |
| Which of the following patients would be at risk for having an alteration in peripheral pulse? | The patient who was just informed of a diagnosis of cancer, a patient with peripheral vascular disease, and a patient who's receiving bolus IV fluids |
| Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? | Auscultate the apical pulse for quality and rate |
| What is the normal pulse range for an adult? | 60-100 beats per minute |
| The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. | False |
| In which of the following patients would the nurse expect to find a decrease in pulse rate? | A patient returning from the operating room and a patient who received morphine for pain |
| The new NAP is unable to palpate a patient’s radial pulse. What could be a possible explanation for this difficulty? | The NAP is assessing for a pulse on the ulnar side of the wrist and the NAP is pressing down too hard on the patient's radial site |
| What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? | Count the respiratory rate again for a full 60secs and assess physiologic factors that may be causing the patient to breathe so fast |
| Which of the following may increase both rate and depth of respiration? | Walking a mile briskly, feeling anxious when taking a test, and having an addiction problem with amphetamines/cocaine. |
| When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse’s best action? | Move the patient's arm over their chest and feel the rise an fall of the chest |
| How can the nurse best obtain an accurate measurement of a patient’s respiratory rate? | Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest |
| The nurse is validating the NAP’s skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? | When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two |
| The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? | To determine if there's a difference in the reading between the two arms |
| Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? | A football player with a diastolic BP pf 94 |
| For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? | A patient with a deep vein thrombosis |
| The student nurse is unsure of the BP measurement. What should the student nurse do first? | Assess the BP in the other arm. |
| It's 7am and the nurse takes the vital signs of a postoperative patient and finds his BP is elevated. Which of the following could explain the cause for this alteration in BP? | The patient complains of pain at a 9 on a 0-10 pain scale |
| The patient has a history of a left mastectomy. Where should the nurse take the patient’s blood pressure? | In the right arm |
| The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error." What priority action should the nurse take? | Take the patient's BP manually using a sphygmomanometer |
| The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best action by the nurse at this time? | Assess the patient yourself, including the pulse oximetry reading |
| Which patient is at high risk for for the pulse oximetry alarm to sound? | A patient with a continuous pulse oximetry reading of 84%. |
| A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? | I will turn the continuous pulse oximetry alarms off at night so you can sleep without interruption." |
| the NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? | Reassess pulse oximetry Place the patient in the high-Fowler's position Assess the patient's respiratory and cardiac status |
| reads patient's record. order for SpO2 every 4 hours. what would be the nurse's best action? 01/25/17 0800 Unable obtain pulse o2. tried X2 fingers each hand. fingers cool to touch. artificial nails. 2 L oxygen per nasal cannula. Respirations nonlabored. | Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. |
| The nurse is caring for a patient who has suffered multiple fractures after a motor vehicle accident. What assessment finding would be most critical? | Respiratory distress |
| Tendons------ | Connect bone to muscle |
| Ligaments---------- | Connect bone to cartilage |
| Cartilage----------- | Cushion joints |
| Joints--------------- | Assist movement |
| The nurse is caring for a patient in the emergency department. The health care provider has ordered antibiotics for a positive fluid specimen of the synovial joint. Which joint is infected? | Knee |
| Which mineral is stored in bone and assists with maintenance of phosphorous? | Calcium |
| Which portion of the musculoskeletal system contains both flat bones and immobile joints? | Skull |
| A nurse is caring for a patient with nervous system impairment. What symptoms may be associated? | Poor balance Involuntary movement |
| A nurse is caring for a patient with complaints of balance problems. What could be the source of this abnormal finding? | Inner ear infection |
| Electrical impulses from nerves to muscles are communicated by what? | Neurotransmitters |
| The nurse is caring for a patient who is being treated for an inner ear infection. What is an expected assessment finding? | Dizziness |
| Which complication associated with immobility affects the neurologic system? | Damage to the cerebrum of the brain |
| The nurse is caring for a patient with cerebellar damage related to traumatic brain injury. What are expected side effects of this condition? | Uncoordinated movement Poor balance Inability to remain upright Unsteady gait |
| A patient complains of feeling that the room is spinning when she turns her head to the side, even though she is in a prone position. What is the suspected source of this complaint? | Inner ear fluid |
| The cardiopulmonary system is responsible for supplying the rest of the body with what? | Nutrients Chemicals Fluids |
| A patient in the telemetry unit is preparing for discharge after suffering an acute myocardial infarction. What does the nurse tell the patient about his expected level of activity after discharge? | The patient should expect that previous levels of activity will take time to rebuild. |
| male adult previously enjoyed running 5-6 miles per day now complains of a “grinding” sensation in the knee when he runs. He states that this has been a gradual problem which seems to be increasing in frequency. What could be responsible for this problem? | Cartilage |
| RN received post-surgical hip patient from PACU who is restricted to bed rest. patient lying supine in bed, pain 8/10, medicates patient with narcotic medication. What types of nursing diagnoses should the nurse assign based on this initial assessment? | Impaired Physical Mobility At Risk for Constipation Impaired Skin Integrity |
| The nurse would assign which nursing diagnosis to a patient with an unsteady gait? | Impaired Ambulation |
| What nursing diagnosis would be directly related to the goal, "Patient will experience no falls during hospital stay"? | Risk for Falls |
| Miranda new patient on orthopedic floor. currently post-op day three, total knee replacement. PT, nursing- encouraging Miranda to walk, rating pain 7/10 with movement. nurse written care plan, reevaluated bases assessment. which diagnosis fits situation | Impaired Mobility Related to Pain |
| Sarah is a post-op total hip replacement patient. She is receiving very good care by a team of professionals in the hospital. Ultimately, which provider is primarily responsible for this patient’s care? | Primary nurse |
| Which professionals would be involved in the collaboration of care for a patient with decreased movement and immobility needs? | Physical therapist Nurse Unlicensed assistive personnel |
| Tom is being discharged from the hospital after a fall at home, and the nurse is providing education for Tom before he leaves. What reminders should the nurse include in his education? Select all that apply. | The home should be free from clutter. Do not get up to walk right away if you are dizzy. Make sure to maintain a nutritious diet. |
| The primary nurse is advocating for the patient. In order to properly evaluate and treat a nursing diagnosis of impaired mobility, the nurse would contact the provider and ask for which order? | Physical therapy consults to evaluate and treat mobility. |
| Bill in car accident over week ago currently on life support. one of his diagnoses has impaired physical mobility. whom would the nurse most likely delegate care such as turning the patient every two hours to maintain skin integrity and range of motion? | Unlicensed assistive personnel |
| nurse is coming on shift and is getting the report on a bed-ridden patient. Upon entering the room, the nurse sees the patient in bed and family visiting. What type of movement and immobility nursing diagnosis could the nurse identify for this patient? | Impaired Bed Mobility |
| A post-surgical patient has been out of bed once. The patient experienced increased heart rate and increased oxygen requirements. What nursing diagnosis would the primary nurse identify for this patient? | Activity Intolerance |
| RN comes on shift goes for primary assessment on patient. assesses patient with a history of multiple sclerosis lying in bed, notices wheelchair at bedside. reports tiredness from pt. Which nursing diagnoses could be identified from this assessment? | Impaired Physical Mobility Impaired Skin Integrity |
| Why is it important for the nurse to have nursing diagnoses when assessing patients for movement and immobility issues? | To plan, collaborate, and evaluate patient-centered care plans |
| Which is an example of a goal with a measurable outcome for the nursing diagnosis Pain Related to Immobility? | Patient will maintain a tolerable pain level of 2/10 during hospital stay. |
| A nurse is discussing the advantages of exercise with a patient with limited mobility. What benefit should the nurse include in the discussion to help facilitate normal movement? | Exercise promotes muscle strength. |
| A nurse is encouraging an immobile patient to turn in bed as a form of isotonic exercise. The patient asks how isotonic exercises work. What is the nurse’s best response? | Isotonic exercises involve active movement with constant muscle contraction. |
| nurse working with patient who has history of falls, displaying generalized weakness, requires assistance with ambulation. patient hasnt used ambulation aid in past. Which aid would be the best choice for the nurse to use with this patient at this time? | Gait belt |
| A patient has a paralyzed right upper extremity and will be undergoing physical rehabilitation. What device would be appropriate to keep the wrist in a functional position? | Splint |
| Following surgery to repair a fractured femur, a patient is asking for something to help with repositioning in bed. Which device would be the most appropriate for this patient? | Trapeze bar |
| The health care team is discussing safe patient handling. A team member asks about available evidence on the subject. Which statement would most accurately reflect current available evidence on safe patient handling? | When moving patients, colleague assistance can reduce nurse injuries. |
| The nurse is teaching a patient coughing techniques. What instruction should be part of that education? | Take two deep breaths in and out to start. |
| A patient asks the nurse how often deep breathing exercises should be performed. What is the appropriate response from the nurse? | Perform 3 to 5 deep breaths in a row and repeat them 10 times per hour. |
| A nurse is caring for a patient on bed rest. The patient does not wish to wear the sequential compression sleeves and asks the nurse why they are so important. What should the nurse say to the patient? | "They help prevent blood clots in your legs, which puts you at risk for a pulmonary embolism." |
| A nurse is teaching a student nurse how to put on antiembolism stockings. Which action would indicate the student nurse understood the teaching? | The student nurse checks the circulation in the patient's toes once the stockings have been applied. |
| The nurse is caring for patient on prolonged bed rest who is refusing to eat. The patient states he has no appetite. What modification should the nurse make to the plan of care to address this issue? | Offer the patient smaller, more frequent meals |
| A bedridden patient is refusing to drink any fluids because of the fear they will have to use the bedpan. What should the nurse say to the patient? | "I understand you don't like using the bedpan; however, drinking fluids helps prevent urinary tract infections and constipation." |
| The nurse is caring for a comatose patient who is at high risk for skin breakdown. The practitioner orders PRAFO boots for the patient. The patient’s spouse asks what a PRAFO boot is. What is an appropriate response from the nurse? | It is rigid aluminum-framed boot, lined with sheepskin, and used to prevent pressure on the heels. |
| RN interested in participating in study regarding use of nursing interventions to decrease patient’s risk for impaired skin integrity. Based on the current review of literature, which should focus of research in prevention of pressure ulceration? | Determining the most effective positions Establishing protocol for the frequency of repositioning |
| The nurse initiates a variety of interventions to decrease a patient’s stress level before undergoing a series of surgical procedures. The nurse knows this is important because stress places the patient at risk for which complication? | Delayed wound healing |
| A nurse is caring for a patient with neurologic impairment. The health care provider has documented that the patient has lower extremity flaccidity. What does this mean? | Lack of muscle tone |
| A nurse is caring for a patient with osteoporosis. In which type of patient is this condition most prevalent? | Older Asian female |
| A patient asks the nurse what dietary supplements to take to reduce the chance of developing brittle bones later on in life. What is the best response by the nurse? | Calcium Vitamin D |
| What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? | Early ambulation after surgery |
| The nurse is caring for an older female patient with recent stroke. In the shift report, the nurse learns that the patient has right-sided hemiparesis. What does this mean? | Impaired movement of the right side |
| The nurse is caring for a young adult male in the emergency department. The patient was involved in a motorcycle crash and is now unable to move any of his extremities. What is the expected documentation of this condition? | Quadriplegia |
| The rehabilitation nurse is caring for a patient with loss of sensation to the lower extremities. What type of injury is related to this? | Lower spinal cord trauma |
| The rehabilitation nurse is caring for a patient with a history of cerebrovascular accident. The MRI revealed that the injury occurred on the right side of the brain. What are the expected impairments? | Left-sided hemiparesis |
| The rehabilitation nurse is caring for a patient with inability to move all four extremities. What type of injury is related to this? | Cervical spinal cord trauma |
| nurse is caring for a patient in the telemetry unit who is complaining of a recent decrease in her ability to perform activities of daily living (ADLS) and routine exercise. Which conditions are possible contributing factors? | Heart failure Peripheral vascular disease COPD |
| A patient has been diagnosed with heart failure. He asks the nurse for clarification on which part of the heart is ineffective. The nurse teaches the patient that heart failure is related to what? | Impaired ventricle |
| A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? | Calcium should be taken with vitamin D to increase calcium absorption. |
| Which cardiopulmonary condition is caused by chronic airway inflammation? | COPD |
| An older adult male is on prolonged bedrest, related to lower extremity trauma. Which cardiopulmonary condition is a concern in this patient? | PVD |
| The nurse is caring for a patient with PVD. Which nursing interventions are expected to be included in the plan of care? | Ambulation Lower extremities elevated |
| The nurse is asking the patient about how far the patient walks each day. The patient asks the nurse why that information is important. What is the nurse’s best response? | "It gives us information about your activity and agility." |
| A patient who has been immobile at home for the last three months is admitted to the hospital. Which problems should the nurse anticipate finding when the patient is examined? | Atrophy of the muscles Contractures Pain with joint movement Joint stiffness |
| The nurse is observing a patient ambulate around the room and notes the patient has an unsteady gait. What action should the nurse take next? | Initiate a fall prevention plan for the patient. |
| The nurse is caring for a patient who has been in bed for several days after surgery. The nurse has orders to get the patient out of bed to a chair. What action should the nurse take first? | Allow the patient to dangle. |
| The nurse is caring for a patient with trauma to the cerebellum. What problem should the nurse anticipate when getting the patient out of bed? | Balance and stability issues |
| An immobile patient had been admitted to the unit following a fall out of bed. The patient is coughing up thick secretions. What action should the nurse take next? | Notify the health care provider that the patient may have pneumonia. |
| nurse working with student nurse who asks about orthostatic hypotension. The nurse responds that it occurs when the patient stands up and experiences a sudden change in vital signs. Which changes in vital signs are indicative of orthostatic hypotension? | Drop in systolic blood pressure of 20 mm Hg Increase in heart rate of 20 beats/min Drop in diastolic pressure of 10 mm Hg |
| While performing an assessment, the nurse notes that a patient has developed redness, warmth, and swelling in the right lower leg. What complication does this place the patient risk for? | Pulmonary embolism |
| While caring for an immobile patient, the nurse notes the patient has a poor appetite. What action should the nurse take to encourage the patient’s nutritional intake? | Interview the patient for food preferences. |
| While talking about nutrition with a patient who has been on bed rest for several days, the patient states, “I am just not hungry. I don’t understand it. I am always hungry.” What is the nurse’s best response to this statement? | "You have been immobile for several days, which can decrease your basal metabolic rate and appetite." |
| A nurse is caring for a comatose patient and is concerned that the patient may develop a urinary tract infection. Which items should be included in the nurse’s assessment? | Fluid intake and output Concentration and odor of urine Urinary frequency |
| A patient on bed rest is concerned about developing constipation. What actions should the nurse take to prevent this from happening? | Increase the patient's dietary fiber and fluid intake. |
| While caring for a comatose patient, a nurse asks a new graduate nurse what the Braden Scale is used for. Which response indicates that the new nurse understands the purpose of the Braden scale? | "It is a standardized tool used to identify patients at risk for pressure ulcers." |
| nurse is caring for an immobile patient who refuses to turn on his side and lays on his back most of the time. Due to the patient’s position, the nurse is most concern that this behavior will contribute to the patient’s development of what complication? | Pressure ulcer |
| nurse has been caring for a patient on bed rest for the last several days. The patient has been calm and cooperative. Today, however, patient is angry and upset about being woken up every night. The nurse suspects patient may be developing which problem? | Sleep pattern disturbance |
Created by:
colby.caswell