• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/38

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

38 Cards in this Set

  • Front
  • Back
To evaluate your Activity tolerance nursing plan for Mrs Gonzales, at the end of 12 weeks an indication of its effectiveness would be that Mrs. Gonzales:
1. Has lot 15 Pounds
2. Has full range of motion to all joints without experiencing pain.
3. Jogs 5 city blocks twice a week
4. Participates in an exercise program at the YWCA 3 days a week.
4. Participates in an exercise program at the YWCA 3 days a week.
Ms Potts is morbidly obese. She underwent abdominal surgery 3 days ago. She informs the nurse that as she was coughing, she felt a "pop" at the incision site. Upon inspections, the nurse notes that the sutures to the incision are intact, however, there is an increase in the amount of serosanguineous drainage. The nurse would suspect wound.
1. Evisceration
2. Fistula
3. Hemorrhage
4. Dehiscence
4. Dehiscence
While caring for a 27-yr-old man on a mechanical ventilator, the ventilator alarms sound. On entering the patient's room, the nurse notes that he is very agitated and his skin is ashen and diaphoretic. His pulse oximeter shows an oxygen saturation of 78%. The nurse is unable to identify any obvious problems with the ventilator. The first step the nurse should take is to:
1 Assess his breath sounds
2 Call the respiratory therapist to troubleshoot the probem
3. manually ventilate him with an Ambu-bag
4 Contact the physician
3. manually ventilate him with an Ambu-bag
The duration of sleep is regulated by the:
1. Electrical impulses transmitted from the cerebral cortex to the cerebellum
2. Person's innate biorhythms
3. Amount of sleep a person usually requires.
4 Reticular activating system
4 Reticular activating system
The head of the bed of a patient who is receiving enteral feedings is elevated to 30 degrees. Which complication associated with enteral feedings does this intervention help prevent?
1. Aspiration
2. Diarrhea
3. Infection
4. Electrolyte imbalane
1. Aspiration
Which of the following goals is appropriate for a client without underlying cardiopulmonary disease who is being monitored with continuous pulse oximetry?
1. Patient will refrain from movement while monitored in order to ensure accurate readings.
2 oxygen saturation will remain at 80%-90% during hospitalization
3 Patient will report pain as less than 3 on a scale of 1-10 during monitoring
4 Oxygen saturation will remain at 95%-100% while monitored.
4 Oxygen saturation will remain at 95%-100% while monitored.
Respiratory function involves which four body systems?
1 Respiratory, neurological, endocrine, and cardiovascular
2 Respiratory, cardiovascular, neurological, and integumentary
3 Respiratory, cardiovascular, neurological, and musculoskeletal
4 respiratory, musculosckeletal, cardiovascular, and endocrine
3 Respiratory, cardiovascular, neurological, and musculoskeletal
The most appropriate nursing diagnosis for Mr Jerome, who developed a fistula, at this time would be:
1. Risk for infection related to dehiscence of wound
2 Body Image Disturbance related to nonhealing surgical wound
3 Risk for impaired skin integrity related to wound drainage
4 Pain related to surgical incision.
3 Risk for impaired skin integrity related to wound drainage
Mrs Ray is a 50-yr-old woman who had a surgical repair of a fracture of her right tibia 2 days ago. She has been using crutches for ambulation and must remain non-weight bearing on her right leg, but must learn to use the steps leading into her house. The nurse should instruct Mrs Ray to:
1 Lay the crutches down and hop on the left leg when going up or down the stairs
2 Use the crutches, maintaining toe-touch weight-bearing on the right leg when going up or down the stairs
3 Have someone carry her up and down the stairs
4 Lead with the left leg when going up steps, and lean with the right leg when going down steps.
4 Lead with the left leg when going up steps, and lean with the right leg when going down steps.
The nurse is caring for a 14-yr-old boy with a history of asthma. He is currently being treated for acute bronchitis. A thorough nursing assessment of his pulmonary status will include (select all that apply)
1. Skin color and temperature
2 Auscultation of breath sounds
3 Testing of cough reflex
4 Chest x-ray
1. Skin color and temperature
2 Auscultation of breath sounds
To obtain the most accurate culture information of a chronic wound, the nurse would recommend:
1 Tissue biopsy
2 swab culture
3 sterile culture
4 Needle aspiration culture
1 Tissue biopsy
Mr Jerome had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects Mr Jerome has:
1 An infected wound
2 Wound dehiscence
3 A hematoma
4 A fistula
4 A fistula
A 10-yr-old boy fell on the playground. He is complaining of pain in his right forearm. The nurse notes that the boy's arm is swelling and tender to touch. There is an area of protrusion on the lateral aspect of his arm, which upon palpation is very firm. The nurse suspects a fracture; however, her suspicion cannot be confirmed until
1. A venous and arterial Doppler are obtained
2. The boy demonstrates that he cannot use his arm
3 The swelling is decreased by applying ice
4 An X-ray is obtained
4 An X-ray is obtained
What signs and symptoms might the nurse expect to see in a patient experiencing hypxia?
1 Altered level of consciousness
2 Peripheral pitting edema
3 Cyanosis of skin and mucous membranes
4 Weak or absent peripheral pulses
1 Altered level of consciousness
3 Cyanosis of skin and mucous membranes
4 Weak or absent peripheral pulses
Mrs Lore required a colostomy after surgery for colon cancer. She has refused to participate in the care of her colostomy or meet with a support member from the ostomy society. She will not look at the site and describes the colostomy as "inhumane". Based on these data, the priority nursing diagnosis for Mrs Lore is:
1. Anxiety related to colostomy
2 Disturbed body image related to colostomy
3 Disturbed Body image related to incontinence of stool
4 Impaired skin integrity related to fecal drainage
2 Disturbed body image related to colostomy
The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3cm X 2cm X 1cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o'clock to 3 o'clock under the wound edges. The nurse would document this as:
1 State IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00
2. State III pressure ulcer with undermining of 3 cm from 12:00 to 3:00
3. Stage IV pressure ulcer with sinus tract from 12:00 to 3:00
4. Stage III pressure ulcer with sinus tract from 12:00 to 3:00
2. State III pressure ulcer with undermining of 3 cm from 12:00 to 3:00
Depression, hyperthyroidism, hypothyroidism, pain, and sleep apnea are examples:
1 Disorders that are provoked by sleep
2 Parasomnias
3 Conditions that cause secondary sleep disorders
4 Disorders associated with narcolepsy
3 Conditions that cause secondary sleep disorders
Mrs Gonzales is morbidly obese with complaints of extreme fatigue. She states, "I am so tired, I can't even clean the house without resting every 5 minutes." Her vital signs are with in normal limits at rest; however, upon minimal exertion she experiences dyspnea, and her pulse rises from 68 to 146. She denies chest pain and has full range of motion to all joints. The physician explains to Mrs Gonzales that she needs to lose weight and begin an exercise program. The nurse has started discussing a diet plan and exercise program with Mrs Gonzales. During her assessment, Mrs Gonzales states, "I can stick to the diet with no problem, but I have tried to exercise before and it doesn't make a difference." The best nursing diagnosis for Mrs Gonzales is:
1. Impaired Physical Mobility related to obesity
2. Risk for disuse syndrome related to musculoskeletal inactivity
3. Activity intolerance related to morbid obesity and dyspnea secondary to sedentary lifestyle.
4 Impaired Physical Mobility related to limited range of motion, secondary to obesity
3. Activity intolerance related to morbid obesity and dyspnea secondary to sedentary lifestyle.
Which of the following nursing interventions would be appropriate for Mrs Gonzales who has a diagnosis of activity intolerance? Encourge Mrs Gonzales to (select all that apply)
1 Participate in a scheduled exercise program
2 Participate in activities outside of the home
3 Increase her fluid intake
4 Increase the length of time between rest periods
1 Participate in a scheduled exercise program
2 Participate in activities outside of the home
4 Increase the length of time between rest periods
Langerhans cells are:
1 Protein-containing cells that give the skin strength and elasticity
2 Cells that provide protection from ultra light
3 Mobile and able to phagocytize foreign material
4 Located in the dermal layer of the skin
3 Mobile and able to phagocytize foreign material
Mr Cannes developed a wound 16 days ago. When performing a wound assessment, the nurse notes the formation of granulation tissue in the wound bed and recognizes that Mr Cannes is in this stage of wound healing
1. Proliferative phase
2. Maturation phase
3. Aggregation phase
4. Inflammatory phase
1. Proliferative phase
Mr Vann has a 3.0 cm X 2.0 eschar on the right heel. The best treatment choice for this wound is:
1 Elevate the right heel off the bed
2 Request a surgical consult for debridement of the area
3 Apply a hydrocolloid to promote autolytic debridement of the wound
4 Request an order for an enzymatic debridement medication
1 Elevate the right heel off the bed
The nurse is planning goals for activity intolerant Mrs Gonzales. Which of the following NOC outcome(s) relate(s) directly to the above nursing diagnosis; that is, which outcome(s), if achieved, would demonstrate resolution of her problem? Select all that apply.
1. Endurance
2. Activity Tolerance
3. Active Joint Movement
4. Mobility Level
1. Endurance
2. Activity Tolerance
The nurse will know interventions were successful when Mrs Lore:
1. Demonstrates the proper method of cleansing her skin
2. Demonstrates proficiency when providing treatment to excoriated skin
3. States she will start caring for the colostomy after she gets home
4. Proficiently performs colostomy care prior to discharge
4. Proficiently performs colostomy care prior to discharge
The nurse is caring for a 78-yr-old woman who was admitted 3 days ago following a cerebrovascular accident. She has had trouble swallowing and has been placed on aspiration precautions. Care of this patient will include (select all that apply)?
1. Ensure she is sitting upright or with the head of the bed elevated to eat and drink
2. Break or crush her pills (if appropriate) before administration
3. Provide only thin, clear liquids
4. Keep suction setup available at all times
1. Ensure she is sitting upright or with the head of the bed elevated to eat and drink
2. Break or crush her pills (if appropriate) before administration
4. Keep suction setup available at all times
The hospital nurse has orders to administer 0400 medications to Mrs Giovanni. Mrs Giovanni is asleep when the nurse enters the room. She is very hard to arouse and confused. Identify the state of sleep Mrs Giovanni was in when the nurse awakened her.
1. REM Sleep
2. Stage IV
3. Stage III
4. Stage II
2. Stage IV
During an admission assessment, the patient reports that he takes vitamin E supplements twice a day. The nurse should explain that taking vitamin E supplements three times a day:
1. Ensures health vision
2. Can lead to toxicity
3. Strengthens the immune system
4. Helps maintain body tissues
2. Can lead to toxicity
During parenteral nutrition administration, a nurse breaks sterile technique. For which complication does this place the patient at risk?
1. Air embolism
2.Sepsis
3. Thrombosis
4. Pneumothorax
2.Sepsis
Mr Green is 50 years old and has no known medical problems, although he is slightly overweight. He tells the nurse that he is a computer programmer and gets little exercise. The nurse suggests to Mr Green that an exercise program would be beneficial, and he states, "I would like to exercise, but I am afraid I will have a heart attack and die, like my father did, if I strain my heart too much."
1. "I understand why you might feel this way"
2. "There is a history of heart attack in your family;tell me more about that"
3. "the risk of having heart attack during strenuous exercise is one in 1 million for a healthy 50-yr-old male who does not smoke or have diabetes"
4. "The risk of having a heart attack during strenous exercise increases in a high-risk patient such as you"
3. "the risk of having heart attack during strenuous exercise is one in 1 million for a healthy 50-yr-old male who does not smoke or have diabetes"
To promote exercise for Mrs. Gonzales, the nurse's best statement would be:
1. "I know exercising is hard, but it is something you are just going to have to do to remain healthy"
2. "From your past experience, I know you feel that exercise didn't make a difference, but gaining weight and getting out of shape takes time, and reversing these changes also takes time"
3. "I know exactly how you feel; I hate to exercise, too"
4. "From your past experience, I know you feel that exercise didn't make a difference; however, the problem was probably the exercise program you participated in"
2. "From your past experience, I know you feel that exercise didn't make a difference, but gaining weight and getting out of shape takes time, and reversing these changes also takes time"
Which food provides the only animal source of carbohydrate?
1. Beef
2. Eggs
3. Milk
4. Chicken
3 Milk
In what structure of the pulmonary system does inhaled air come in contact with the blood of the pulmonary circulation?
1. Apex of the lungs
2. Alveolar-capillary membrane
3. Cilia in the bronchi
4. Right and left main-stem bronchi
2. Alveolar-capillary membrane
Which action should the nurse take after administering a dose of medication through a percutaneous endoscopic gastrostomy (PEG) tube?
1. Continue the enteral feeding
2. Flush the tube with 30 ml of water
3. Wait 2 hours before resuming the feeding
4. Check residual volume
2. Flush the tube with 30 ml of water
The nurse is counseling a 17-yr-old on smoking cessation. The nurse should include the following helpful tips in her education (select all that apply)
1. Keep healthy snacks or gum available to chew instead of smoking
2. Do not tell your friends and family you are trying to quit, so you will not have to explain if you are unsuccessful
3. Plan a time to quit when you will not have many other demands or stressors in your life.
4. Reward yourself with an activity you enjoy when you quit smoking.
1. Keep healthy snacks or gum available to chew instead of smoking
3. Plan a time to quit when you will not have many other demands or stressors in your life.
4. Reward yourself with an activity you enjoy when you quit smoking.
The nurse is providing care to a pregnant woman in preterm labor. The patient is 33 weeks pregnant. Initially the patient states, "I've gained 30 pounds. That should be enough for the baby. Everything will be OK if I deliver now." The nurse will know her teaching is effective if the patient later make which of the following statements?
1. "The baby's lungs are well developed now, but he will be at increased risk for Sudden Infant Death Syndrome if I deliver early."
2. "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early"
3. "If I deliver this early my baby is at risk for Respiratory Distress Syndrome, a condition that can be fatal"
4. "Thanks for reassuring me. I was pretty sure there isn't any risk to the baby this far along in my pregnancy"
3. "If I deliver this early my baby is at risk for Respiratory Distress Syndrome, a condition that can be fatal"
A patient who is receiving a continuous enteral feeding at 80 ml/hour has a residual volume of 120 ml 6 hours after the last check. How should the nurse proceed?
1. Continue administering the enteral feeding
2. Hold the enteral feeding and notify the physician immediately
3. Hold the feeding for 1 hour and recheck
4. Hold the feeding for 2 hours, then resume the feeding
3. Hold the feeding for 1 hour and recheck
A 45-yr-old woman presents to the emergency department with complaints of shortness of breath, anxiety, dizziness, and numbness and tingling around her mouth. Her respirations are deep, at a rate of 28 per minute. Her lungs are clear with good aeration throughout. Oxygen saturation is 100%. An arterial blood gas shows a PO2 of 110 and PCO2 of 29. Based on this assessment, an appropriate nursing diagnosis would be:
1. Ineffective airway clearance
2. Decreased Cardiac Output
3. Impaired gas exchange
4. Hypocarbia
3. Impaired gas exchange
The nurse must verify enteral tube placement before administering a tube feeding. Which method should she use?
1. Place the proximal end of the tube in water, if no bubbling occurs, placement is confirmed
2. Inject 30 cc of air into the proximal end of the feeding tube while auscultating the stomach; a swooshing sound confirms placement
3 Aspirate stomach contents from the proximal end of the tube, and measure the pH
4. Obtain a chest x-ray
3 Aspirate stomach contents from the proximal end of the tube, and measure the pH