Final exam part 2 Flashcards
1
Q
What does Pallor mean?
A
Decreased hematocrit
2
Q
This type of laxative/cathartic can lead to dependence for defecation
A
Stimulant
3
Q
what enema solution is isotonic?
A
Normal saline
4
Q
stimulation of the vagus nerve can cause:
A
A decrease in HR
5
Q
which laxative is least likely to cause fluid and electrolyte shifts?
A
Bulk forming
6
Q
which type of enema pulls fluid into the intestine to stimulate peristalsis?
A
Hypertonic
7
Q
A BMI of 31.2 indicates what?
A
Obese
8
Q
which finding indicates a client with a nutritional deficit?
A well healing wound
Triglycerides of 200 mg/dL
Positive Nitrogen balance
Albumin of 2.9 g/dL
A
Albumin of 2.9 g/dL (normal is 3.4-5.4)
9
Q
a potato is an example of what specific type of nutrient?
A
Polysaccharide
10
Q
Beef contains what type of fat?
A
Saturated
11
Q
what is minimum daily intake of water for adults?
A
1,500 mL
12
Q
What vitamin is spinach a major source for?
A
Vitamin E
13
Q
clients with cancer have what metabolic needs?
A
Increased
14
Q
what is essential to clients with AIDS bc of their reduced resistance to infection?
A
Food safety
15
Q
popsicles can be given for which diet?
A
Clear liquid
16
Q
a client with heart failure or hypertension will often prescribed a diet limiting what?
A
Sodium and saturated trans fats
17
Q
what is not limited on a renal diet?
A
Carbohydrates
18
Q
what liquid consistency is as thick as heavy syrup and can be sipped through a straw?
A
Nectar
19
Q
orthopnea
A
SOB when lying down
20
Q
Dyspnea
A
Difficulty breathing, SOB
21
Q
Hemoptysis
A
Bloody sputum
22
Q
tachypnea
A
RR >24 and shallow
23
Q
hyperventilation
A
RR >24 and deep
24
Q
Bradypnea
A
RR<10
25
RR <10 and irregular and shallow
Hypoventilation
26
wax and wean with apnea (regular)
Cheyne-stokes
27
Biot respiration
Wax and wean with apnea (regular)
28
COPD respiration
Prolonged expiration with dyspneic episodes
29
palpable vibration assessment
Tactile fremitus
30
What breath sound is high-pitched monophonic crowing on inspiration (possibly life threatening)
stridor, upper airway obstruction, croup or acute eipiglottitis, foreign body inhalation
31
Dysmetria
Incoordination
32
dyskinesia
Involuntary movement
33
Spinothalmic tract
Pain, temperature, light touch
34
posterior column tract
Vibration, kinesthesia, tactile discrimination
35
Stereognosis
identify objects in hand with eyes closed
36
Graphesthesia
Draw picture on client with their eyes closed, can distinguish shape
37
two point discrimination
Can distinguish two separate touches at two locations of same stimuli
38
extinction
Whether they can sense one stimuli in the presence of another (does it disappear)
39
point location
Determine if same stimuli is at same place (two interactions)
40
Ramadan
Islam
41
ash Wednesday’s and lent
Roman Catholics
42
You kippur
Judaism
43
Kosher
Orthodox Judaism and islam
44
religious vegetarians
Seventh day Adventist, Hinduism, buddhism
45
What do you start with amount wise for feeding someone with dysphagia?
1/4 tsp
46
Which QSEN competency is being demonstrated when the staff nurses research and implement new safety guidelines?
Quality improvement
Patient centered care
Teamwork
Safety
Quality improvement
47
which role is the nurse performing when they call the primary care provider to report a change in a client’s status?
Scholarly inquiry
Collaboration
Leadership
Stewardship
Collaboration
48
which strategies should the nurse take to improve critical thinking? (Select all that apply
Use a journal to write about the outcomes of clinical judgements
Find a mentor
Limit consultations with other professionals involved with a clients care
Make quick decisions when unsure about a clients needs
Review articles about evidence-based practice
Use a journal to write about the outcomes of clinical judgements, find a mentor, review articles about evidence-based care
49
After receiving pain medication, a client report's their pain as not relieved. Based on this evaluation, which action should the nurse take, according to the nursing process?
Reassess the client.
Wait 24 hours.
Educate the client about pain management.
Provide different pain relief.
Reassess the client
50
Which QSEN competency is being performed when the nurse assesses a client's need for spiritual support?
Quality Improvement
Patient Centered Care
Teamwork
Evidence-Based Practice
Patient centered care
51
Which action will the nurse take to perform culturally competent care for a client?
Value the client's life patterns and their meanings.
Value personal beliefs over all others.
Redirect the client to the nurses life patterns.
Teach the client about their community's cultural norms.
Value the clients life patterns and their meanings
52
Which attitude should the nurse display when practicing patient centered care?
Value seeing health care situations, "through the clients' eyes"
Recognize that a client's family and friends are not a part of providing patient centered care.
Recognize that healthcare outcomes should be the same for all clients.
Value the healthcare providers expertise above the client's values related to thier health.
Value seeing healthcare situations “through the clients’ eyes”
53
Which action will the nurse take when planning care for a client?
Standardize interventions to client medical diagnosis.
Never utilize previous nursing experience.
Work with the client to set realistic goals.
Only include the medical team in planning goals.
work with the client to set realistic goals
54
Which role is the nurse taking when discussing the wishes of a critically ill client to the family?
Communicator
Educator
Caregiver
Advocate
Advocate
55
Which step in the nursing process is the nurse taking when asking a client for their pain level 20 minutes after administering pain medication?
Evaluation
Assessment
Implementation
Diagnosis
Evaluation
56
The nurse is admitting a client diagnosed with Mycobacterium tubuerculosis. Which type of isolation will the nurse assign for this client?
Airborne isolation
Contact isolation
Protective isolation
Droplet isolation
Airborne isolation
57
The nurse is documenting client data. Which of the following should the nurse identify as subjective data?
Dizziness
Hypertension
Bloody drainage
Fever
Dizziness
58
Which of the following actions will the nurse perform to implement patient centered care during a client interview?
Telling the client their goals for the day
Begin the interview with a series of close-ended questions.
Keeping the client's room door open.
Sit face to face and make eye contact with the client.
Sit face to face and make eye contact with the client
59
The nurse will perform which action when correctly following standard precaution recommendations?
Wear a mask when changing the linens on a client's bed
Wear a gown when completing a physical assessment.
Wear gloves when changing a wound dressing on a client.
Wear a gown to transfer a client to the bed side chair.
Wear gloves when changing a wound dressing on a client
60
The nurse is caring for a client who does not speak English. The nurse who is linguistically competent will take which action to ensure effective communication with the client?
Ask the client's bilingual sister to interpret healthcare information.
Advise the client that language assistance services cost extra.
Use a qualified medical interpreter who speaks the client's dialect.
Speak to the client slowly and in short sentences in English.
Use a qualified medical interpreter who speaks the client’s language
61
Which of the following would the nurse note as an performing a general survey on a client. (Select all that apply)
The client grimacing.
The client's speech is rapid.
The client's clothing is appropriate for the weather.
The client's hands are trembling bilaterally.
The client is sitting upright.
The client is grimacing, the client’s speech is rapid, the client’s hands are trembling bilaterally
62
Which of the following nursing actions will the nurse perform during a physical exam?
Perform painful procedures toward the end of the assessment.
Document all findings of the assessment during the assessment.
Increase the speed of the assessment if the client is fatigued.
Assess the system most at risk for being abnormal last.
Perform painful procedures toward the end of the assessment
63
The nurse is preparing to entering a client's room and is going to apply complete PPE. What is the correct sequence for donning all articles of PPE?
Gown, mask, goggles, gloves
64
Which of the following abbreviations will the nurse question?
U
TID
BID
PO
U- does it stand for unit? Spell it out!
65
The nurse is assessing a group of clients for health disparities. Which client is at risk for health disparities?
The client with a high paying job
The client who regularly sees their primary care physician.
The client without health insurance.
The client who is a Caucasian heterosexual.
The client without health insurance
66
A client with dark skin who is experiencing a reduced amount of oxyhemoglobin may appear to have a yellow-brown or ashen grey skin tone. (True or False)
True
67
The nurse is assessing the integumentary system of an adult client for signs of decreased systemic fluid volume. Which intervention will the nurse correctly perform?
Tap the client's skin over the mid-clavicle.
Press a thumb into the skin over the sternum.
Pinch up the client's skin over the mid clavicle or sternum
Feel for warm and dry skin with the dorsa of the hand.
pinch up the client’s skin over the mid clavicle or sternum
68
Which temperature measurement site will the nurse use to take the most accurate temperature of a client who is short of breath and diaphoretic?
Oral
Tympanic membrane
Temporal artery
Rectal
Tympanic membrane
69
How will the nurse document the client's single elevated nevus, 0.5 cm in size, on the right shoulder of a client?
Nodule
Macule.
Wheal
Papule.
papule
70
The nurse is inspecting a client's tympanic membrane with an otoscope. What findings should the nurse expect in a healthy adult? A tympanic membrane which is:
Transparent and yellow, bulging, with drainage.
Cloudy white
Translucent and pink with a dark oval center.
Translucent pearly gray
Translucent pearly gray
71
Prior to performing eye irrigation, the nurse should remove crust on the external eye by wiping the eye from the outer canthus to the inner canthus with a moistened sterile gauze pad. T/F
False
72
The nurse is performing percussion on a healthy adult client's lung fields. Which finding should the nurse expect?
Dullness.
Tympany.
Resonance.
Hyperresonance.
Resonance
73
Which test will the nurse perform to test a client's cerebellar function?
Muscle size and strength.
Finger to nose test.
Spinothalamic test.
Finger to nose test
74
Which nursing interventions should be implemented to reduce the effects of immobility on the respiratory system.
Turn the client Q2 hrs.
Increase fluid intake
Coughing and deep breathing.
Bed rest.
Place the client supine.
Teach incentive spirometry
turn the client Q 2 hours
Increase fluid intake
Coughing and deep breathing
Teach insentive spirometer
75
The nurse receives an order to "discontinue NPO status and advance diet as tolerated" for a client. Which food is the client going to first offer this client?
Chicken broth
Crackers
Ice cream
Applesauce
Chicken broth
76
A client asks the nurse to recommend a nutrient dense food. The nurse should recommend which of the following foods to this client
broccoli
beef
beer
butter
Broccoli
77
The nurse is caring for a client who is post operative and has a large surgical incision. To best promote wound healing, the nurse should encourage the client to:
decrease carbohydrate intake.
decrease fat intake.
increase protein intake.
increase calorie intake.
increase protein intake
78
The nurse knows that on Mondays the hospital serves pork for dinner so the culturally competent nurse will inquire about alternative dinner options for the clients of which religions? (Select all that Apply)
Mormon
Buddhism
Catholic
Judiam
Islam
Buddhism,Judaism,Islam
79
The nurse is providing education to a client about the benefits of eating whole grains and oats. Which statement represents correct understanding of the client education?
"Eating more fiber can increase my fecal bulk."
"I should eat polysaccharides to maintain tissue repair."
"Eating more monosaccharides will decrease my cholesterol."
"Simple carbohydrates do not have calories."
Eating more fiber can increase my fecal bulk
80
The nurse is teaching an adolescent client about their nutritional needs based on their stage of development. Which statement by the client indicates understanding of the teaching?
"I should regulate my calorie intake by following a low carbohydrate diet."
"I should increase my caloric intake of lean meats and dairy."
"I should decrease my caloric intake by limiting meat and whole grains."
"I should increase my calcium and iron intake by only eating fresh fruit."
I should increase my caloric intake of lean means and dairy
81
Vitamin K is a fat-soluble vitamin that is stored in the fatty compartments of the body increasing risk for toxicity.
A) True
B) False
True
