Fundamentals Final Exam

Question 1

after surgery, what do you do for a pt who has constipation?

Answer 1

get them moving (walking up and down the hall), fiber, water

Question 2

how do you decrease lifestyle stress?

Answer 2

exercise, healthy diet, prayer, rest

Question 3

Who is most at risk for fluid volume deficit?
6mo learning to drink from sippy cup
12yo moderately active in 80 degree weather
43yo with severe diarrhea
90yo with headaches

Answer 3

43 yo with severe diarrhea

Question 4

what do you check stool for?

Answer 4

color, odor, consistency

Question 5

what’s the best way to determine fluid status?

Answer 5

daily weights (same time, same clothes, same scale, after voiding, before breakfast)

Question 6

what are some myths about older adults?

Answer 6

they have to be in ECFs, they smell, they have grey hair, they’re confused

Question 7

range of motion exercises

Answer 7

flexion, extension, rotation, abduction, adduction, supination, pronation, inversion, eversion

Question 8

what do you do for pain during ROM exercises?

Answer 8

give pain meds 30 minutes beforehand; only extend to the point of discomfort

Question 9

in a nursing dx, what are the “defining characteristics”?

Answer 9

signs and symptoms (AEB)

Question 10

when talking to a patient, what is clarifying?

Answer 10

restating what they say to show that you understand

Question 11

how do you chart hearing clear breath sounds?

Answer 11

no adventitious sounds

Question 12

what’s the difference between a nursing diagnosis and a medical diagnosis?

Answer 12

medical diagnoses deal with the physiologic or medical condition; nursing diagnoses deal with the response to alteration in health (signs and symptoms)

Question 13

where is the apical pulse taken?

Answer 13

fifth intercostal space on the left

Question 14

fahrenheit to celsius conversion?

Answer 14

F = 9/5C + 32
C = 5/9(F-32)

Question 15

what’s the difference between subjective and objective data?

Answer 15

subjective - what the pt tells you (symptom)

objective - data (sign)

Question 16

what’s the difference between closed and open ended questions?

Answer 16

closed ended questions have a definite answer

open ended questions require a longer explanation

Question 17

which pulse cannot accurately be taken on both sides of the body at the same time?

Answer 17

carotid

Question 18

which is an independent nursing action?
administering meds
ordering a CT scan
providing teaching
sending the pt to PT

Answer 18

providing teaching

Question 19

what’s one advantage to using a nursing dx?

Answer 19

it’s universal

Question 20

what’s the important diagnosis acronym and what does it stand for?

Answer 20

NANDA - north american nursing diagnosis association

Question 21

pt with serious vitamin c deficiency would have:
muscle weakness
bleeding gums
night blindness
confusion

Answer 21

bleeding gums

Question 22

what is the soft palate?

Answer 22

the fleshy, flexible part toward the back of the roof of the mouth; responsible for closing off the nasal passageway during swallowing and for closing off the airway

Question 23

what do you do before repositioning a pt with a urinary cath, IV, and O2 via nasal cannula?

Answer 23

make sure all the tubes are connected, stable, and correctly positioned

Question 24

what do you do for a pt who has difficulty swallowing aspirin?

Answer 24

crush it (first option) or see if they have a different format

Question 25

what are some barriers to effective communication?

Answer 25

being defensive, giving your opinion, making assumptions

Question 26

what's the best way to control transmission of organisms?

Answer 26

hand hygiene

Question 27

what's the difference between empathy and sympathy?

Answer 27

empathy - relating to your pt because you have been in a similar situation sympathy - comforting your pt and/or their familiy

Question 28

maslow's hierarchy of needs

Answer 28

1) physiological needs 2) safety 3) love and belonging 4) self-esteem 5) self-actualization

Question 29

what's the most therapeutic response to a pt who wants you to pray with him?

Answer 29

"how would you like us to pray?"

Question 30

what's the best way to obtain a clean catch midstream urine specimen (CCMS)?

Answer 30

wipe first with towelette, start stream of urine, obtain specimen, finish urinating

Question 31

what's the primary purpose of TED hose?

Answer 31

to prevent deep vein thrombosis (DVT)

Question 32

what's the primary reason you don't want pts to strain during BMs?

Answer 32

arrhythmias

Question 33

what's the trend with the color of blood in stool?

Answer 33

the higher up the bleeding, the darker the blood in the stool

Question 34

what do you do if you have a pt that reports feeling dizzy after getting out of bed?

Answer 34

1) help him sit down | 2) take vitals

Question 35

how do you transfer pt from bed to chair using a gait belt?

Answer 35

have your feet planted flat on the floor with the pt facing you (and don't forget - the gait belt goes on the pt, not you!)

Question 36

how do you administer eyedrops?

Answer 36

head tilted back, have them look up, drop it in the lower conjunctival sac, do not let the dropper touch the eye

Question 37

what do we use instead of "cc"?

Answer 37

mL

Question 38

rules regarding pt restraints

Answer 38

physician's order every 24 hours, take restraints off every 1-2 hours, check skin, observe the pt more often

Question 39

what does inversion of the foot look like?

Answer 39

ankle is turned so the sole of the foot moves medially toward the footline

Question 40

which fluid loss is most difficult to measure?

Answer 40

insensible (lungs, skin)

Question 41

documentation - know what you should and shouldn't chart

Answer 41

- bilateral breath sounds clear (yes) - needle tracks on right arm (no because it's an assumption that they're needle tracks) - "i'm happy i'm going home" -pt (yes) - transfer pt from bed to chair with one assist (yes)

Question 42

which vitamin is associated with weak bones? how do you supplement a deficiency?

Answer 42

vitamin D - sunlight and milk/dairy products

Question 43

what do you do to determine level of anxiety for a pt who seems nervous and has had no visitors?

Answer 43

ask if something is bothering him

Question 44

what can poor people eat that is high in protein?

Answer 44

beans and peas

Question 45

what is anorexia nervosa?

Answer 45

self-imposed starvation

Question 46

if you have a worried pt with a high degree of emotional stress and loss of income, what should you assess?

Answer 46

suicide risk

Question 47

difference between ileostomy and colostomy?

Answer 47

ileostomy is higher up because of the location of the ileum

Question 48

when you deal with scientific principles, what is your main focus?

Answer 48

rationale

Question 49

when you talk about bathing a pt, when would you give a full bath as opposed to a partial bath?

Answer 49

it depends on the pt ability (mobility related to surgery, strength, etc.)

Question 50

your pt is unable to expand lungs completely - what type of breath sounds will you hear?

Answer 50

diminished breath sounds

Question 51

what do you do to promote respiratory function in an immobilized pt?

Answer 51

have the pt cough, incentive spirometry, deep breathing

Question 52

which part of the nursing process is taking vitals part of?

Answer 52

assessment

Question 53

what is the primary reason for pressure ulcers?

Answer 53

immobility/not repositioning pt

Question 54

is the nursing process dynamic or static?

Answer 54

dynamic (changing)

Question 55

what do you do during the evaluation step of the nursing process?

Answer 55

see if pt met goals; if not, determine why and revise the goals

Question 56

kubler-ross stages of death and dying

Answer 56

``` denial anger bargaining depression acceptance (DABDA) ```

Question 57

how would you respond to a pt in stages of death and dying?

Answer 57

ask open ended questions and reaffirm them

Question 58

what food is a complete protein?

Answer 58

EGGS!!!

Question 59

what do you give a confused and disoriented pt to eat?

Answer 59

chicken soup

Question 60

when cleaning pt's eyes, what do you do?

Answer 60

turn the pt on the same side as you're going to clean

Question 61

clear liquid diet

Answer 61

broth, coffee, tea, carbonated beverages, popsicles

Question 62

full liquid diet

Answer 62

same as clear liquid with addition of smooth-textured dairy products (ice cream, custards, pureed vegetables, pudding)

Question 63

pureed diet

Answer 63

same as liquid diet, with addition of scrambled eggs, pureed meats/veggies/fruits, mashed potatoes

Question 64

mechanical soft diet

Answer 64

ground or finely diced meats, cottage cheese, rice, pancakes, cooked veggies, bananas, peanut butter

Question 65

soft/low residue diet

Answer 65

pastas, casseroles, tender meats, desserts without nuts or coconut

Question 66

hard palate

Answer 66

bony front part of the roof of the mouth; important for feeding and speech

Question 67

what type of chicken would you offer to a pt with dementia?

Answer 67

chicken fingers (finger foods)

Question 68

steps of pt eye care

Answer 68

see page 799 for process

Question 69

what are appropriate foods/fluids for a pt with diarrhea?

Answer 69

bananas, rice, applesauce, and toast (BRAT diet)

Question 70

before you take care of people from other cultures, what should you do?

Answer 70

understand your own culture | the same goes for spirituality

Question 71

what's the primary function of the large intestine?

Answer 71

absorption of fluids

Question 72

when you observe a pt for signs of distress, what are you doing?

Answer 72

inspecting

Question 73

stress

Answer 73

physiological or psychological tension that threatens homeostasis or a person's psychological equilibrium

Question 74

hemiparesis

Answer 74

weakness on one side of the body

Question 75

vagal response

Answer 75

fainting

Question 76

insensible water loss

Answer 76

water loss that is continuous and not perceived by the person

Question 77

inference

Answer 77

a conclusion reached on the basis of evidence and reasoning

Question 78

name the part of a nursing diagnosis

Answer 78

PES: problem (diagnostic label) etiology (related to) signs and symptoms (defining characteristics/AEB)