37051154
Descripción
Test por champagne papii, actualizado hace más de 1 año
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Creado por champagne papii
hace más de 2 años
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Pregunta 1
Pregunta
The nursing assistive personnel (NAP) is working on a medical surgical unit in a hospital and has been providing patient care without performing hand hygiene. Several of the patients on the unit have suffered hospital-associated diarrhea infections (Clostridium difficile). The hospital-associated disease transmission is best described as what?
Respuesta
-
natural passive immunity.
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indirect.
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natural active immunity.
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direct.
Pregunta 2
Pregunta
When checking for proper blood pressure cuff size, the nurse knows that which guideline is correct?
Respuesta
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The width of the rubber bladder should equal 80% of the arm circumference.
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The length of the rubber bladder should equal 40% of the arm circumference.
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The standard cuff size is appropriate for all sizes.
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The length of the rubber bladder should equal 80% of the arm circumference.
Pregunta 3
Pregunta
There was an outbreak of Salmonella infection at a nursing home. Several residents were hospitalized as a result of the infection. What is the best term to describe this infection?
Respuesta
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Community-acquired infection
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Exogenous infection
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Asepsis
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Endogenous infection
Pregunta 4
Pregunta
A nurse is assigned to multiple patients on a busy surgical unit. To minimize the onset and spread of infection, the nurse should:
Respuesta
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Insert indwelling catheters to prevent incontinence.
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Use barriers sparingly to reduce the patient’s sense of isolation.
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Use sterile technique when performing procedures.
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Keep mucus membranes dry to prevent maceration.
Pregunta 5
Pregunta
A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.
Which initial action will the nurse take next to revise the plan of care?
Respuesta
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Establish a new plan of care
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Assess the patient
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Consult physical therapy
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Set new priorities for the patient
Pregunta 6
Pregunta
The nurse is admitting a patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection located in the patient's pressure ulcer. On what precautions should the nurse place the patient?
Respuesta
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Contact precautions.
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Protective environment.
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Airborne precautions
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Droplet precautions.
Pregunta 7
Pregunta
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
Respuesta
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Document results of goal achievement.
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Determine whether outcomes or standards are met
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Ambulate patient 25 feet in the hallway.
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Administer medications to decrease pain
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Use self-reflection and correct errors.
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Set priorities for patient care.
Pregunta 8
Pregunta
The student nurse is caring for a postsurgical patient who has developed a health care– acquired wound infection that has become systemic. Which of the following should be the student nurse’s top priority?
Respuesta
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Providing emotional support
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Taking vital signs
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Providing personal hygiene
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Providing patient education
Pregunta 9
Pregunta
The nurse is taking the pulse of an adult patient and finds that the patient’s heart rate is 48 beats per minute. What should the nurse document as the finding?
Respuesta
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bradycardia
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bradypnea
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normal heart rate
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tachycardia
Pregunta 10
Pregunta
A 36-year-old patient has been admitted to the hospital. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?
Respuesta
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Ask the patient what his blood pressure normally measures for comparison.
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Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.
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Tell the patient that they have hypertension and educate them on normal BP values.
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Immediately call the health care provider and request antihypertensive medication.
Pregunta 11
Pregunta
The nurse has had a nasal culture performed and has been found to be MRSA positive. Because the nurse has not been ill from the bacteria, the nurse’s nasal cavity can best be described as a:
Respuesta
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susceptible host.
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portal of entry.
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reservoir.
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mode of transmission.
Pregunta 12
Pregunta
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
Respuesta
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Reads over the steps and performs a procedure despite lack of clinical competency
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Establishes goals for a particular patient without assessment
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Determines whether an intervention is correct and appropriate for the given situation
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Evaluates the effectiveness of interventions
Pregunta 13
Pregunta
A nurse is preparing to collect a blood sample from a patient who is diagnosed with Tuberculosis. What personal protective equipment should the nurse wear prior to entering the patients room?
Respuesta
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Surgical mask and gloves
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Gloves and gown only
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N95 or Respirator mask, gloves and gown
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Surgical mask, gloves and gown
Pregunta 14
Pregunta
The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
Respuesta
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Implementation
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Assessment
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Diagnosis
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Planning
Pregunta 15
Pregunta
A 26-year-old man was working on a roof in the hot 105-degree weather. His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing the patient?
Respuesta
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Apply a hyperthermia blanket to lower temperature slowly.
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Take the patient’s temperature.
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Place the patient in a tub of iced water.
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Remove fans to prevent premature chilling.
Pregunta 16
Pregunta
Where is the pain located?
Respuesta
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Radiate
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Provokes
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Time
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Quality
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Severity
Pregunta 17
Pregunta
What causes the pain?
Respuesta
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Radiate
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Provokes
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Time
-
Quality
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Severity
Pregunta 18
Pregunta
Does it come and go?
Respuesta
-
Radiate
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Provokes
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Time
-
Quality
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Severity
Pregunta 19
Pregunta
What does the pain feel like?
Respuesta
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Radiate
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Provokes
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Time
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Quality
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Severity
Pregunta 20
Pregunta
What is the rating on a scale of 0 to 10?
Respuesta
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Radiate
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Provokes
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Time
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Quality
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Severity
Pregunta 21
Pregunta
A nursing student is working on a surgical unit in the hospital. Included in the job description is to assist in the cleaning and disinfection of equipment stored on the unit. Which of the following is the best explanation of disinfection?
Respuesta
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Removing organic material
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Destroying all forms of microbial life
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Removing inorganic material
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Eliminating almost all pathogenic organisms
Pregunta 22
Pregunta
apical pulse Heartbeat as listened to with the bell or diaphragm of a stethoscope placed on apex of the heart
Respuesta
- True
- False
Pregunta 23
Pregunta
apnea Cessation of airflow through the nose and mouth
Respuesta
- True
- False
Pregunta 24
Pregunta
bradycardia Slower than normal heart rate; heart contracts fewer than 60 times
Respuesta
- True
- False
Pregunta 25
Pregunta
bradypnea Abnormally slow rate of breathing
Respuesta
- True
- False
Pregunta 26
Pregunta
diastolic pressure the blood pressure at the instant of maximum cardiac relaxation
Respuesta
- True
- False
Pregunta 27
Pregunta
A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
Respuesta
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Implementation
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Assessment
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Evaluation
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Planning
Pregunta 28
Pregunta
Nursing is the most trusted profession where professionalism should be shown in all actions. Which of the statements are true to what professionalism means to nurses (select all that apply):
Respuesta
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Only respects patients
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Team player
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Lifelong learner
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Does not participate in self-care
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Respect to self and each other
Pregunta 29
Pregunta
In terms of your nursing practice, a general survey has the following characteristics (select all that apply):
Respuesta
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Includes subjective parameters
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Includes objective parameters
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Proves the registered nurse an overall impression
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Conveys health state and obvious physical characteristics
Pregunta 30
Pregunta
Which of the following statement best reflects objective data?
Respuesta
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Facial features, patient denies drug use, patient's family appears nervous
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Age, sex, skin color
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Level of consciousness, patient complains of light headedness, patient reports of burning urination
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Pain level of 5/10, patient shouting for help
Pregunta 31
Pregunta
The best location to assess the pulse during a routine physical assessment is:
Respuesta
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Popliteal
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Brachial
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Radial
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Apical
Pregunta 32
Pregunta
You received shift report from the night shift and your first action is to complete an orthostatic blood pressure. Which of the following is the most accurate?
Respuesta
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Reading should be taken 1 minute apart in the following positions: supine, sitting and standing
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Reading should be taken right after patient wakes up in the morning.
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Readings should be taken 3 minutes part in the following positions: supine, sitting and standing
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Reading should be taken standing first to prevent dizziness
Pregunta 33
Pregunta
In regards to assessing pain in your assigned patients, which accurately reflects the "PQRST" assessment:
Respuesta
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Pain, Quantity, Region, Sign, Temperature
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Provokes, Quality, Radiation, Severity, Timing
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Promotion, Quantity, Radiation, Symptom, Treatment
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Promote, Quality, Readiness, Sequence, Timing
Pregunta 34
Pregunta
hypertension Disorder characterized by an elevated blood pressure persistently exceeding 120/80mm Hg.
Respuesta
- True
- False
Pregunta 35
Pregunta
hypotension
Abnormal lowering of blood pressure that is inadequate for normal perfusion and oxygenation of tissues
Respuesta
- True
- False
Pregunta 36
Pregunta
hypothermia
Abnormal lowering of body temperature below 35 C, or 95 F, usually caused by prolonged exposure to cold
Respuesta
- True
- False
Pregunta 37
Pregunta
orthostatic hypotension Abnormally low blood pressure occurring when a person stands up.
Respuesta
- True
- False
Pregunta 38
Pregunta
systolic pressure The pressure representing ventricular contraction
Respuesta
- True
- False
Pregunta 39
Pregunta
tachycardia Rapid regular heart rate ranging between 100 and 150 beats per minute.
Respuesta
- True
- False
Pregunta 40
Pregunta
Which of following does not belong when speaking about critical thinking:
Respuesta
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Specific knowledge base
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Competencies
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Attitudes
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Experience
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Lack of knowledge base
Pregunta 41
Pregunta
Which of the following vital signs recorded for an older adult would be considered acceptable (i.e., within normal limits)?
Respuesta
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Temp 96.8° F, P 60, R 18, BP 160/90, O2 sat 93%
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Temp 97.0° F, P 60, R 16, BP 116/78, O2 sat 95%
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Temp 98.0° F, P 76, R 22, BP 110/70, O2 sat 88%
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Temp 98.6° F, P 56, R 20, BP 120/80, O2 sat 91%
Pregunta 42
Pregunta
Which of the following situations may affect a patient’s vital signs? Select all that apply.
Respuesta
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Isolation precautions
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Seasons
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Moving from a lying to a standing position
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Time of day
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Pain rated as a 7 on a 1 to 10 pain scale
Pregunta 43
Pregunta
Which nursing diagnosis statement is written correctly?
Respuesta
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Altered tissue perfusion related to heart failure
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Impaired tissue integrity related to sacral redness
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Ineffective airway clearance related to weak cough effort.
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Altered urinary elimination related to reduced urine output.
Pregunta 44
Pregunta
Which method of data collection will the nurse use to establish a patient’s database?
Respuesta
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Checking orders for diagnostic and laboratory tests
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Reviewing the current literature to determine evidence-based nursing actions
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Ordering medications
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Performing a physical examination
Pregunta 45
Pregunta
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Respuesta
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Determines whether outcomes have been achieved
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Intervenes based on priorities of patient care
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Completes a comprehensive database
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Identifies pertinent nursing diagnoses
Pregunta 46
Pregunta
A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will alert the charge nurse to intervene immediately?
Respuesta
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Urinary retention
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Impaired swallowing
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Hemorrhage
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Wandering
Pregunta 47
Pregunta
A nurse is providing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
Respuesta
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Evaluation
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Assessment
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Planning
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Implementation
Pregunta 48
Pregunta
Which of the following is true about the force, or strength, of a pulse?
Respuesta
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It reflects the blood volume in the arteries during diastole.
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It demonstrates elasticity of the vessel wall.
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It is usually recorded on a 0- to 2-point scale.
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It is a reflection of the heart’s stroke volume.
Pregunta 49
Pregunta
A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?
Respuesta
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“Nurses use evaluation to determine the effectiveness of nursing care.”
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“During evaluation, you determine when to downsize staffing on nursing units.”
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“Evaluation eliminates unnecessary paperwork and care planning.”
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“An evaluation helps you determine whether all nursing interventions were completed.”
Pregunta 50
Pregunta
A patient’s blood pressure is 118/82. They ask the nurse to explain “what the numbers mean.” What would be the nurse’s best response?
Respuesta
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“The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”
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“The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure.”
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“The numbers are within normal range and are nothing to worry about.”
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“The bottom number is the diastolic pressure and reflects the stroke volume of the heart.”
Pregunta 51
Pregunta
A patient is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions?
Respuesta
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Lower the head of the bed and return the patient to the supine position.
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Obtain vital signs.
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Allow the patient to rest for 20 to 30 minutes.
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Notify the health care provider immediately.
Pregunta 52
Pregunta
A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis (sweating). Which outcome would the nurse recognize as appropriate for this patient?
Respuesta
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Patient’s bedding is changed when it becomes damp.
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Patient understands the need for increased fluid intake.
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Patient’s skin remains cool and dry throughout hospitalization.
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Patient has a balanced intake and output.
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