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Test sobre Basic Nursing Quiz 3, creado por mminter002 el 11/10/2014.

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Basic Nursing Quiz 3

Pregunta 1 de 21

1

From what stage of sleep are people typically most difficult to arouse?

Selecciona una de las siguientes respuestas posibles:

  • NREM, sleep spindles

  • NREM, delta waves

  • NREM, alpha waves

  • REM

Explicación

Pregunta 2 de 21

1

A patient’s vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling “itchy and hot.” The nurse discovered a rash on the patient’s trunk. Vital signs were: T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?

Selecciona una de las siguientes respuestas posibles:

  • Administer an antihistamine (anti-allergenic) medication.

  • Flush the blood tubing with D5W immediately.

  • Stop the blood transfusion immediately.

  • Prepare for emergency resuscitation

Explicación

Pregunta 3 de 21

1

Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Catecholamines

  • Protease

  • Cortisol

  • Histamines

Explicación

Pregunta 4 de 21

1

You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?

Selecciona una de las siguientes respuestas posibles:

  • Notify the physician of the patient's signs of fluid overload

  • Provide endotracheal suctioning

  • Provide tracheostomy care

  • Call the respiratory therapist to check the ventilator settings

Explicación

Pregunta 5 de 21

1

Patency is the condition of being open, expanded, or unobstructed.

Selecciona uno de los siguientes:

  • VERDADERO
  • FALSO

Explicación

Pregunta 6 de 21

1

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient’s pain?

Selecciona una de las siguientes respuestas posibles:

  • Acute

  • Neuropathic

  • Chronic

  • Intractable

Explicación

Pregunta 7 de 21

1

A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain?

Selecciona una de las siguientes respuestas posibles:

  • Phantom

  • Referred

  • Radiating

  • Psychogenic

Explicación

Pregunta 8 de 21

1

The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following?

Selecciona una de las siguientes respuestas posibles:

  • Osmosis

  • Diffusion

  • Hydrostatic pressure

  • Active transport

Explicación

Pregunta 9 de 21

1

When a patient has metabolic acidosis, which body system influences the acid–base imbalance to produce the compensatory changes in the arterial blood gases?

Selecciona una de las siguientes respuestas posibles:

  • Respiratory system

  • Renal system

  • Neurological system

  • Vascular system

Explicación

Pregunta 10 de 21

1

What is the rationale for wrapping petroleum gauze around a chest tube insertion site?

Selecciona una de las siguientes respuestas posibles:

  • Prevents air from leaking around the site

  • Prevents infection at the insertion site

  • Prevents the tube from becoming dislodged

  • Absorbs drainage from the insertion site

Explicación

Pregunta 11 de 21

1

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?

Selecciona una de las siguientes respuestas posibles:

  • Nasal cannula

  • Venturi mask

  • Non-rebreather mask

  • Partial rebreather mask

Explicación

Pregunta 12 de 21

1

Which pain management task can be safely delegated to nursing assistive personnel?

Selecciona una de las siguientes respuestas posibles:

  • Assessing the quality and intensity of the pt's pain

  • Evaluating the effectiveness of pain medication

  • Administering oral dose of acetaminophen

  • Providing a therapeutic back massage

Explicación

Pregunta 13 de 21

1

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?

Selecciona una de las siguientes respuestas posibles:

  • Applying and removing the restraints

  • Assessing the pt's status

  • Evaluating the pt's response to restraints

  • Determining the need for restraint

Explicación

Pregunta 14 de 21

1

A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?

Selecciona una de las siguientes respuestas posibles:

  • Pneumonia

  • Hemothorax

  • Pneumothorax

  • Metabolic alkalosis

Explicación

Pregunta 15 de 21

1

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

Selecciona una de las siguientes respuestas posibles:

  • Diffusion

  • Active transport

  • Filtration

  • Osmosis

Explicación

Pregunta 16 de 21

1

A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first?

Selecciona una de las siguientes respuestas posibles:

  • Encourage a family member to stay with the patient.

  • Administer lorazepam (an antianxiety medication).

  • Keep all four of the patient’s bed side rails up.

Explicación

Pregunta 17 de 21

1

While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately?

Selecciona una de las siguientes respuestas posibles:

  • Set up a new drainage system, and connect it to the chest tube.

  • Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU.

  • Clamp the chest tube close to the insertion site.

  • Place the disconnected end nearest the patient into a bottle of sterile water.

Explicación

Pregunta 18 de 21

1

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?

Selecciona una de las siguientes respuestas posibles:

  • Risk for Suffocation (drowning)

  • Risk for Ineffective Airway Clearance (choking)

  • Risk for Poisoning

  • Risk for Falls

Explicación

Pregunta 19 de 21

1

Which electrolyte is the primary regulator of fluid volume?

Selecciona una de las siguientes respuestas posibles:

  • K+

  • Na+

  • Calcium

  • Magnesium

Explicación

Pregunta 20 de 21

1

What is typically the most reliable indicator of pain?

Selecciona una de las siguientes respuestas posibles:

  • Past medical Hx

  • Description by caregiver(s)

  • Pt's self-report

  • Behavioral cues

Explicación

Pregunta 21 de 21

1

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

Selecciona una de las siguientes respuestas posibles:

  • Cheyne-Stokes respirations

  • Biot's breathing

  • Sleep apnea

  • Kussmaul's respirations

Explicación