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Combo with "Fundamentals Test 2" and 1 other Questions With Complete Solutions
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Combo with "Fundamentals Test 2" and 1 other Questions With Complete Solutions
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Combo with "Fundamentals Test 2" and 1 other QuestionsWith Complete Solutions
" Patient will ambulate in the hall 3 times a day by 4/22"
Correct Answer A correct outcome statement
" Patient will ambulate independently in 3 days Correct Answer
An correct goal statement
A 39 year old man is at the gym exercising and develops a pain
in his upper right quadrant. The paramedics are called; their
initial vital sign readings indicate a pulse of 175 beats/min. This
pulse would be considered what? Correct Answer Elevated due
to pain, elevated due to activity
A 49 year old man comes to the clinic complaining of wakening
at night to void and voiding more than once in a two hour time
period. The patient has a history of bladder irritation. What
would be an appropriate nursing diagnosis for this patient?
Correct Answer Risk for urge incontinence
A 5 year old girl is admitted to the PACU after the repair of her
fractured femur. What activities would best indicate pain in this
child according to the FLACC scale? (Mark all that apply)
Correct Answer Difficulty consoling, leg movement, arched
back
A 52 year old patient is scheduled to undergo ileal conduit
surgery. The patient has several appropriate questions. What
would be the most appropriate nursing diagnosis for this patient?
,Correct Answer Knowledge deficit about the surgical procedure
and postoperative care
A 58 year old African American man is admitted to observation
unit with right lower quadrant pain. He has not kept down any
food or drink for 24 hours. His temperature is 38.6 orally. The
patient describes the pain as achy with periods of sharp, stabbing
sensations. What would be the most appropriate nutritional
nursing diagnosis for a patient with these assessment data?
Correct Answer Fluid volume less than body requirements
related to inability to tolerate fluids
A 60 year old man is having his skin assessed. The patient tells
the nurse he has been a heavy smoker for the last 40 years. He
has clubbing of the fingernails. What does this finding tell the
nurse? Correct Answer The patient has chronic hypoxia
A 97-year-old patient asks why a protein supplement has been
prescribed. What is the nurse's best response?
a."You have increased circulation of free drug."
b."You have decreased hepatic size."
c."You have decreased calcium absorption."
d."You have increased motility."
(Kee: Pharmacology, A Patient-Centered Nursing Process
Approach, 8th Edition, Chapter 8) Correct Answer Answer: A.
A client's temperature is 102 F. Which of the following would
the nurse also expect to find? Correct Answer Tachycardia
greater than 100 bpm
,A contaminated or traumatic wound may show signs of infection
within 24 hours. A surgical wound infection usually develops
postoperatively within 14 days.
A. True
B. False
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Correct Answer Answer: B.
A contaminated or traumatic wound may show signs of infection
early, within 2 to 3 days. A surgical wound infection usually
develops postoperatively within 4 to 5 days.
A family member calls the nurse to ask for advice regarding
their mother who has developed a "bedsore" on her right heel.
The family member describes the pressure ulcer as "a blister that
has now popped and you can see redness." Based on this
description, at what stage would the nurse classify this pressure
ulcer?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)
Correct Answer Answer: B.
A stage II pressure ulcer can be described as an abrasion, a
blister, or shallow crater with skin loss involving the epidermis
, and/or dermis. A stage I pressure ulcer appears as an area of
color change (e.g., persistent redness) on intact skin. A stage III
pressure ulcer presents clinically as a deep crater. A stage IV
pressure ulcer involves bone, muscle, or supporting structures.
A hospitalized patient has been NPO with only IV fluid intake
for a prolonged period. What assessment finding might indicate
protein-calorie malnutrition? Correct Answer poor wound
healing, apathy, edema
A new nurse states that she is confused about using evaluative
measures when caring for patients and asks the charge nurse for
examples and an explantion. Which of the following is the most
accurate response from the charge nurse? Correct Answer b.
Evaluative measures include assessment data used to determine
whether patients have met their expected outcomes and goals
A nurse assess that a patient has not voided in 6 hours. Which
question should the nurse ask to assist in establishing a nursing
diagnosis of urinary retention? Correct Answer a.Do you feel
like you need to use the bathroom
A nurse assessing a patient's wound documents the findings of
purulent drainage. What is the composition of this type of
drainage? Correct Answer white blood cells, debris, bacteria
A nurse assessing the skin of patients knows that the following
are health states that may predispose patients to skin alterations.
Select all that apply: Correct Answer Jaundice, low BMI,
excessive perspiration, obesity
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