The basic principles and practices of nursing as taught in educational programs for nurses. In a course on the fundamentals of nursing, traditionally required in the first semester of the program, the student attends classes and gives care to selected patients. A fundamental of nursing course emphasizes the importance of the fundamental needs of humans as well as competence in basic skills as prerequisites to providing comprehensive nursing care.
Restlessness
Pale, warm, dry skin
Heart rate of 110 beats/minute
Urine output of 30 ml/hour
Barely visible outside the tonsillar pillar.
Halfway between the tonsillar pillar and the uvula.
Touching the uvula.
Touching each other.
The pulse pressure.
The pulse deficit.
The pulse rhythm.
Pulsus regularis.
The mother will have less trouble holding a quiet, upright infant.
Lying down can cause the fontanels to recede, making assessment more difficult.
The infant can breathe more easily when sitting up.
Lying down and crying can cause the fontanels to bulge.
Place a tongue blade on the front of the tongue and ask the client to say "ah."
Place a tongue blade lightly on the posterior aspect of the tongue.
Place a tongue blade on the middle of the tongue and ask the client to cough.
Place a tongue blade on the uvula.
Overhydration causes the skin to tent.
Dehydration causes the skin to appear edematous and spongy.
Inelastic skin turgor is a normal part of aging.
Normal skin turgor is moist and boggy.
Any quadrant first.
The symptomatic quadrant first.
The symptomatic quadrant last.
The symptomatic quadrant either second or third.
Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference
Measuring the arm about 2" (5 cm) above the antecubital space
Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference
Using a bladder that is 6" (15 cm) long.
Slants upward.
Slants downward.
Is horizontal.
Slants backward.
Fingertips
Finger pads
Back (dorsal surface)
Ulnar surface
Radial
Apical
Carotid
Brachial
Level of consciousness (LOC)
Memory
Personality changes
Intellectual ability
The client can read the entire vision chart at 40′ (12 m).
The client can read from 20′ (6 m) what a person with normal vision can read at 40′.
The client can read the vision chart from 20′ with the right eye and from 40′ with the left eye.
The client can read at 30′ (9 m) what a person with normal vision can read at 40′.
The body is supine.
Arms are elevated at shoulder level.
Palms are turned forward.
The body is facing backward.
Coma or seizures.
Sunken eyeballs and poor skin turgor.
Increased heart rate with hypotension.
Thirst or confusion.
Having more frequent aches and pains.
Failing eyesight, especially close vision.
Increasing loss of muscle tone.
Accepting limitations while developing assets.
Have the client stand with feet together and arms at the sides and try to balance, first with eyes open and then with eyes closed.
Instruct the client to walk across the room on the heels and to return walking on the toes.
Ask the client to touch the thumb of one hand to each finger on that hand and then repeat this action using the other hand.
Instruct the client to lie on the back and slowly slide the heel down the shin of the opposite leg, from the knee to ankle.
S1 and S2 sound equally loud over the entire cardiac area.
S1 and S2 sound fainter at the apex.
S1 and S2 sound fainter at the base.
S1 is loudest at the apex, and S2 is loudest at the base.
Have the client lie down while taking his blood pressure.
Inflate the cuff to at least 200 mm Hg.
Take blood pressure readings in both arms.
Inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.
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Assess extremities, ensuring that the extremity with the splint feels cooler than the unsplinted extremities
Move the client's fingers or toes to test movement
Compare the capillary refill of each extremity, making sure it's the same bilaterally
Be aware that edema and pulse checks aren't part of the neurovascular assessment
Flat, nonpalpable, and colored
Solid, elevated, and circumscribed
Circumscribed, elevated, and filled with serous fluid
Elevated, pus-filled, and circumscribed
Radial
Brachial
Femoral
Carotid
The client took small steps at a rate of 40 to 50 per minute.
The client reported feeling dizzy and weak and perspired profusely.
The client's head was down, gaze was cast down, and toes were pointed outward.
The client's pulse and respiratory rates increased moderately during ambulation.
Constriction and divergence
Dilation and convergence
Constriction and convergence
Dilation and divergence
Young-old
Middle-old
Old-old
Frail elderly
The bell detects high-pitched sounds best.
The diaphragm detects high-pitched sounds best.
The bell detects thrills best.
The diaphragm detects low-pitched sounds best.
Insert an oral airway.
Withhold food and fluids.
Position the client on his side.
Introduce a nasogastric (NG) tube.
Hyperresonance
Tympany
Resonance
Dullness
Using deep palpation
Assessing the painful area last
Assessing the painful area first
Checking for warmth in the painful area
Mediastinum
Mouth
Vertebral canal
Reproductive organs
Vagal stimulation.
Vomiting, anger, or suctioning.
Fear, pain, or anger.
Stress, pain, or vomiting.
Dullness over the liver
Bowel sounds occurring every 10 seconds
Shifting dullness over the abdomen
Vascular sounds heard over the renal arteries
A respiratory rate of 24 breaths/minute with accessory muscle use
Effective breathing at a rate of 16 breaths/minute through the established airway
Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds
Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds
Pustules
Papule
Plaque
Vesicles
Progressively deeper breaths followed by shallower breaths with apneic periods.
Rapid, deep breaths with abrupt pauses between each breath.
Rapid, deep breaths and irregular breathing without pauses.
Shallow breaths with an increased respiratory rate.
Aging can reduce the body's ability to regulate body temperature.
Aging can increase pain perception.
Anesthesia usually causes psychotic behavior postoperatively in a geriatric client.
The risk of developing emphysema is highest in elderly people.
Because the nurse's touch may calm the child
Because the child may cry as the assessment proceeds, making auscultation difficult
Because the nurse's touch may frighten the child
Because the nurse's hand or stethoscope may feel cold, making the child recoil
"When did the rash start?"
"Are you allergic to any medications, foods, or pollen?"
"How old are you?"
"What have you been using to treat the rash?"
"Have you recently traveled outside the country?"
"Do you smoke cigarettes or drink alcohol?"
39° C
47° C
38.9° C
40.1° C
Keep the client warm.
Maintain room temperature at 78° F (25.6° C).
Keep the client uncovered.
Match the room temperature with the client's body temperature.
Fingertips.
Ulnar surface of the hand.
Dorsal surface of the hand.
Finger pads.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Distended neck veins.
Hypothermia.
Hypertension.
Tachycardia.
Vital signs
Laboratory test results
Client's description of pain
Electrocardiographic (ECG) waveforms
Prolonged half-life
Prolonged half-life
Potential for drug dependence
Potential for hepatotoxicity
No sounds heard over either carotid artery
Faint swishing sounds heard over both carotid arteries
Throbbing pulsations heard bilaterally
Louder sounds heard over the right carotid artery than over the left carotid artery
Contraction
Fibrinoplastic
Lag
Inflammation
Decreased bowel motility.
Increased bowel motility.
Nothing abnormal.
Abdominal cramping.
A rub occurs during expiration only and produces a light, popping, musical noise.
A rub occurs during inspiration only and may be heard anywhere.
A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.
A rub occurs during inspiration only and clears with coughing.
Pallor and coolness of the left foot.
A decrease in the left pedal pulse.
Loss of hair on the lower portion of the left leg.
Left calf circumference 1" (2.5 cm) larger than the right.
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