Practice Test: Fundamentals Of Nursing Quiz

When administering medications, it is essential for the nurse to ensure that the patient actually takes the medication as prescribed. This is necessary for both patient safety and accurate documentation. In this situation, the nurse should return to the patient's room after a few minutes and wait until the patient takes the medication. Leaving the medication at the bedside without supervision, instructing the patient to take the medication without ensuring they do so, or not waiting for the patient to return to bed before leaving the medication at the bedside are not appropriate actions. These approaches do not guarantee that the patient has taken the medication as prescribed and may lead to errors or complications. The nurse should follow the "Five Rights" of medication administration: the right patient, the right drug, the right dose, the right route, and the right time. Ensuring that the patient takes the medication while the nurse is present is an essential part of this process.

Subjective data refers to information that is provided by the patient or their family members, which cannot be directly observed or measured by the healthcare professional. This type of data includes the patient's perceptions, feelings, and concerns, such as pain, discomfort, or emotional distress. In this case, the patient's statement, "I feel pain when urinating," is an example of subjective data because it reflects their personal experience and cannot be directly verified by the nurse. The other options (heart rate of 68 beats per minute, yellowish sputum, and noisy breathing) are examples of objective data, which can be directly observed, measured, or verified by the healthcare professional through physical examination or diagnostic tests.

Mrs. Caperlac's practice of maintaining a low-sodium, low-fat diet to control her blood pressure is an example of a health belief. Health beliefs are personal convictions or perceptions about health-related behaviors, conditions, or treatments that influence how individuals approach their healthcare. In this case, Mrs. Caperlac believes that following a low-sodium, low-fat diet will help her manage her hypertension, which is supported by scientific evidence and healthcare recommendations. Cultural, personal, and superstitious beliefs may also play a role in shaping an individual's health behaviors, but in this scenario, Mrs. Caperlac's actions are directly related to her understanding of the connection between diet and blood pressure management, making it a health belief.

Tachypnea is a medical term used to describe rapid and shallow breathing, characterized by a respiratory rate greater than 20 breaths per minute. In Jake's case, his respiratory rate of 30 breaths per minute indicates tachypnea. This condition can be a symptom of various underlying health issues, such as heart or lung problems, infection, or anxiety. The nurse's documentation of Jake's tachypnea will help inform the healthcare team of his condition and guide further assessment and treatment.

By asking the patient to repeat the medication instructions, the nurse is performing the professional role of an educator. Patient education is a crucial aspect of nursing care, as it empowers patients with the knowledge and skills necessary to manage their health and adhere to treatment plans. In this scenario, the nurse is ensuring that the patient understands the medication regimen following thyroidectomy, which is essential for preventing complications and promoting optimal recovery. By asking the patient to repeat the instructions, the nurse can assess the patient's understanding and address any misconceptions or gaps in knowledge. While the roles of manager, caregiver, and patient advocate are also important in nursing practice, the primary role being demonstrated in this situation is that of an educator.

The outcome or the product of the planning phase of the nursing process is a Nursing care plan.

Formulating a nursing diagnosis is a collaborative process between the nurse and the patient. The nurse gathers subjective and objective data from the patient through assessment, including the patient's health history, physical examination, and personal experiences. Based on this information, the nurse analyzes the data to identify patterns, actual or potential health problems, and the patient's strengths and limitations. The nurse then works with the patient to develop a nursing diagnosis that accurately reflects the patient's unique health needs and goals. This collaborative approach ensures that the patient's perspectives and preferences are considered in the care planning process, fostering patient-centered care and engagement in their own healthcare. While doctors and family members may provide valuable input or contribute to the overall care plan, the primary responsibility for formulating a nursing diagnosis lies with the nurse and patient.

If the nurse notices that the venipuncture site is red and swollen, the first action should be to stop the infusion. These signs may indicate inflammation, infection, or extravasation (leakage of IV fluid into the surrounding tissue), which require immediate attention. Stopping the infusion prevents further harm and allows the nurse to assess the situation and intervene appropriately. After stopping the infusion, the nurse can elevate the extremity and apply a warm or cold compress as needed, based on the specific issue. The nurse should also notify the physician about the complication and document the incident in the patient's medical record. Slowing the infusion or placing a cold towel on the site might be considered after the initial assessment but should not be the first intervention in this case.

The trial and error approach to problem-solving involves testing various solutions until one is found that effectively addresses the problem. This method is often used when there is limited information or understanding of the problem, and it may require persistence and patience to find a successful solution. In contrast, the scientific method is a more systematic approach to problem-solving that involves forming a hypothesis, designing and conducting experiments or observations, and drawing conclusions based on the results. Routine and intuition are not specific problem-solving approaches but rather refer to established habits or instincts that may guide decision-making.

Wheezes are high-pitched, whistling, or hissing sounds that occur during breathing, usually on exhalation. These sounds are often associated with narrowed airways, as air is forced through a smaller opening than normal. In Mrs. Sullen's case, the nurse's documentation of wheezes will alert the healthcare team to a potential issue with her respiratory system, such as inflammation, obstruction, or other underlying conditions. The other options (rhonchi, gurgles, and vesicular sounds) are different types of lung sounds that describe various other respiratory conditions or normal breath sounds.

The outcome of the planning phase in the nursing process is the development of a nursing care plan. This individualized plan outlines specific goals, interventions, and expected outcomes for the patient based on their unique needs, health problems, and priorities. The nursing care plan serves as a roadmap for the implementation phase of the nursing process, guiding nurses in delivering appropriate and targeted care to help the patient achieve their health goals. The other options (nursing history, nursing notes, and nursing diagnosis) are not outcomes of the planning phase but rather components of the overall nursing process. The nursing history and assessment data contribute to the formulation of nursing diagnoses, while nursing notes document the patient's progress, interventions, and any changes in their condition throughout the care process.

While computerized documentation of the nursing process offers many advantages, such as improved accuracy, legibility, and rapid communication, one of the main disadvantages is the concern for privacy. Storing sensitive patient information in digital formats increases the risk of unauthorized access, data breaches, or hacking, potentially compromising patient confidentiality. To mitigate these risks, healthcare organizations must implement robust security measures, such as encryption, access controls, and regular software updates, to protect patient data and ensure compliance with privacy regulations. Despite these concerns, the benefits of computerized documentation generally outweigh the risks, leading to its widespread adoption in modern healthcare settings.

To obtain a sterile urine specimen from an indwelling catheter while minimizing the risk of infection, the nurse should aspirate urine from the tubing port using a sterile syringe. This method allows for the collection of a fresh and uncontaminated urine sample without disrupting the closed catheter system, which helps maintain sterility and reduce the risk of introducing bacteria into the urinary tract. Using sterile gloves is important for maintaining aseptic technique during the procedure, but it is not sufficient on its own to prevent infection when obtaining a urine sample. Opening the drainage bag or disconnecting the catheter from the tubing can introduce bacteria into the system, increasing the risk of contamination and urinary tract infection. By aspirating urine from the tubing port with a sterile syringe, the nurse can collect an appropriate sample for testing while adhering to best practices for infection prevention.

During an abdominal examination, the patient should be positioned supine (lying flat on their back) with the head of the bed at 0 degrees. This position allows for optimal visualization and palpation of the abdominal structures, as it helps to relax the abdominal muscles and promotes proper assessment of the abdominal organs. While some examinations or procedures may require different positions, such as elevating the head of the bed to 30 or 45 degrees, the standard position for an abdominal examination is supine with the head of the bed at 0 degrees.

Placing the feeding 20 inches above the point of insertion of the nasogastric tube (NGT) is an inappropriate nursing action when administering NGT feeding. Elevating the feeding container too high can lead to a rapid flow of the feeding solution, increasing the risk of aspiration or discomfort for the patient. The appropriate height to hang the feeding container is around 12-18 inches above the point of insertion, allowing for a gradual and controlled flow of the feeding solution. The other options (introducing the feeding slowly, instilling 60ml of water into the NGT after feeding, and assisting the patient in Fowler's position) are all appropriate nursing actions when administering NGT feeding. It's essential to ensure that the patient is in an appropriate position, such as Fowler's position, to minimize the risk of aspiration during feeding. Introducing the feeding slowly prevents sudden distension of the stomach and associated discomfort, while instilling water into the NGT after feeding helps clear the tubing and maintain its patency.

During a change-of-shift report, it is essential to communicate pertinent information about the patient's current status, recent interventions, and any changes in their condition. In this case, the fact that the patient's nasogastric tube (NGT) was removed 2 hours ago is the most important information to relay to the nurse assuming responsibility for the patient's care. The removal of the NGT indicates a change in the patient's treatment plan and may have implications for their nutrition, medication administration, or monitoring for complications. The nurse assuming responsibility needs to be aware of this information to provide appropriate care and assess the patient's response to the removal of the NGT. While the other options (the patient verbalizing that their headache is gone, the patient's barium enema results from 3 days ago, and the patient's family visiting in the morning) may be relevant to the patient's overall care and progress, they do not have the same immediate impact on the patient's current care plan as the removal of the NGT.

Sister Roy’s theory is called the adaptation theory, and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that an individual has a need for self-care actions. King’s theory is the Goal attainment theory and describes nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of the nursing model and identified the 14 basic needs.

In this context, the adreno-cortical response can lead to decreased urine output (oliguria) as a result of increased water and sodium reabsorption in the kidneys. The hormones released during the adreno-cortical response, such as cortisol and adrenaline, can promote the retention of water and electrolytes to maintain fluid balance and blood pressure during periods of stress or fasting. While this response is not the primary focus of the adreno-cortical activation, it is an important aspect of the overall physiological adaptation to stress, ensuring that the body can conserve water and essential ions when needed.

To convert a temperature from Fahrenheit (°F) to Celsius (°C), you can use the following formula:



°C = (°F - 32) / 1.8



In this case, the patient's temperature is 101 degrees Fahrenheit (°F):



°C = (101°F - 32) / 1.8



°C = (69°F) / 1.8



°C ≈ 38.33



So, the equivalent temperature in degrees Celsius is approximately 38.33°C.