Nursing 6700 Exam 2 Questions With Complete Solutions
0+= absent
1+= Weak/Thready
2+= Normal
3+= Full; greater than expected
4+= Bounding; may be visble Correct Answers Grade of
arterial pulses:
1-2 hours Correct Answers How soon should bowel sounds be
heard after birth?
1-2 weeks Correct Answers How long does it take the
umbilical cord to fall off?
1. Assessment
2. Diagnosis
3. Outcomes
4. Planning
5. Interventions
6. Evaluation Correct Answers Steps of the Nursing Process:
10-20 breaths per minute Correct Answers Normal adult
respiratory rate
120/80 Correct Answers Normal Adult Blood Pressure
2 arteries and 1 vein Correct Answers Umbilical cord contains
_____ and ______
,20-26 breaths per minute Correct Answers Normal respiratory
rate for a child 8-10 years old
3 part nursing diagnosis Correct Answers Diagnosis, Cause,
Supporting Evidence
1. Review NANDA approved list and identify a nursing
diagnosis that addresses each area of your problem list
2. Identify the cause of the problem and include it in the nursing
diagnosis, but do not write a medical diagnosis as a cause or a
related event
3. Include evidence to support your diagnosis
30-40 breaths per minute Correct Answers Normal respiratory
rate for a neonate
5 minutes in each quadrant Correct Answers How long must
you listen to abdominal sounds before declaring they are absent?
50-95 beats/min Correct Answers Normal HR for adults
9-26 (Gardasil men and women)
9-25 (Cervarix- only for females) Correct Answers How old do
you have to be to get the HPV vaccine?
97-99% Correct Answers Normal SpO2
adventitious lung sounds Correct Answers abnormal lung
sounds
, All patients must have an assessment of physical, psychosocial,
environmental, self-care, knowledge level and discharge
planning needs
Documentation must be within the context of the nursing
process
• Patient Teaching
• Discharge Planning
Frequency of documentation is mandated by healthcare
institutions and these standards will change depending on
facility- documentation should be in line and follow the rules
and regulations
Must keep all patient information confidential and protected
from unauthorized persons Correct Answers Documentation
rules:
Anasarca Correct Answers Generalized body edema caused by
CHF. Other causes include renal and liver failure; patient has
swelling everywhere
Anterior chest Correct Answers contains mostly upper and
middle lobe; very little lower lobe
Aorta Correct Answers just to the left of the midline in the
upper part of the abdomen. It descends behind the peritoneum
and at 2cm below the umbilicus it bifurcates into the right and
left common iliac arteries. You can palpate the aortic pulsations
in the upper anterior abdominal wall.
Aortic Aneurysm Correct Answers aorta has distended and has
enlarged to the point of rupturing; contributing factor is
hypertension; bulging pulsating mass >5 cm
0+= absent
1+= Weak/Thready
2+= Normal
3+= Full; greater than expected
4+= Bounding; may be visble Correct Answers Grade of
arterial pulses:
1-2 hours Correct Answers How soon should bowel sounds be
heard after birth?
1-2 weeks Correct Answers How long does it take the
umbilical cord to fall off?
1. Assessment
2. Diagnosis
3. Outcomes
4. Planning
5. Interventions
6. Evaluation Correct Answers Steps of the Nursing Process:
10-20 breaths per minute Correct Answers Normal adult
respiratory rate
120/80 Correct Answers Normal Adult Blood Pressure
2 arteries and 1 vein Correct Answers Umbilical cord contains
_____ and ______
,20-26 breaths per minute Correct Answers Normal respiratory
rate for a child 8-10 years old
3 part nursing diagnosis Correct Answers Diagnosis, Cause,
Supporting Evidence
1. Review NANDA approved list and identify a nursing
diagnosis that addresses each area of your problem list
2. Identify the cause of the problem and include it in the nursing
diagnosis, but do not write a medical diagnosis as a cause or a
related event
3. Include evidence to support your diagnosis
30-40 breaths per minute Correct Answers Normal respiratory
rate for a neonate
5 minutes in each quadrant Correct Answers How long must
you listen to abdominal sounds before declaring they are absent?
50-95 beats/min Correct Answers Normal HR for adults
9-26 (Gardasil men and women)
9-25 (Cervarix- only for females) Correct Answers How old do
you have to be to get the HPV vaccine?
97-99% Correct Answers Normal SpO2
adventitious lung sounds Correct Answers abnormal lung
sounds
, All patients must have an assessment of physical, psychosocial,
environmental, self-care, knowledge level and discharge
planning needs
Documentation must be within the context of the nursing
process
• Patient Teaching
• Discharge Planning
Frequency of documentation is mandated by healthcare
institutions and these standards will change depending on
facility- documentation should be in line and follow the rules
and regulations
Must keep all patient information confidential and protected
from unauthorized persons Correct Answers Documentation
rules:
Anasarca Correct Answers Generalized body edema caused by
CHF. Other causes include renal and liver failure; patient has
swelling everywhere
Anterior chest Correct Answers contains mostly upper and
middle lobe; very little lower lobe
Aorta Correct Answers just to the left of the midline in the
upper part of the abdomen. It descends behind the peritoneum
and at 2cm below the umbilicus it bifurcates into the right and
left common iliac arteries. You can palpate the aortic pulsations
in the upper anterior abdominal wall.
Aortic Aneurysm Correct Answers aorta has distended and has
enlarged to the point of rupturing; contributing factor is
hypertension; bulging pulsating mass >5 cm
