FUNDAMENTALS 1, 2, AND FINAL
QUESTIONS AND ANSWERS
terminalmsillnessmsandmsquestionsmsdirectedmstomsnursemsaboutmsreligionmsandmsdeathms-
msanswer--encouragemsthemspatientmstomsexpressmsfeelingmsaboutmsdeathmsandmsdyingms
-therapeuticmstechniquemsofmsreflection
firstmsprioritymsactionmswhenmsperformingmstracheostomymscarems-msanswer--
1.msperformmshandmshygiene
-Themsnursemsshouldmsalso-
msdonmssterilemsgloves,msopenmsallmssterilemssuppliesmsandmssolutions,msandmsstabilizemsth
emstracheostomymstubemsbutmstheymsallmswillmscomemsaftermshandmshygienemsinmsordermstom
spreventmscontaminationmsofmsthemstrachmstube
whatmsshouldmsamsnurse'smsprioritymsactionmsbemswhenmstheymsnoticemsamspatient'smspulsem
sismsirregular?ms-msanswer--
auscultatemsthemsapicalmspulsemsandmslistenmsforms1msminutemstomsobtainmsandmsaccuratems
ratemsandmsdocumentmsthemsirregularitymsinmsthemschart
-checkmsperipheralmspulsesmsbilaterallymstomsdeterminemsequalitymsofmsbloodmsperfusion
-checkmspedalmspulsesmstomsdeterminemscirculationmsinmsptsmslowermsextremities
-
amsdopplermsultrasoundmsshouldmsbemsusedmswhenmsamsptmshasmsamsnonpalpablemspulse/
msverymsdifficultmstomspalpate
firstmsnursingmsactionmswhenmsreceivingmsamsnewmspatientms-msanswer--
1.msobtainmsthemsptsmsinformation
-
othermsstepsmsthatmsfollowmsthismsinclude:msidentifymsgoalsmsofmscare,msdocumentmsnursing
msfindings,msevaluatemseffectivenessmsofmscare
transferringmsamspatientmsfrommsamsstretchermstomsamsbedmsfollowingmsanmsabdominalmssur
geryms-msanswer--lockmsthemswheelsmsofmsthemsstretchermsandmsthemsbed
-ptmsshouldmscrossmstheirmsarmsmsovermsthemschestmstomspreventmsinjury
-stretchermsshouldmsbemsnomsmoremsthanms1.3mscmmsabovemsthemsheightmsofmsbed
-
logrollmstechniquemsusedmstomspreventmsinjurymsofmsptsmsrequiringmsimmobilizationmsofmsne
ck,msback,msspine
,prioritymsnursingmsactionmsformsamspatientmsadmittedmswithmsdecreasedmscirculationmsofmsth
emsleftmslegms-msanswer--evaluatemspedalmspulses
-
nursemsshouldmsalsomsobtainmsamsmedicalmshistory,msassessmsvitalsmsandmsassessmsformsle
gmspainmsbutmsthesemsaren'tmsthemsfirstmspriority
abdominalmsassessmentmsofmsamspatientmspostoperativemswithmsamsparalyticmsileumms-
msanswer--absent msbowelmssoundsmsw/msdistention
-paralyticmsileusmsismsanmsimmobilemsbowelmsw/
msabsentmsbowelmssounds,msabdominalmsdistention,msdecreasedmsperistalsis,msnomsflatule
ncemsormsstool
teachingmsformsanmsoldermsadultmswhomshasmsconstipationms-msanswer--
sitmsonmsthemstoiletmsforms30msminutesmsaftermseatingmsamsmeal
-
increasedmsperistalsismsoccursmsaftermseating,mssittingmsonmsthemstoiletmsforms30msminmsafte
rmseatingmsismsrecommendedmsbowelmsretrainingmstomstreatmsconstipation
-consumemsamsminimummsofms1500msmLmsofmswater
increasemsintakemsofmscoarse-fibermsandmswholemsgrains,msnotmsrefined-fiber
-domsnotmsusemsdailymssoftenersmsbecausemsitmshindersmsbowelmsretrainingmsprocess
patientmswhomshasmschestmspainmsthatmsworsensmsuponmsinspirationmsandmsamshigh-
pitchedmsscratchingmssoundsmsismsauscultatedmsduringmssystolemsandmsdiastolemsbymsthem
snursemswithmsthemsdiaphragmmsofmsthemsstethoscopemspositionedmsatmsthemsleftmssternalms
border.msWhatmsheartmssoundmsshouldmsthemsnursemsdocument?ms-msanswer--
pericardialmsfrictionmsrub
-pericardialmsfrictionmsrubmshigh-
pitchedmsscratching,msgrating,mssqueakingmsleatherymssoundmsheardmsbestmsw/
msthemsdiaphragmmsofmsthemsstethoscopemsatmsthemsleftmssternalmsborder
-commonmsmanifestationmsofmspericardialmsinflammation;mscanmsbemsheardmsw/
msineffective mspericarditismsw/
msMI,msfollowingmscardiacmssurgerymsormstrauma,msormssomemsautoimmunemsdisordersmssu
chmsasmsrheumaticmsfever
-typicallymshasmssignsmsofmschestmspainmsthatmsincreasesmsw/
msinspirationmsormscoughingmsandmsismsrelievedmsbymssittingmsupmsormsleaningmsforward
-audiblemsclick,msoccursmsinmsptsmsaftermsprostheticmsvalvemsreplacementmssurgery
-murmurms=msswishing,mswhistlingmssound,mshearmsbestmsw/msbellmsofmsstethoscope
-thirdmsheartmssoundms=mslow-
pitchedmssoundmsafterms2ndmsheartmssoundmscausedmsbymsrapidmsventricularmsfillingmsdurin
gmsdiastole,msbestmsheardmsatmsmitralmsareamsw/
msptmsonmsLmsside;mscommonlymsheardmsinmsptsmsw/msHDmsandmsindicativemsofmsHF
, amsnursemsdemonstratesmspostopmsbreathingmsandmscoughingmsexcisesmstomsamspatientms
havingmsanmsemergencymssurgerymsformsappendicitis.msWhatmsstatementmsindicatesmsthem
spatientmshasmsamslackmsofmsreadinessmstomslearn?ms-msanswer--ptmsreportsmsseveremspain
-ptmsw/mspainmsismsunablemstomsconcentratemsandmsperformmsexercises
-
Ptmsaskingmstomsrepeatmsthemsinstructions,mshowmsoftenmstomsperformmsthemsexercises,msan
dmsstatingmsthatmsitmswillmsprobablymsbemspainfulmstomsperformmsthem.msAremsallmsstatement
smsthatmsshowmsamsreadinessmstomslearn
*F1*ms
nursemsteachingmsamsgroupmsofmsoldermsadultsmsaboutmsthemsexpectedmschangesmsofmsagin
g.mswhatmsstatementmsindicatesmsanmsunderstandingmsofmsthemsteaching?ms-
msanswer--"Imsshouldmsexpectmsmymsheartmsratemstomstakemslongermstomsreturnmstomsnormal
msaftermsexercisemsasmsImsgetmsolder."
-
d/
tmsdecreasedmscardiacmsoutputmswhichmscausesmsanmsincreasedmspulsemsratemsduringmsex
ercise
-Bladdermscapacitymsdecreasesmsw/
msagemsbutmsurinarymsincontinencemsismsnotmsanmsexpectedmsfindingmsofmsaging
-
Havemsanmsincreasemsofmsearmswaxmsbuildupmswhichmsmaymsincreasemsincidencemsproble
msmsw/mshearingmsloss
-Decreasedmsgastricmsemptyingmsismsanmsexpectedmsfinding
whatmsstatementmsshouldmsamsnursemsmakemswhenmsamspatientmswithmsDM1msismsresistant
mstomslearningmsself-injectionmsofmsinsulin?ms-
msanswer--"TellmsmemswhatmsImscanmsdomstomshelpmsyoumsovercomemsyourmsfearmsofmsgiving
msyourselfmsinjections."
-therapeutic,msptmsablemstomsexpressmsfeelings
Amspatientmsismsscheduledmsformsanmsarthroplastymsinmsthemsnextmsmonthmsandmsmaymsnee
dmsamsbloodmstransfusion.msThemspatientmsexpressesmsconcernmsaboutmsthemsriskmsofmsdev
elopingmsanmsinfectionmsfrommsthemstransfusion.msWhatmsstatementmsshouldmsthemsnursems
makemstomsthemspatient?ms-
msanswer--"donatemsautologousmsbloodmsbeforemsthemssurgery"
-collectionmsandmsreinfusionmsofmsthemsptsmsownmsblood,msbloodmsismsdrawnms3-
5msweeksmspriormstomssurgery;mssafestmsformmsofmsbloodmstranfusions
-
takingmsepoetinmspriormstomssurgerymscanmsboostmsHCTmslevelsmsbutmsismsinappropriatemsif
mstheirmslevelsmsaremsw/
inmsnormalmsandmsthismsmightmsnotmseliminatemsneedmsformstransfusion
-
takingmsironmssupplementmscanmsboostmshemoglobinmslevelsmsbutmsinappropriatemsifmsleve
lsmsaremsw/inmsrangemsandmsmaymsnotmseliminatemsneedmsformstransfusion