Nursing Fundamentals
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Questions and Answers

In which scenario might simultaneous palpation of bilateral arteries pose the greatest risk to a patient?

  • Determining blood flow to the brain in a patient with suspected stroke. (correct)
  • Assessing circulation in both feet after applying compression stockings.
  • Measuring pulse rate during CPR.
  • Evaluating the strength of peripheral pulses in arms during exercise.

How does considering the spiritual and mental well-being of Hispanic patients impact healthcare delivery?

  • It reinforces stereotypes and may lead to assumptions about patients' healthcare preferences.
  • It primarily focuses on alternative medicine, disregarding conventional treatment options.
  • It necessitates the exclusion of family members from the patient's care plan.
  • It allows for a more holistic approach to patient care, integrating cultural beliefs and practices. (correct)

A patient is exhibiting deep, slow, labored breathing. How would you relate this breathing pattern to the underlying physiological process?

  • The patient has a neurological condition affecting the respiratory center in the brainstem.
  • The patient is experiencing anxiety, leading to hyperventilation followed by a compensatory pause.
  • The patient has a pulmonary embolism, causing reduced oxygen exchange and rapid, shallow breaths.
  • The body is attempting to compensate for metabolic acidosis, often seen in conditions like diabetic ketoacidosis. (correct)

A client with a terminal diagnosis promises to attend religious services if they survive. What is the most appropriate nursing intervention during this stage?

<p>Provide emotional support and facilitate access to spiritual resources based on client preference. (D)</p> Signup and view all the answers

When documenting patient care, which approach ensures comprehensive and legally sound documentation?

<p>Include the site of measurement, the client’s response, and interventions taken. (B)</p> Signup and view all the answers

Which blood pressure reading indicates the highest level of concern, potentially requiring immediate intervention?

<p>140/90 mmHg (A)</p> Signup and view all the answers

A patient is scheduled for an elective surgery next month. How would this type of hospital admission be classified?

<p>Routine admission (A)</p> Signup and view all the answers

Which statement made by a new graduate nurse about patient assessments requires correction by a preceptor?

<p>&quot;Nursing assessments are primarily for data collection without a direct impact on care planning.&quot; (B)</p> Signup and view all the answers

An 80-year-old patient is admitted to the hospital. Which primary insurance plan would the nurse expect this patient to have?

<p>Medicare (D)</p> Signup and view all the answers

During a routine assessment of a highly trained athlete, which finding would the nurse most likely expect?

<p>Bradycardia (C)</p> Signup and view all the answers

In the initial assessment of a patient in the emergency room, which of the following takes the highest priority?

<p>Airway (B)</p> Signup and view all the answers

A client has a documented temperature of 103.1°F (39.5°C). Which nursing intervention is most appropriate to initiate?

<p>Remove excess clothing (A)</p> Signup and view all the answers

A terminally ill patient expresses a desire to update their will. According to Kübler-Ross' stages of grief, which stage does this behavior likely represent?

<p>Acceptance (A)</p> Signup and view all the answers

A nurse assesses a client with an oxygen saturation of 85%. Beyond immediate oxygen administration, what is the MOST appropriate next step?

<p>Encourage the client to take slow, deep breaths to improve oxygenation. (D)</p> Signup and view all the answers

A newly licensed nurse is learning about hospice care. Which statement BEST reflects the core philosophy of hospice?

<p>Hospice care prioritizes comfort and quality of life for clients with terminal illnesses. (C)</p> Signup and view all the answers

When assessing a client with pneumonia, which finding would the nurse MOST likely expect?

<p>Tachypnea (abnormally rapid breathing) (C)</p> Signup and view all the answers

A nurse is teaching about cultural bias in healthcare. How can cultural bias MOST significantly impact therapeutic relationships?

<p>Cultural bias can create misunderstandings and mistrust, impairing the therapeutic relationship. (C)</p> Signup and view all the answers

When assessing a client's radial pulse, which technique should the nurse employ?

<p>Palpate the radial artery on the thumb side of the wrist to feel the pulse. (B)</p> Signup and view all the answers

A nurse detects a pulse deficit while assessing a client. What is the MOST appropriate initial action?

<p>Request another nurse to simultaneously assess the apical and radial pulses for verification. (B)</p> Signup and view all the answers

Which physiological process contributes the MOST to the body's heat production?

<p>The metabolism of nutrients and energy (A)</p> Signup and view all the answers

Which of the following BEST describes the sound of rhonchi?

<p>Coarse, low-pitched, continuous rumbling sounds. (E)</p> Signup and view all the answers

Considering variations in practice and evolving views, which of the following statements BEST reflects the traditional, though debated, stance within Catholicism regarding unbaptized infants?

<p>Unbaptized babies do not go to heaven. (C)</p> Signup and view all the answers

Simultaneous palpation of the carotid arteries is contraindicated primarily due to the risk of:

<p>Triggering a vasovagal response, leading to bradycardia or syncope. (A)</p> Signup and view all the answers

When providing culturally competent care to Hispanic patients, which approach demonstrates the BEST understanding of their holistic health beliefs?

<p>Addressing the interconnectedness of spiritual, mental, and physical well-being. (B)</p> Signup and view all the answers

A patient's arterial blood gas results show a pH of 7.30, PaCO2 of 18 mmHg, and HCO3- of 15 mEq/L. Based on these values, the patient is MOST likely exhibiting which type of breathing pattern?

<p>Kussmaul respirations (A)</p> Signup and view all the answers

A patient with a terminal illness pledges to volunteer regularly at a homeless shelter if they experience a remission. According to Kübler-Ross, this statement MOST likely indicates which stage of grief?

<p>Bargaining (C)</p> Signup and view all the answers

When evaluating the effectiveness of a new antihypertensive medication, which blood pressure reading, taken 30 minutes after administration, would indicate the medication is working as intended?

<p>140/90 mmHg (pre-administration reading was 160/100 mmHg) (C)</p> Signup and view all the answers

A patient is admitted for observation due to possible appendicitis, but a surgical consult is not yet needed. How should this type of hospital admission be classified?

<p>Observation Admission (C)</p> Signup and view all the answers

A newly graduated nurse states, 'I only need to perform a complete nursing assessment when a patient is first admitted; after that, I just focus on changes.' Which response from the preceptor is MOST appropriate?

<p>&quot;You should perform focused assessments regularly to identify new needs.&quot; (A)</p> Signup and view all the answers

An 82-year-old patient is admitted with pneumonia and has a history of hypertension and type 2 diabetes. Which insurance plan would MOST likely be the primary payer for this patient's hospital stay?

<p>Medicare (B)</p> Signup and view all the answers

When assessing a long-distance runner immediately after a race, which vital sign finding would be MOST expected?

<p>Increased body temperature (D)</p> Signup and view all the answers

Upon arriving at the scene of a motor vehicle accident, the nurse identifies one patient who is unresponsive and not breathing and another patient who is conscious but has a severe leg wound that is actively bleeding. According to basic triage principles, which action should the nurse prioritize?

<p>Establish an airway on the unresponsive, non-breathing patient. (C)</p> Signup and view all the answers

A patient with a fever of 103.1°F (39.5°C) is experiencing significant discomfort and shivering. While administering prescribed antipyretics, what additional intervention should the nurse implement to promote patient comfort and reduce body temperature?

<p>Administer a tepid bath or cooling sponge bath. (B)</p> Signup and view all the answers

A terminally ill patient who previously denied the severity of their condition begins to discuss funeral arrangements and expresses a desire to reconcile with estranged family members. According to Kübler-Ross' stages of grief, which stage is MOST likely represented by these behaviors?

<p>Acceptance (A)</p> Signup and view all the answers

A client with an oxygen saturation of 85% is not showing signs of respiratory distress. After administering oxygen, what is the MOST appropriate next step?

<p>Encourage the client to take deep breaths and monitor oxygen saturation. (A)</p> Signup and view all the answers

A newly licensed nurse is explaining the criteria for hospice eligibility to a patient. Which statement indicates a correct understanding of hospice care?

<p>Hospice care is appropriate when a patient's life expectancy is limited, and the focus is on comfort and quality of life. (A)</p> Signup and view all the answers

A nurse is assessing a client with pneumonia. Which assessment finding, combined with a respiratory rate of 28 breaths per minute (tachypnea), would warrant the MOST immediate intervention?

<p>Use of accessory muscles during respiration. (C)</p> Signup and view all the answers

A nurse is teaching a group of nursing students about the impact of cultural bias in healthcare. Which example BEST illustrates how unconscious bias can negatively affect patient outcomes?

<p>Assuming a patient's pain level based on their ethnicity and consequently under-medicating them. (B)</p> Signup and view all the answers

A nurse is assessing a patient's peripheral circulation. After palpating the radial pulse, the nurse notes it is weak and thready. What is the MOST appropriate next step?

<p>Assess the pulse at the next proximal site and evaluate capillary refill. (A)</p> Signup and view all the answers

A nurse assesses a pulse deficit in a client. After notifying the provider, what collaborative intervention is MOST important to implement?

<p>Simultaneously auscultating the apical pulse while another nurse palpates the radial pulse. (A)</p> Signup and view all the answers

A patient is experiencing hypothermia due to prolonged exposure to cold weather. Beyond providing warm blankets, what physiological mechanism should the nurse anticipate as the body's primary compensatory response?

<p>Shivering to generate heat through muscle activity. (D)</p> Signup and view all the answers

During auscultation of a patient's lungs, a nurse hears continuous, low-pitched rattling sounds that seem to clear somewhat with coughing. How should the nurse document these findings?

<p>&quot;Rhonchi auscultated bilaterally, partially clearing with cough.&quot; (B)</p> Signup and view all the answers

Flashcards

Low Oxygen Saturation

Low oxygen saturation, below 90%, requires intervention.

Hospice Care

Focuses on comfort and quality of life for terminally ill patients.

Tachypnea

Increased respiratory rate, often seen in pneumonia.

Cultural Bias Impact

Can negatively impact trust and understanding.

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Palpating a Radial Pulse

Involves feeling the artery to assess pulse.

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Verify Pulse Deficit

Ensures accuracy when a difference exists between apical and radial pulses.

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Shivering

Involuntary muscle contraction to generate heat.

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Rhonchi

Continuous, low-pitched rattling lung sounds.

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Catholicism and Unbaptized Babies

In Catholicism, it's traditionally believed that unbaptized babies do not immediately go to heaven.

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Palpating Carotid Arteries

Never palpate (feel) both carotid arteries (in the neck) at the same time. Doing so can decrease blood flow to the brain.

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Hispanic Patient Care

In Hispanic cultures, the spiritual and mental aspects of life and health are highly valued.

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Kussmaul Respirations

Deep, slow, and labored breathing is classified as Kussmaul respirations.

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Bargaining (Grief Stage)

The bargaining stage of grief involves attempting to negotiate with a higher power or fate to postpone the inevitable.

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Concerning Blood Pressure Reading

Blood pressure of 140/90 mmHg or higher.

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Routine Admission

A pre-scheduled hospital admission.

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Incorrect Nursing Assessment View

Assessment data is just information, not care guidance.

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Medicare

U.S. health insurance program for individuals 65 or older.

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Bradycardia (in Athletes)

Lower than normal heart rate.

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Emergency Assessment Priority

Ensuring the patient has an open and clear passage for air.

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Action for High Temperature

Reducing layers helps dissipate heat.

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Acceptance (Grief Stage)

Final stage: accepting the reality of death and preparing for it.

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Comprehensive Documentation

Complete and comprehensive documentation includes the site of measurement, the client’s response, and interventions taken.

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Kussmaul Breathing

Deep, rapid, and labored breathing is classified as Kussmaul respirations.

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Grief: Bargaining Stage

In the bargaining stage, a person attempts to negotiate with a higher power or fate.

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Cultural Sensitivity: Hispanic

In Hispanic cultures, the spiritual and mental aspects of life are highly valued, and important in considering an approach to health and care.

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Carotid Artery Palpation

Never palpate the carotid arteries simultaneously because it can decrease blood flow to the brain.

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Fever's Effect on Heart Rate

A higher than normal heart rate.

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Blood Pressure Teaching

Nurses need to teach patients proper BP measurement techniques.

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Deep Breathing for Hypoxia

Breathing exercises can improve oxygen saturation.

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Purpose of Hospice

Focuses on quality of life, not curative treatment, for terminally ill patients.

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Tachypnea Definition

An abnormally rapid rate of breath.

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Cultural Bias Effects

Can hinder trust and understanding between healthcare provider and client.

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Checking Radial Pulse

Involves feeling the artery to assess pulse rate and rhythm.

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Pulse Deficit Verification

Requires confirmation with another nurse to ensure accuracy.

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Shivering and Heat

Involuntary muscle contraction to produce heat, raises body temperature.

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Rhonchi Lung Sound

Continuous, low-pitched rattling lung sounds, often due to secretions in airways.

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Study Notes

Okay, I will incorporate the new information into the existing study notes, maintaining the format and guidelines specified.

  • For a client with an oxygen saturation of 85%, encourage the client to take deep breaths.
  • Hospice care is for clients who are terminally ill.
  • An expected finding when assessing a client with pneumonia is tachypnea.
  • Cultural bias can impair therapeutic relationships.
  • When taking a radial pulse, palpate the radial artery.
  • The first action to take when checking a pulse deficit is to call another nurse for verification.
  • Body heat production is primarily conducted by shivering.
  • Rhonchi is best described as a coarse, low-pitched rattling lung sound.
  • A belief in Catholicism is that unbaptized babies do not go to heaven.
  • Never palpate the carotid artery in the body simultaneously on both sides.
  • When caring for Hispanic patients, remember that the spiritual and mental aspects of life are highly valued.
  • Deep, slow, and labored breathing is classified as Kussmaul respirations.
  • A client who states, "I will go to church if I survive," when dealing with a terminal diagnosis is in the bargaining stage of grief per the Kübler-Ross model.
  • Document the site of measurement, client's response, and interventions taken.
  • A blood pressure reading of 140/90 mmHg is the most concerning.
  • A routine admission is a scheduled admission planned in advance.
  • "Nursing assessments are provided to gather information only" requires intervention.
  • An elderly patient might have Medicare.
  • Bradycardia is expected in an athlete.
  • In an emergency room assessment, airway takes priority.
  • If a client has an oral temperature of 39.5°C (103.1°F), remove excess clothing.
  • A terminally ill client who states, "I want to update my will" is in the acceptance stage.
  • Obtain data on a client with a temperature of 102°F then an increased heart rate should be expected.
  • Releasing the valve so it drops by 10 mmHg per second indicates further teaching is needed for blood pressure measurement.
  • For a client admitted with a productive cough at 10 AM, and encouraged to cough and take deep breaths at 10:15 AM, expect the temperature to worsen, the pulse and respiratory rate to improve, and blood pressure to remain unchanged at 11 AM.

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Description

Nursing fundamentals cover essential concepts like oxygen saturation management with deep breaths, hospice care for terminally ill patients, and assessment of pneumonia symptoms like tachypnea. Cultural sensitivity can enhance therapeutic relationships, and accurate pulse measurement requires radial artery palpation. Understanding respiratory patterns such as Kussmaul respirations, and being aware of religious beliefs are crucial aspects of nursing care.

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