1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be…
a. Maintain the patient on strict bed rest a... [Show More] t all times
b. Maintain the patient in an orthopneic position as needed
c. Administer oxygen by Venturi mask at 24%, as needed
d. Allow a 1 hour rest period between activities
B. When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of
hypoxia.
2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
a. Tachypnea
b. Eupnca
c. Orthopnea
d. Hyperventilation
C . Orthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without
effort.
3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
a. Instructing the patient about this diagnostic test
b. Writing the order for this test
c. Giving the patient breakfast
d. All of the above
C . A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test.
4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
a. A ham and Swiss cheese sandwich on whole wheat bread
b. Mashed potatoes and broiled chicken
c. A tossed salad with oil and vinegar and olives
d. Chicken bouillon
B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken bouillon contain
large amounts of sodium and are contraindicated on a low sodium diet.
5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily.
Nursing responsibilities for Mrs. Mitchell now include:
a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
b. Reporting an APTT above 45 seconds to the physician
c. Assessing the patient for signs and symptoms of frank and occult bleeding
d. All of the above
D . All of the identified nursing responsibilities are pertinent
when a patient is receiving heparin. The normal activated partial
thromboplastin time is 16 to 25 seconds and the normal
prothrombin time is 12 to 15 seconds; these levels must remain
within two to two and one half the normal levels. All patients
receiving anticoagulant therapy must be observed for signs and
symptoms of frank and occult bleeding (including hemorrhage,
hypotension, tachycardia, tachypnea, restlessness, pallor, cold
and clammy skin, thirst and confusion); blood pressure should
be measured every 4 hours and the patient should be
instructed to report promptly any bleeding that occurs with
tooth brushing, bowel movements, urination or heavy
prolonged menstruation.
6. The four main concepts common to nursing that appear in each of the current conceptual models are:
a. Person, nursing, environment, medicine
b. Person, health, nursing, support systems
c. Person, health, psychology, nursing
d. Person, environment, health, nursing
D . The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs.
7. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is:
a. Love
b. Elimination
c. Nutrition
d. Oxygen
D . Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs. [Show Less]
