B. MAINTAIN THE PATIENT IN AN ORTHOPNEIC POSITION AS NEEDED

FUNDAMENTALS

OF NURSING

EXAM 2 (50

ITEMS)

• The most appropriate nursing order for a patient who develops

dyspnea and shortness of breath would be…

• Maintain the patient on strict bed rest at all times

B. MAINTAIN THE PATIENT IN AN ORTHOPNEIC POSITION AS NEEDED

• Administer oxygen by Venturi mask at 24%, as needed
• Allow a 1 hour rest period between activities

• 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:

• Tachypnea
• Eupnea

C. ORTHOPNEA

• Hyperventilation

• The physician orders a platelet count to be performed on Mrs. Smith

after breakfast. The nurse is responsible for:

• Instructing the patient about this diagnostic test
• Writing the order for this test

C. GIVING THE PATIENT BREAKFAST

• All of the above

• 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 ham and Swiss cheese sandwich on whole wheat bread

B. MASHED POTATOES AND BROILED CHICKEN

• A tossed salad with oil and vinegar and olives
• Chicken bouillon

• The physician orders a maintenance dose of 5,000 units of 1 / 3

subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities

for Mrs. Mitchell now include:

• Reviewing daily activated partial thromboplastin time (APTT) and prothrombin

time.

• Reporting an APTT above 45 seconds to the physician
• Assessing the patient for signs and symptoms of frank and occult bleeding

D. ALL OF THE ABOVE

• The four main concepts common to nursing that appear in each of

the current conceptual models are:

• Person, nursing, environment, medicine
• Person, health, nursing, support systems 2 / 3

• Person, health, psychology, nursing

D. PERSON, ENVIRONMENT, HEALTH, NURSING

• In Maslow’s hierarchy of physiologic needs, the human need of

greatest priority is:

• Love
• Elimination
• Nutrition

D. OXYGEN

• The family of an accident victim who has been declared brain-dead

seems amenable to organ donation. What should the nurse do?

• Discourage them from making a decision until their grief has eased

B. LISTEN TO THEIR CONCERNS AND ANSWER THEIR QUESTIONS

HONESTLY

• Encourage them to sign the consent form right away
• Tell them the body will not be available for a wake or funeral

• A new head nurse on a unit is distressed about the poor staffing on

the 11 p.m. to 7 a.m. shift. What should she do?

• Complain to her fellow nurses
• Wait until she knows more about the unit

C. DISCUSS THE PROBLEM WITH HER SUPERVISOR

• Inform the staff that they must volunteer to rotate

• Which of the following principles of primary nursing has proven the

most satisfying to the patient and nurse?

• Continuity of patient care promotes efficient, cost-effective nursing care
• Autonomy and authority for planning are best delegated to a nurse who knows

the patient well

• Accountability is clearest when one nurse is responsible for the overall plan

and its implementation.

D. THE HOLISTIC APPROACH PROVIDES FOR A THERAPEUTIC

RELATIONSHIP, CONTINUITY, AND EFFICIENT NURSING CARE.

• If nurse administers an injection to a patient who refuses that

injection, she has committed:

A. ASSAULT AND BATTERY

• Negligence
• Malpractice
• None of the above

• If patient asks the nurse her opinion about a particular physicians

and the nurse replies that the physician is incompetent, the nurse could

be held liable for:

• / 3