VN 100 Fundamentals Of Nursing Final

VN 100 Fundamentals Of Nursing Final Exam

A patient who has had spinal surgery is not permitted to bend at the waist

or sit in a chair. To position the patient safely in bed, the nurse:

• uses logrolling to accomplish position changes from side to side
• keeps her in a prone position to keep pressure off her back
• moves the top half of her body first, then the middle, and finally legs
• places her in low or semi-fowlers position only

(Ans- a. uses logrolling to accomplish position changes from side to side

(logrolling, or moving the patient's body as one unit, is used after back surgery or trauma or when twisting or flexion must be avoided. Logrolling is accomplished using a sheet and at least two persons)

Before the nurse administers a dose of digoxin (Lanoxin) to a patient, the

nurse should assess:

• blood pressure
• respiratory rate
• apical heart rate
• level of consciousness

(Ans- c. apical heart rate

(The apical heart rate is measured before giving a dose of digoxin

(Lanoxin) to determine whether it is safe to give: the apical rate should be

greater then 60 beats/min for an adult patient)

The nurse would anticipate a patient diagnosed with damage to the

hypothalamus after suffering a head injury from a fall to exhibit:

• a blood pressure elevation
• a decrease in pulse rate
• depressed respirations 1 / 4

• temperature abnormality

(Ans- d. temperature abnormality

the hypothalamus controls body temperature. Any damage to it prevents proper temperature regulation

If a nurse is reported to a state board of nursing for repeatedly making

medication errors, it is most likely that:

• the nurse will immediately have his or her license revoked
• a course in legal aspects of nursing care will be required
• there will be a hearing to determine whether the charges are true
• the nurse will have to take the licensing examination again

(Ans- c. there will be a hearing to determine whether the charges are true

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

• "4 cm reddened area over sacrum, skin interact, warm and dry"
• "patients says she is still slightly nauseated, would like to try some toast

and tea"

• "taking fluids poorly, but more than yesterday"
• Apparently comfortable all night, offers no complaints of pain"

(Ans- a. "4 cm reddened area over the sacrum, skin interact, warm and dry"

provision of specific objective data-size, location, and characteristics of the patient's skin is clear and brief and informative

Nursing liability insurance is a policy purchased and put into effect by the

nurse for the purpose of:

• providing protection against being sued
• providing the hospital with added protection
• reducing the chance of litigation
• paying attorney fees and any award won by the plaintiff

(Ans- d. paying attorney fees and any award won by the plaintiff

• / 4

nursing liability insurance pays attorney fees and any award won by the plaintiff

The nurse explains that medical asepsis differs from surgical asepsis in

that medical asepsis:

• is confined to the patient's room
• kills all organisms
• uses sterile attire to protect the patient
• uses sterile equipment before contact with the patient

(Ans- a. is confined to the patient's room

medical asepsis confines the microorganisms to the patient's room. Medical asepsis does not kill all organisms' it uses clean attire and equipment

An older adult patient is having difficulty swallowing an enteric-coated tablet for which there is no liquid form available. To help swallow the dose more easily the nurse should.

• Take only a small sip of water to swallow the tablet
• brush the pill and administer it in applesauce
• use a spoon to place the tablet at the back of the tongue
• request the patient to tilt the chin down slightly to swallow

(Ans- d. request the patient to tilt the chin down slightly to swallow

They should swallow a sip of water first, then place the tablet toward the back of the tongue then take a large sip of water. Place the tongue on the roof of the mouth and swallow with thin tilted

A patient has advance directives spelled out in a durable power of attorney, with the appointment of his daughter as his health care agent. The

daughter will be responsible for:

• paying only for those health care decisions based on the advance

directives 3 / 4

• paying all medical bills associated with the father's illness.
• making all choices about her father's health care if the father is unable
• making all informed consent decisions for her father

(Ans- c. making all choices about her father's health care if the father is unable

health care agent makes decisions for the patient only when a patient is unable, according to the wishes made known by the patient in advance directives. A health care agent is not responsible for financial decisions or payments

The nurse takes into consideration that a patient who uses alcohol is at risk

for a vitamin deficiency in:

• ascorbic acid
• iron
• thiamine
• cyanocobalamin

(Ans- c. thiamine

The nurse is aware that the best time to schedule a postural drainage

treatment is:

• 1 hour after supper
• shortly after the patient arises in the morning before breakfast
• in the morning immediately after breakfast
• 30 minutes after lunch

(Ans- b. shortly after the patient arises in the morning before breakfast

postural drainage is best accomplished in the morning prior to eating because more secretions accumulate while the patient is asleep

The nurse would record a pulse as bradycardic if the rate were:

• 59 beats/min
• / 4