Review Fundamentals of Nursing Exam #3 South Tampa University

Exam Review

Fundamentals of Nursing Exam #3 South Tampa University

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy

Experience unlimited access to all questions, exams, video tutorials and study guides. Subscribe now to access all questions.

Total Questions : 48

Showing 25 questions, Sign in for more

Question 1:

The nurse is caring for a patient with a puncture wound.
How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

A. 10 years B. 1 year C. 5 years D. 2 years

Answer and Explanation

Choice A:

Tetanus is an acute infectious disease caused by spores of the bacterium Clostridium tetani.The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/feces of animals and humans, and on the surfaces of skin and rusty tools like nails, needles, barbed wire, etc.Anyone can get tetanus, but the disease is particularly common and serious in newborn babies and pregnant women who have not been sufficiently immunized with tetanus-toxoid-containing vaccines.

To ensure that there is adequate antitoxin to neutralize tetanus toxin in the case of a tetanus-prone injury, a booster dose is advised if it has been longer than 10 years since the last tetanus vaccine dose.This is because a single dose of tetanus toxoid produces a rapid anamnestic response. Therefore, if a patient with a puncture wound has not received a tetanus toxoid vaccination in the last 10 years, they would require an additional injection before being discharged from the emergency department.

Choice B:

While it might seem prudent to administer a tetanus toxoid vaccination every year, this is not necessary according to current medical guidelines.Over-vaccination could potentially lead to an increased risk of adverse reactions without providing additional benefits. Therefore, a tetanus toxoid vaccination is not required every year.

Choice C:

A 5-year interval for tetanus toxoid vaccination is not the standard recommendation for general population.However, in some specific cases, such as when indicated for wound management, a tetanus toxoid–containing vaccine might be administered if ≥5 years have elapsed since the previous receipt of any tetanus toxoid–containing vaccine.

Choice D:

A 2-year interval for tetanus toxoid vaccination is not the standard recommendation.The tetanus toxoid vaccination provides protection for a much longer period, and therefore, it is not necessary to administer the vaccine every 2 years.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 2:

The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique is correct?

A. The nurse aspirates immediately prior to injecting the medication. B. The nurse gently massages the injection site immediately afterward. C. The nurse draws up the medication into a 1-mL syringe with a 32-gauge needle. D. The nurse injects the medication into the soft tissue of the patient’s abdomen.

Answer and Explanation

Choice A:

Aspirating prior to injecting enoxaparin is not recommended. Aspiration was once a common practice to check if a needle had entered a blood vessel. However, research has shown that aspiration is not necessary for subcutaneous injections and may even be harmful. It can cause pain, bruising, and hematoma formation. Additionally, aspirating can increase the risk of needlestick injuries. For these reasons, aspiration is no longer recommended for subcutaneous injections of enoxaparin or other anticoagulants.

Choice B:

Massaging the injection site after administering enoxaparin is not recommended. Massaging can increase the risk of bruising and hematoma formation. It can also cause the medication to be absorbed too quickly, which can increase the risk of bleeding. The best practice is to apply gentle pressure to the injection site with a dry gauze pad for a few seconds after the injection. This will help to prevent bleeding and bruising.

Choice C:

The size of the syringe and needle used to administer enoxaparin is not specified in the question. However, a 1-mL syringe with a 32-gauge needle is a common choice for subcutaneous injections. This size syringe is small enough to be easy to handle, and the 32-gauge needle is thin enough to minimize discomfort.

Choice D:

The abdomen is the preferred site for subcutaneous injections of enoxaparin. The abdomen has a large surface area of soft tissue, which makes it easy to inject the medication. The abdomen is also relatively free of blood vessels and nerves, which reduces the risk of bruising, bleeding, and pain. Other potential injection sites for enoxaparin include the upper arms, thighs, and buttocks. However, the abdomen is generally the preferred site.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 3:

The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is the appropriate site for the injection?

A. Dorsal gluteal B. Deltoid C. Vastus lateralis D. Lateral piriformis

Answer and Explanation

Choice A:

The dorsal gluteal site (also known as the dorsogluteal site) was previously a common injection site, but it's now not recommended due to several significant risks: Proximity to the sciatic nerve: The sciatic nerve is the largest nerve in the body, and it runs close to the dorsal gluteal site. Accidental injection into or near the nerve can cause severe pain, nerve damage, and potential paralysis. Difficulty in locating landmarks: The landmarks for the dorsal gluteal site can be difficult to locate accurately, especially in obese patients or those with decreased muscle mass. This increases the risk of injecting into the wrong area. Risk of injury to blood vessels: The dorsal gluteal site also has a higher risk of injury to blood vessels, as several large vessels run through the area.

Choice B:

The deltoid muscle is located in the upper arm and is a common site for intramuscular injections, but it has limitations for larger volumes: Small muscle size: The deltoid muscle is relatively small compared to other IM injection sites. It's generally recommended for smaller volumes of medication (up to 1 mL in adults). Subcutaneous tissue: The deltoid muscle often has a layer of subcutaneous tissue (fat) that can hinder absorption of medication.

Choice C:

The vastus lateralis muscle is the preferred site for intramuscular injections in adults for several reasons: Large muscle size: It's a large, thick muscle that can accommodate larger volumes of medication (up to 5 mL in adults). Easy to locate landmarks: The landmarks for the vastus lateralis are easy to identify, even in obese patients. Few major nerves or blood vessels: It has fewer major nerves or blood vessels in the area, reducing the risk of injury. Pain tolerance: It's generally considered to be a less painful injection site than the deltoid or dorsogluteal sites.

Choice D:

The lateral piriformis muscle is not a recognized or recommended site for intramuscular injections. It's a deep muscle located in the buttocks, and injecting into it would be difficult and potentially dangerous due to its proximity to the sciatic nerve and other important structures.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 4:

The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

A. The patient correctly demonstrates the exercises and how to use the spirometer. B. The patient explains to the nurse why the exercises and spirometer are important. C. The patient will correctly demonstrate how to use pursed-lip breathing. D. The patient’s pulse oximetry will stay greater than 94% with at least 12 breaths/minute.

Answer and Explanation

Choice A:

None

Choice B:

None

Choice C:

None

Choice D:

None

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 5:

Which medication order is written appropriately?

A. Metformin 0.5 g PO B. Methotrexate 15.0 mg PO C. Meropenem 1.0 g IV D. None of the above

Answer and Explanation

Choice A:

Incorrect dosage form: Metformin is typically administered orally as a tablet or liquid suspension, not as a powder for reconstitution (PO). Missing route of administration: The medication order does not specify the route of administration, such as oral (PO), intravenous (IV), or intramuscular (IM). Potential for medication errors: The lack of clarity in the medication order could lead to errors in administration, such as giving the wrong dose or administering the medication by the wrong route.

Choice B:

Incorrect dosage unit: Methotrexate is typically administered in milligrams (mg), not grams (g). Potential for overdose: The order for 15.0 g of methotrexate is a very high dose that could lead to serious adverse effects, including toxicity and death.

Choice C:

Correctly written: The medication order specifies the drug name (meropenem), the dose (1.0 g), the dosage form (IV), and the route of administration (IV). Appropriate dosage range: The dose of 1.0 g of meropenem is within the typical dosage range for this antibiotic. Clear and concise: The medication order is clear, concise, and easy to understand, which helps to reduce the risk of medication errors.

Choice D:

Incorrect: While choices A and B are both incorrect, choice C is a correctly written medication order.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 6:

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.

Which are the appropriate actions of the nurse? (Select all that apply.)

A. Teach the patient to splint the incision when coughing to minimize pain. B. Assist the patient to sit up in the chair and ambulate in the hallway. C. Watch the patient use the incentive spirometer and ensure hourly usage. D. Dim the lights, provide warm blankets, and maintain a quiet environment. E. Maintain patient privacy and use therapeutic touch as desired by the patient.

Answer and Explanation

Choice A:

Splinting the incision when coughing helps to minimize pain and discomfort, which can encourage deeper breathing and coughing. This is essential because deep breathing and coughing help to clear secretions from the lungs and prevent atelectasis (collapse of lung tissue). Steps for splinting the incision: Place a pillow or folded towel over the incision site. Instruct the patient to apply gentle pressure to the pillow or towel with their hands when coughing or deep breathing. Encourage the patient to relax their abdominal muscles during coughing and deep breathing exercises.

Choice B:

Sitting up in a chair and ambulating promote lung expansion and help to mobilize secretions. This is because gravity assists in moving secretions from the smaller airways into the larger airways, where they can be more easily coughed up. Additional benefits of sitting up and ambulating: Improved circulation Decreased risk of pneumonia Enhanced recovery from surgery

Choice C:

Using an incentive spirometer hourly helps to increase lung capacity and prevent atelectasis. The device encourages the patient to take slow, deep breaths, which helps to inflate the alveoli (air sacs) in the lungs. Instructions for using an incentive spirometer: Sit upright in a chair or bed. Place the mouthpiece of the spirometer in your mouth and seal your lips around it. Inhale slowly and deeply through the mouthpiece, aiming to raise the piston inside the device as high as possible. Hold your breath for 3-5 seconds. Exhale slowly and completely through the mouthpiece. Repeat the process 10-15 times per hour, or as instructed by your healthcare provider.

Choice D:

Choice E:

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 7:

How will the nurse administer a nitroglycerin sublingual tablet to the patient?

A. Have the patient swallow the tablet with a sip of water. B. Crush the tablet and dissolve it in a teaspoon of water. C. Place the tablet in the patient’s mouth next to the cheek. D. Place the tablet under the patient’s tongue.

Answer and Explanation

Choice A:

Incorrect because swallowing the tablet with water would lead to slower absorption and a delayed onset of action. Nitroglycerin is rapidly absorbed through the oral mucosa, and swallowing it would route it through the digestive system, where it would be absorbed more slowly and less effectively. Swallowing the tablet could also increase the risk of side effects, such as headache and flushing, due to the larger amount of the drug that would be absorbed systemically.

Choice B:

Incorrect because crushing the tablet and dissolving it in water would also delay its absorption. This method would require the tablet to dissolve in the water before it could be absorbed through the oral mucosa, which would slow down the onset of action. Crushing the tablet could also damage the medication and make it less effective.

Choice C:

Incorrect because placing the tablet in the patient's mouth next to the cheek would not allow for optimal absorption. The oral mucosa under the tongue is more permeable than the cheek, so placing the tablet under the tongue allows for faster and more efficient absorption. Placing the tablet in the cheek could also increase the risk of the patient accidentally swallowing it.

Choice D:

Correct because placing the tablet under the patient's tongue allows for rapid absorption and a quick onset of action. The sublingual route is the preferred method of administration for nitroglycerin because it allows the medication to bypass the digestive system and be absorbed directly into the bloodstream. This method also allows for the patient to easily remove the tablet if they experience any side effects.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 8:

Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?

A. Ineffective breathing pattern related to incisional pain and anesthesia. B. Risk for suffocation related to emotional and cognitive stress after surgery. C. Readiness for enhanced comfort related to desire for rest after surgery. D. Deficient diversional activity related to boredom from hospitalization.

Answer and Explanation

Choice A:

Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 9:

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

A. The patient’s last bowel movement was before surgery, 4 days ago. B. The patient has refused enoxaparin injections after surgery. C. The patient’s platelet count was 45,000/mm^3 this morning. D. The patient required transfusion of two units of packed red blood cells.

Answer and Explanation

Choice A:

A patient's last bowel movement being 4 days ago does not directly increase their risk of pulmonary embolism (PE). While constipation can be a risk factor for deep vein thrombosis (DVT), which can lead to PE, it is not a significant risk factor on its own. It's important to assess for other risk factors for DVT, such as immobility, recent surgery, or a history of blood clots, in conjunction with constipation.

Choice C:

A platelet count of 45,000/mm^3 is low (thrombocytopenia), but it does not directly increase the risk of PE. In fact, a low platelet count can sometimes hinder clot formation. However, it's important to monitor patients with thrombocytopenia for bleeding risks, as they may be more prone to bleeding complications.

Choice D:

While receiving a transfusion of two units of packed red blood cells can increase blood viscosity, which could theoretically slightly increase the risk of PE, it is not a major risk factor. Patients who receive transfusions are often already at an elevated risk of PE due to other underlying conditions or surgeries. It's essential to assess for other risk factors in these patients.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 10:

The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?

A. Check intravenous lines for patency or redness. B. Check nasogastric tube and presence of bowel sounds. C. Check airway, lung sounds, and pulse oximetry. D. Check Foley catheter and surgical fluid intake.

Answer and Explanation

Choice A:

While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.

Choice B:

Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.

Choice C:

Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care: Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency. Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort. Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs. By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.

Choice D:

Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 11:

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications.
Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

A. postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications.

Answer and Explanation

Choice A:

A: Hypovolemia Impaired perfusion: Hypovolemia, or a decrease in circulating blood volume, leads to reduced blood flow to the wound site. This means that less oxygen and nutrients are delivered to the tissues, which are essential for healing processes like cell growth and collagen synthesis. Impaired oxygen delivery: Oxygen is crucial for white blood cells to fight infection and for fibroblasts to create new tissue. Hypovolemia can significantly hinder wound healing by reducing oxygen availability at the wound site. Delayed inflammatory response: The inflammatory phase of wound healing relies on adequate blood flow to deliver immune cells and initiate tissue repair. Hypovolemia can delay this response, leading to prolonged inflammation and delayed healing. Decreased fibroblast activity: Fibroblasts, the cells responsible for collagen production, require oxygen and nutrients to function effectively. Hypovolemia can impair fibroblast activity, leading to reduced collagen synthesis and delayed wound closure.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 12:

Which assessment finding indicates that the patient is not a candidate for acupuncture therapy?

A. The patient follows a lactose-free diet. B. The patient has a history of thrombocytopenia. C. The patient has several herniated lumbar disks. D. The patient is allergic to latex and strawberries.

Answer and Explanation

Choice A:

A lactose-free diet does not contraindicate acupuncture therapy. Lactose intolerance is a digestive condition that does not affect blood clotting or the ability to receive acupuncture safely. Acupuncture needles are very fine and do not typically cause bleeding. Even if minor bleeding occurs, it is not a concern for individuals without bleeding disorders. Therefore, a lactose-free diet does not pose a risk for acupuncture.

Choice B:

Thrombocytopenia is a condition characterized by a low platelet count. Platelets are essential for blood clotting. Acupuncture involves the insertion of needles into the skin. This can cause minor bleeding, even when performed correctly. In individuals with thrombocytopenia, even minor bleeding can be difficult to control and may lead to excessive bruising or hematoma formation. Therefore, thrombocytopenia is a contraindication to acupuncture therapy due to the increased risk of bleeding complications.

Choice C:

Herniated lumbar disks are a common condition that can cause back pain. Acupuncture is often used to treat back pain, including pain caused by herniated disks. Studies have shown that acupuncture can be effective in reducing pain and improving function in patients with herniated disks. Therefore, the presence of herniated lumbar disks does not contraindicate acupuncture therapy.

Choice D:

Latex and strawberry allergies are not contraindications to acupuncture therapy. Acupuncture needles are typically made of stainless steel, which does not contain latex. Additionally, acupuncture does not involve the use of strawberries or any other substances that are common allergens. Therefore, latex and strawberry allergies do not pose a risk for acupuncture.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 13:

The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.

Which term will the nurse use to describe this area?

A. Secondary erythema. B. Nonblanchable erythema. C. Blanchable hyperemia. D. Reactive hyperemia.

Answer and Explanation

Choice A:

Secondary erythema refers to redness that develops after the initial injury or insult. It's not the most accurate term to describe an area that doesn't blanch, as blanching specifically assesses for the presence of blood in the tissue. Secondary erythema can be blanchable or nonblanchable, depending on the underlying cause.

Choice B:

Nonblanchable erythema is the most accurate term to describe an area of redness that does not turn lighter in color when pressed with a finger. This indicates that blood is not flowing to the area and that the tissue is likely damaged. Nonblanchable erythema is a significant finding because it can be a sign of a pressure injury (also known as a bedsore or pressure ulcer). Key points about nonblanchable erythema: It's a sign of impaired blood flow to the tissue. It's a potential indicator of a pressure injury. It requires prompt assessment and intervention to prevent further tissue damage.

Choice C:

Blanchable hyperemia is a reddening of the skin that blanches (turns lighter) when pressed. This indicates that blood is still flowing to the area and that the tissue is not damaged. It's not the correct term for an area that doesn't blanch.

Choice D:

Reactive hyperemia is a temporary increase in blood flow to an area that has been deprived of blood flow. It's often seen after pressure is relieved from a body part. While reactive hyperemia can cause redness, this redness typically blanches when pressed.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 14:

A nurse is caring for a patient who will be undergoing a surgical procedure that will take 7 to 8 hours to complete.
What is the appropriate outcome for the diagnosis of perioperative positioning injury related to prolonged immobilization?

A. The patient’s skin will be free of redness or breakdown when surgery is complete. B. The patient’s privacy and dignity will be maintained throughout the procedure. C. The patient’s bony prominences will be padded with pressure-reducing cushions. D. The patient’s skin will be assessed prior to surgery to identify areas at risk.

Answer and Explanation

Choice A:

Directly addresses the primary goal of preventing perioperative positioning injury: The absence of redness or breakdown in the skin is the most definitive indicator that the patient has not sustained any skin or tissue damage as a result of prolonged immobilization during surgery. Focuses on the patient outcome, not just interventions: While interventions such as padding bony prominences and assessing skin prior to surgery are important, they are means to achieve the ultimate goal of preventing skin injury. This outcome statement directly measures the success of those interventions. Aligns with best practices for pressure injury prevention: The National Pressure Injury Advisory Panel (NPIAP) and other expert organizations emphasize the importance of setting goals that focus on maintaining skin integrity and preventing injury.

Choice B:

Addresses a crucial aspect of patient care, but not directly related to positioning injury: Maintaining privacy and dignity is essential for all patients, but it does not specifically address the risk of skin breakdown from prolonged immobilization. Not a measurable outcome for positioning injury: It is difficult to objectively assess whether a patient's privacy and dignity have been maintained, making it less suitable as an outcome statement for this particular diagnosis.

Choice C:

Describes an important intervention, but not a patient outcome: Padding bony prominences is a key strategy to reduce pressure and prevent skin injury. However, it is an action taken by the nurse, not a measurable outcome that reflects the patient's status. Does not guarantee prevention of injury: Even with appropriate padding, patients can still develop pressure injuries if other risk factors are present or if repositioning is not performed adequately.

Choice D:

Represents an essential assessment step, but not a final outcome: Assessing the skin prior to surgery is important for identifying areas that are at increased risk of breakdown. However, it is a preliminary step in the prevention process, not the ultimate goal. Does not ensure prevention of injury: Identifying at-risk areas is helpful for targeting interventions, but it does not guarantee that skin breakdown will not occur.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 15:

The nurse is scheduled to administer the patient’s next dose of vancomycin at 9:30 a.m. At what time should the nurse draw the patient’s blood to check the trough vancomycin level?

A. 10:30 a.m. B. 8:30 a.m. C. 9:00 a.m. D. 10:00 a.m.

Answer and Explanation

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 16:

Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action for the nurse to take?

A. Provide meticulous oral care and allow the patient to have ice chips for dry mouth. B. Notify the surgeon immediately and prepare the patient for emergency surgery. C. Keep the patient NPO and document the finding in the patient’s medical record. D. Allow the patient to have clear liquids as tolerated to help bowel function return.

Answer and Explanation

Choice A:

While providing meticulous oral care and allowing ice chips for dry mouth can promote comfort, it does not address the primary concern of absent bowel sounds. Ice chips could potentially stimulate bowel activity, but this is not a reliable or recommended method for managing absent bowel sounds in the immediate postoperative period. It's essential to prioritize actions that assess and address the potential causes of absent bowel sounds, as they can indicate serious complications.

Choice B:

Notifying the surgeon immediately and preparing for emergency surgery is not the appropriate first course of action in this situation. Emergency surgery would be considered only if there were clear signs of a life-threatening complication, such as bowel perforation or peritonitis. These complications would typically present with additional symptoms such as severe abdominal pain, fever, and hemodynamic instability. Absent bowel sounds alone, without other concerning signs, do not warrant immediate surgical intervention.

Choice C:

Keeping the patient NPO (nothing by mouth) is the most appropriate action when bowel sounds are absent after major abdominal surgery. This allows the bowel to rest and recover from the surgical manipulation. It also prevents potential complications such as aspiration and nausea/vomiting that could arise from premature oral intake. Documenting the absence of bowel sounds in the patient's medical record is essential for communication among healthcare providers and for monitoring the patient's progress. This documentation provides a clear record of the patient's clinical status and facilitates appropriate decision-making regarding further interventions.

Choice D:

Allowing the patient to have clear liquids as tolerated is not appropriate when bowel sounds are absent. Introducing oral intake before bowel function has returned can increase the risk of nausea, vomiting, and aspiration. It's crucial to wait for the return of bowel sounds before initiating oral intake to ensure proper digestion and minimize complications.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 17:

The patient has a large red, blistered area on the left hip.
Which pressure injury stage will be recorded in the patient’s chart?

A. Stage 2 B. Stage 4 C. Stage 3 D. Stage 1

Answer and Explanation

Choice A:

Stage 2 pressure injuries are characterized by partial-thickness loss of skin layers involving the epidermis and/or dermis. They present as a red, blistered area, often with an intact or ruptured serum-filled blister. The wound bed is typically moist and may be painful. There is no exposure of underlying bone, tendon, or muscle. Key features of Stage 2 pressure injuries that align with the patient's presentation: Red, blistered area: This is a hallmark sign of Stage 2, indicating tissue damage and inflammation in the epidermis and dermis. Large size: The size of the wound suggests more extensive tissue damage, consistent with Stage 2 rather than Stage 1. Absence of deeper tissue involvement: The absence of exposed bone, tendon, or muscle rules out Stage 3 or 4 pressure injuries. Rationales for other choices:

Choice B:

B: Stage 4 Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. This is not consistent with the patient's presentation, which does not describe exposed deeper tissues.

Choice C:

C: Stage 3 Stage 3 pressure injuries involve full-thickness tissue loss, but without exposed bone, tendon, or muscle. They often present with a deep crater-like appearance and may have undermining or tunneling. The patient's wound does not exhibit these features, making Stage 3 less likely.

Choice D:

D: Stage 1 Stage 1 pressure injuries are characterized by intact skin with non-blanchable redness over a bony prominence. They do not involve blisters or open wounds. The patient's presentation clearly exceeds the features of Stage 1.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 18:

The patient is admitted to the cardiac unit.

Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order?

A. STAT B. prn C. One-time D. Standing

Answer and Explanation

Choice A:

STAT orders are urgent and require immediate action. They are typically used for life-threatening situations or when a rapid response is needed to prevent serious harm. In this case, an EKG is important for patients admitted to the cardiac unit, but it is not necessarily an urgent procedure that requires immediate action in all cases. STAT orders are often given verbally or over the phone, and they are typically written in all capital letters with the word "STAT" prominently displayed. Examples of STAT orders include medications for cardiac arrest, intubation for respiratory distress, or emergency surgery for a ruptured appendix.

Choice B:

PRN orders are "as needed" orders, meaning they are only carried out when a specific condition or symptom arises. They are not routinely implemented for all patients in a particular unit or setting. PRN orders allow for flexibility in treatment plans and can help to manage pain, nausea, anxiety, or other symptoms that may fluctuate over time. Examples of PRN orders include pain medication, anti-nausea medication, or sedatives.

Choice C:

One-time orders are administered only once and are not repeated. They are often used for procedures, diagnostic tests, or medications that are not required on an ongoing basis. In this case, an EKG is typically a one-time order for patients outside of the cardiac unit, but it becomes a standing order for patients admitted to the cardiac unit due to the increased importance of cardiac monitoring in this setting. Examples of one-time orders include a chest X-ray, a blood draw, or a dose of antibiotics.

Choice D:

Standing orders are routine orders that are implemented for all patients in a particular unit or setting, unless otherwise specified. They are designed to provide consistent and standardized care, and they often reflect best practices or guidelines for a specific patient population. Standing orders can help to streamline care processes, reduce the need for individual orders, and ensure that patients receive necessary treatments or interventions without delay. In this case, the standing order for an EKG upon admission to the cardiac unit ensures that all patients receive this important cardiac assessment, even if the ordering provider does not specifically write an order for it. Other examples of standing orders in a cardiac unit might include daily weights, regular vital sign checks, or administration of cardiac medications.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 19:

The nurse administers a medication to the patient.
Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?

A. Alopecia and diaphoresis B. Heartburn and flatulence C. Nausea and constipation D. Itchy rash and difficulty breathing

Answer and Explanation

Choice A:

Alopecia (hair loss) and diaphoresis (excessive sweating) can be side effects of certain medications, but they are not typically associated with allergic reactions. Alopecia is often a delayed side effect of medications, meaning it can take weeks or months to develop after starting a medication. It is usually caused by the medication interfering with the normal hair growth cycle. Diaphoresis can be a side effect of medications that affect the nervous system, such as antidepressants and anti-anxiety medications. It can also be a side effect of medications that cause fever, such as antibiotics.

Choice B:

Heartburn and flatulence are common side effects of many medications, especially those that affect the digestive system. Heartburn is a burning sensation in the chest that is caused by stomach acid refluxing back up into the esophagus. It is often triggered by eating certain foods, lying down after eating, or taking certain medications. Flatulence is the release of gas from the intestines. It is often caused by eating foods that are difficult to digest, such as beans and cabbage. It can also be a side effect of medications that slow down the digestive system.

Choice C:

Nausea and constipation are also common side effects of many medications. Nausea is a feeling of sickness or unease in the stomach that can lead to vomiting. It is often caused by medications that irritate the stomach lining or that stimulate the vomiting center in the brain. Constipation is a condition in which bowel movements are infrequent or difficult to pass. It is often caused by medications that slow down the movement of food through the intestines.

Choice D:

Itchy rash and difficulty breathing are classic symptoms of an allergic reaction. An allergic reaction occurs when the body's immune system overreacts to a substance that it perceives as a threat. This can cause a variety of symptoms, including itchy rash, difficulty breathing, swelling, hives, and anaphylaxis. Itchy rash is a common symptom of allergic reactions to medications. It is often caused by the release of histamine, a chemical that is involved in the body's inflammatory response. Difficulty breathing is a serious symptom of an allergic reaction that can be life-threatening. It is often caused by swelling of the airways, which can restrict airflow.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 20:

The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication.

The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient’s condition?

A. The patient is experiencing a moderate allergic reaction and should improve shortly. B. These symptoms are probably due to food poisoning because very few patients have true allergic responses. C. The patient is having an anaphylactic reaction and emergency interventions should be started. D. The patient is having a mild reaction that can be treated easily with an antihistamine.

Answer and Explanation

Choice A:

A: Incorrect. While the patient is experiencing an allergic reaction, it is not moderate. The presence of difficulty breathing and a drop in blood pressure are signs of a severe, life-threatening anaphylactic reaction. Anaphylaxis is a severe, rapid-onset allergic reaction that can lead to death if not treated promptly. It typically involves multiple body systems, including the skin, respiratory system, cardiovascular system, and gastrointestinal system. Moderate allergic reactions typically present with localized symptoms such as hives, itching, and redness. They do not typically involve respiratory or cardiovascular compromise. Rationale for

Choice B:

B: Incorrect. The patient's symptoms are not consistent with food poisoning. Food poisoning typically causes gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal cramps. It does not typically cause hives, difficulty breathing, or a drop in blood pressure. The timing of the symptoms, occurring 2 hours after receiving an antibiotic, strongly suggests an allergic reaction to the medication. Rationale for

Choice C:

C: Correct. The patient's symptoms are consistent with anaphylaxis, a severe allergic reaction that requires immediate emergency treatment. Key features of anaphylaxis include: Skin involvement (hives, itching, flushing, swelling) Respiratory distress (difficulty breathing, wheezing, tightness in the chest) Cardiovascular compromise (drop in blood pressure, lightheadedness, fainting) Gastrointestinal symptoms (nausea, vomiting, diarrhea) Swelling of the tongue or throat Rationale for

Choice D:

D: Incorrect. The patient's reaction is not mild and cannot be treated with an antihistamine alone. Antihistamines are effective for mild allergic reactions, but they are not sufficient to treat anaphylaxis. Anaphylaxis requires immediate treatment with epinephrine, which is a life-saving medication that can reverse the effects of the allergic reaction.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 21:

For the Nursing Exam #3 (Winter 2023), which of the following is an example of allopathic treatment?

A. Burning dried herbs to relieve chronic abdominal pain and diarrhea. B. Use of tai chi exercises to relieve chronic back pain. C. Prescription of antibiotic medication for a bacterial infection. D. Manipulation of the spine to relieve migraine headaches.

Answer and Explanation

Choice A:

Burning dried herbs is a form of traditional medicine, not allopathic medicine. Traditional medicine encompasses a wide range of practices and therapies that have been used for centuries across different cultures. It often relies on natural substances and processes, such as herbs, acupuncture, and massage, to promote healing and well- being. While traditional medicine can offer valuable benefits, it's important to note that it's not always based on scientific evidence and its efficacy can vary depending on the specific practice and condition being treated.

Choice B:

Tai chi exercises are a form of complementary and alternative medicine (CAM), not allopathic medicine. CAM encompasses a diverse group of therapies that are not considered part of mainstream conventional medicine. Tai chi is a mind-body practice that involves gentle, flowing movements and deep breathing. It has been shown to offer a range of health benefits, including reducing stress, improving balance, and easing pain. However, it's important to note that tai chi is not a cure-all and should not be used as a substitute for conventional medical care when necessary.

Choice C:

Prescription of antibiotic medication is a hallmark of allopathic medicine. Allopathic medicine, also known as conventional or Western medicine, is based on the scientific understanding of the body and disease. It focuses on diagnosing and treating specific diseases or conditions using medications, surgery, or other interventions that have been proven effective through rigorous scientific research. Antibiotics are a type of medication that specifically targets and kills bacteria. They are essential for treating bacterial infections, which can cause a wide range of illnesses, from minor skin infections to life- threatening pneumonia.

Choice D:

Manipulation of the spine, also known as chiropractic care, is a form of CAM, not allopathic medicine. Chiropractic care focuses on the musculoskeletal system, particularly the spine. Chiropractors use manual adjustments to the spine to relieve pain, improve range of motion, and restore function. While some studies have shown that chiropractic care can be effective for certain conditions, such as lower back pain, it's important to note that it's not a cure-all and should not be used as a substitute for conventional medical care when necessary.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 22:

What is the first intervention of the nurse for changing the dressing to a painful burn?

A. Loosen the tape gently by pressing the skin away from it. B. Observe the wound bed for presence of granulation tissue. C. Administer pain medication 30 minutes beforehand. D. Gently irrigate the wound using sterile normal saline.

Answer and Explanation

Choice A:

Loosening the tape gently by pressing the skin away from it is an important step in changing a burn dressing. However, it is not the first intervention that should be performed. This is because removing the tape can be painful, and it is important to ensure that the patient is adequately pain-free before proceeding.

Choice B:

Observing the wound bed for the presence of granulation tissue is also an important part of burn care. Granulation tissue is a sign of healing, and its presence indicates that the wound is progressing as expected. However, this assessment is not the first priority when changing a dressing. Pain management should always be addressed first.

Choice C:

Administering pain medication 30 minutes beforehand is the most important first intervention when changing a painful burn dressing. This allows time for the medication to take effect and ensure that the patient is comfortable before the dressing change begins. Pain management is crucial in burn care, as it can help to reduce anxiety, promote healing, and improve patient outcomes.

Choice D:

Gently irrigating the wound using sterile normal saline is another important step in burn care. Irrigation helps to cleanse the wound and remove any debris or dead tissue. However, it should not be performed until the patient's pain has been adequately controlled.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 23:

A patient has an order for a subcutaneous injection of insulin.
Into which of the following tissues will the nurse prepare to give this injection?

A. Into the patient’s intravenous line. B. Into the patient’s vastus lateralis. C. Into the fatty tissue of the patient’s abdomen. D. Into the patient’s deltoid.

Answer and Explanation

Choice A:

Intravenous (IV) administration delivers medication directly into the bloodstream. This route is not appropriate for insulin because it would result in a rapid and potentially dangerous drop in blood glucose levels. Insulin needs to be absorbed more slowly to mimic the natural release of insulin from the pancreas. IV administration also requires sterile technique and specialized equipment, making it more complex and time-consuming than subcutaneous injection. Additionally, there is a higher risk of infection and other complications with IV administration.

Choice B:

The vastus lateralis is a muscle in the thigh that is commonly used for intramuscular (IM) injections. However, IM injections are not typically used for insulin administration because they can be more painful and have a slower absorption rate than subcutaneous injections. IM injections also carry a higher risk of hitting a blood vessel, which could lead to erratic absorption of insulin.

Choice C:

The fatty tissue of the abdomen is the ideal site for subcutaneous insulin injection because it provides slow and consistent absorption of insulin. The abdomen has a rich blood supply, which helps to distribute the insulin throughout the body. The subcutaneous tissue in the abdomen is relatively thin, which makes it easy to inject insulin without causing pain or discomfort. The abdomen is also a large area, which allows for multiple injection sites to be used and rotated to prevent lipohypertrophy (thickening of the subcutaneous tissue).

Choice D:

The deltoid is a muscle in the upper arm that can be used for subcutaneous injections. However, the abdomen is generally the preferred site for insulin injection because it has a greater amount of subcutaneous fat, which helps to slow the absorption of insulin and provide a more consistent effect. The abdomen is also a more convenient site for self-injection, as it is easily accessible.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 24:

What is the appropriate medication dosage for the patient as needed?

A. 60 mg PO every 12 hours. B. IV medication every 4 hours as needed. C. Oxycodone 10 mg/325 mg PO every 6 hours. D. Transdermal patch 25 mcg every 3 days.

Answer and Explanation

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 25:

Which term is used to describe the following condition in a patient’s medical record: perineal skin breakdown after sitting in wet underclothes for many hours?

A. Debridement. B. Evisceration. C. Maceration. D. Dehiscence.

Answer and Explanation

Choice A:

Debridement refers to the removal of dead, damaged, or infected tissue to promote healing. It is not a term used to describe skin breakdown caused by moisture.

Choice B:

Evisceration is the protrusion of internal organs through a wound or surgical incision. It is not relevant to the condition of perineal skin breakdown due to wetness.

Choice C:

Maceration is a term used to describe skin that has become softened and broken down due to prolonged exposure to moisture. This is the most accurate term to describe the condition of perineal skin breakdown after sitting in wet underclothes for many hours. Key features of maceration: Skin softening: The skin becomes white and wrinkled, resembling a prune. Epidermal loss: The outer layer of skin (epidermis) may slough off, leaving the underlying tissue exposed. Redness: The affected area may become red and inflamed. Pain or tenderness: The area may be painful or tender to the touch. Increased risk of infection: Macerated skin is more susceptible to infection due to the breakdown of the skin barrier. Causes of maceration: Prolonged exposure to moisture: This can include sweat, urine, feces, wound drainage, or excessive bathing. Friction: Rubbing or chafing of the skin can also contribute to maceration. Impaired circulation: Poor blood flow to the area can make it more vulnerable to maceration. Prevention of maceration: Keep skin clean and dry: This is the most important step in preventing maceration. Change wet or soiled clothing or dressings promptly. Apply barrier creams or ointments: These can help to protect the skin from moisture. Use incontinence products: These can help to keep the skin dry if the patient is incontinent. Reposition the patient frequently: This helps to reduce pressure and friction on the skin.

Choice D:

Dehiscence is the separation of a surgical wound. It is not applicable in this case, as there is no mention of a surgical wound.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Sign Up or Login to view all the 48 Questions on this Exam

Join over 100,000+ nursing students using Naxlex’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.

Exam Review

Fundamentals of Nursing Exam #3 South Tampa University Share this Share This Link Share on social media Facebook Messager WhatsApp Share URL Copy Close

Total Questions : 48

Sign Up or Login to view all the 48 Questions on this Exam

Fundamentals of Nursing Exam #3 South Tampa University

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy