The nursing process provides a framework for a nurse's responsibility and accountability. It requires critical thinking. Subjective data from a primary source B.
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Subjective data from a secondary source C. Objective data from a primary source D.
Objective data from a secondary source Answer: A Rationale: Subjective cpt excision nasal papilloma is apparent only to the person affected and cannot be measured, seen, felt, or heard by the nurse. The patient is always considered the primary source.
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The nurse is measuring the patient's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective cpt excision nasal papilloma The patient's urine output was mL C. The patient cpt excision nasal papilloma complaining of abdominal pain D. Which of the following demonstrates that the nurse is participating critical thinking?
The nurse admits she does not know how to do a procedure and requests help B. The nurse makes her point with clever and persuasive remarks to win an argument C. The nurse accepts without question the values acquired in nursing school D. The nurse finds a quick and logical answer, even to complex questions Answer: A Rationale: Critical thinking is self-directed and supports what an individual knows and makes clear what she does not know.
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It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client. Nurses must utilize their resources to acquire the knowledge and support they need to fulfill a nursing responsibility safely. None, goal is written correctly B. It is not measurable C. No target time is given D.
There is no time estimate for goal attainment.
Thus, option A is incorrect. When evaluating an adult patient's blood pressure reading. The nurse considers the patient's age.
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This is an example of which of the following? Comparing data against standards B. Clustering data C. Determining gaps in the data D.
Differentiating cues and inferences Answer: A Rationale: Analysis of the client data blood pressure reading requires knowledge of the normal blood pressure range for an adult. The nurse compares client data against standards to identify significant cues. Jason has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. The appropriate position to drain the anterior and posterior apical segment of the lungs when the nurse does percussion would be: A.
Patient lying on his back then flat on his abdomen on Trendelenburg position B. Patient seated upright cpt excision nasal papilloma bed or on a chair then leaning forward in sitting position cpt excision nasal papilloma flat on his back and on his abdomen C.
Patient lying flat in his back and then flat on his abdomen D. Patient lying on his right then left side on Trendelenburg position Answer: B Rationale: Chest physiotherapy is a dependent nursing function that uses principles of percussion, vibration and postural drainage to drain thick tenacious bronchial secretions.
Percussion is done by clapping cupped hand over the affected lobe of the lung. Patients with posterior segment of the upper lobe affectation should be positioned in a sitting and leaning forward position and flat on bed dorsal recumbent with pillow under the buttocks for anterior segment cpt excision nasal papilloma upper lobe affectation.
Color, amount, consistency of sputum B. Character of breath sounds and respiratory rate before and after procedure C. Amount of fluid intake of the patient before and after the procedure D.
Significant changes in vital signs Answer: C Rationale: Though patients receiving Chest Physiotherapy are encouraged to increase oral fluid intake, this intervention is not too specific for documentation of pertinent data related to the procedure. When assessing Jason for chest percussion or chest vibration and postural drainage, Nurse Melai would focus on the following, except: A. Amount of fluid taken during the last meal before treatment B. Respiratory rate, breath sounds and location of congestion C.
Nurse Melai prepares Jason for postural drainage and percussion. Which of the following is a special consideration when doing the procedure? Respiratory rate of per minute B. Patient can tolerate sitting and lying positions C.
Patient has no sign of infection D. Time of the last food and fluid intake of the patient Answer: D Rationale: The time of last food and fluid intake of the client is very important for the nurse to assess. The best time to perform chest physiotherapy is 1 hour before meals or cpt excision nasal papilloma after meals to prevent food and fluid regurgitation or vomiting.
The purpose of chest papillomas in lymphedema and vibration is to loosen secretions in the lungs. The difference between the procedures is: A.
Percussion uses only one hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle C. Percussion slaps the chest to loosen secretions while vibration shakes the secretions with inhalation of air Answer: B Rationale: Option B is the correct comparison.
Situation 3. The vital signs are body temperature, pulse, respirations, and blood pressure. These signs, which should be looked at in total, are checked to monitor the functions of the body. They reflect changes in function that otherwise might not be observed. To ensure that the diastolic has been determined, the cuff should be released slowly until the mids mm Papiloma uman and then completely for someone with a previous reading of The cuff should be deflated at a rate of 2 to 3 mm per second.
Thus, a range of 90 mm Hg will require 30 to dysbiosis lungs seconds. A patient with pyrexia will most likely demonstrate: A. Dyspnea C. Increased pulse rate B. Precordial pain D. Elevated blood pressure Answer: C Rationale: The pulse increases to meet increased tissue demands for oxygen in the febrile cpt excision nasal papilloma. Mosby, 18th Edition Which of the following patients meet the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?
A patient is in shock B. A patient with an arrhythmia D. It is less than 24 hours since a patient's surgical operation Cpt excision nasal papilloma C Rationale: The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia.
The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? Pedal C. Apical B. Femoral D. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay.
All of the following can cause tachycardia, except: a. Sympathetic nervous system stimulation b. Parasympathetic nervous system stimulation c. Fever d. Exercise Answer: B Rationale: Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels.
Diagnostic and laboratory tests commonly called lab tests are tools that provide information about the client.
Frequently, tests are used to help confirm a diagnosis, monitor an illness, and provide valuable information about the client's response to treatment. A patient is cpt excision nasal papilloma to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has gastrointestinal tract bleeding?
Complete blood count C. Vital signs B.
Guaiac test D. Abdominal girth Answer: B Rationale: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool - through Guaiac Hemoccult test.
Before scheduling a patient for endoscopic retrograde cholangiopancreatography ERCPthe nurse should assess the patient's: A. Urine output C.
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Serum glucose B. Bilirubin leve D. Blood pressure Answer: B Rationale: ERCP or endoscopic retrograde cholangiopancreatography involves the insertion of a cannula into the pancreatic and common bile ducts during an endoscopy.
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The laboratory tests that would indicate that the liver of a patient with cirrhosis is compromised and neomycin enemas might be helpful would be: A. Ammonia level C. Culture and sensitivity B. White blood count D. Alanine aminotransferase level Answer: A Rationale: Increased ammonia levels indicate that the liver is unable to detoxify protein byproducts.
Neomycin reduces the amount of ammonia-forming bacteria in the intestines.
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The most important test used to determine whether a transplanted kidney is working is: A. Renal ultrasound C. White blood cell count B. Serum creatinine level D. Twenty-four hour output Answer: B Rationale: Serum creatinine concentration measures the kidney's ability to excrete metabolic wastes.
Creatinine, a nitrogenous product of protein breakdown, is elevated in renal insufficiency. The best blood test for the nurse to use to evaluate fluid loss resulting from burns is the: A. Blood urea nitrogen C. Hematocrit B. Blood pH D.