Fundamentals of Nursing are the concept for nursing interventions and proper techniques from assessment, planning, implementation, and evaluation. Here are some questions and rationale pertaining to the fundamentals of nursing.
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 at 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 is the correct answer. 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.
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
C is the correct answer. Orthopnea is the 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.
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 is the correct answer. 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.
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|
|c. A tossed salad with oil and vinegar and olives|
|d. Chicken bouillon|
B is the correct answer. 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.
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 is the correct answer. 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.
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 is the correct answer. 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.
In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is
|b. b. Elimination|
D is the correct answer. 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.
The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?
|a. Discourage them from making a decision until their grief has eased|
|b. Listen to their concerns and answer their questions honestly|
|c. Encourage them to sign the consent form right away|
|d. Tell them the body will not be available for a wake or funeral|
B is the correct answer. The brain-dead patient’s family needs support and reassurance in making a decision about organ donation. Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. However, the family’s concerns must be addressed before members are asked to sign a consent form. The body of an organ donor is available for burial.
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?
|a. Complain to her fellow nurses|
|b. Wait until she knows more about the unit|
|c. Discuss the problem with her supervisor|
|d. Inform the staff that they must volunteer to rotate|
C is the correct answer. Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. In this case, the supervisor is the resource person to approach.
Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?
|a. Continuity of patient care promotes efficient, cost-effective nursing care|
|b. Autonomy and authority for planning are best delegated to a nurse who knows the patient well|
|c. 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.|
D is the correct answer. Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps.