Question

7:36 7 call LTE Back Fundamentals Midterm Prep 13. The nurse is caring for a patient who is receiving vancomycin (Vancocin) to treat a severe infection. The next vancomycin dose is due to be administered at 10:00 A.M. what time will the nurse draw the vancomycin serum trough level? a. 7:30 AM b. 9:30 AM c. 11:30 AM d. 1:30 PM 14. The nurse begins a shift on a busy medical-surgical unit. The nurse will be caring for multiple patients. Which patient will the nurse assess first? a. A patient who would like some acetaminophen (Tylenol) for a mild headache. b. A patient who has question about her daily medication C. A patient who needs discharge teaching about antibiotic d. A patient who just received nitroglycerin for chest pain 15. The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation 16. The nursing interventions that are implemented for patients must be documented or charted. Proper documentation of interventions: a. facilitates communication with all members of the health care team b. are only considered "legal" if documented in the proper chart c. leads to errors of omission and repetition of care d. does not directly measure goals, achievement or outcome 17. The nurse writes a short-term goal for patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is: a. The patient will walk to the bathroom within 48 hours after surgery b. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after Surgery. c. The patient will walk to the bathroom without experiencing shortness of breath d. The patient will walk to the bathroom without experiencing shortness of breath after surgery. 18. The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as: a. The foundation that nurse use to provide care b. A complex process during which nurses think about their thinking c. The process that allow nurse to collect essential data d. Thinkine in douanin plan of care

Answer 1

14) correct option is option d, Because this nitroglycerin may lower the patient's blood pressure. This can cause lightheadedness, dizziness, and fainting when the patient stand up. This is called orthostatic hypotension. It may happen as soon as he/she takes the drug. The patient should sit down while taking this medication and then stand up slowly. So it may be needed to check the blood pressure before and during the treatment with this drug. It is also needed to observe if the angina is getting relieved after administration of nitroglycerin as if the angina is not getting relieved even after administration of nitroglycerin this may suggest the presence of unstable angina which is an emergency as it may indicate that the patient is having a heart attack.

15) correct option is option a. Assessment.Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse.

16) correct option is option a. Nurses document their work and outcomes for a number of reasons: the
most important is for communicating within the health care team and
providing information for other professionals, primarily for individuals
and groups involved with accreditation, credentialing, legal, regulatory
and legislative, reimbursement, research, and quality activities.
Communication within the Health Care Team
Nurses and other health care providers aim to share information about
patients and organizational functions that is accurate, timely,
contemporaneous, concise, thorough, organized, and confidential.
Information is communicated verbally and in written and electronic
formats across all settings. Written and electronic documentation are
formats that provide durable and retrievable records.

17) correct option is option is b.

The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after the surgery. Nursing goals should be S.M.A.R.T that is specific, measurable, attainable, relevant, timely. Hence the correct option should include the specific objective i.e. being able to walk after the surgery which will be attained after a measurable time that is 48 hours without experiencing shortness of breath which is relevant as shortness of breath is common issue faced by patients after surgery because of anaesthesia.

18) correct option is option a. The foundation that nurse use to provide care.

Nursing process is defined as systematic, continuous, dynamic, method of providing care to the client, as it involves series of sequential phases developed upon the preceding step and each step leading to the next one the nursing process — assess, diagnose, plan, implement, and evaluate — forms the foundation for clinical reasoning.

13) correct option is option b. 9:30 am

Trough levels are collected just prior to a person's next vancomycin dose. Peak levels are collected 1 to 2 hours after the completion of the intravenous vancomycin dose. As the patient's next dose is at 10:00 am serum trough levels will be drawn just prior to it, that is 9:30 am