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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. Another term for a focused assessment is
The patient
Stroke volume x's heart rate
Ongoing assessment
To simulate eating motions with the hands

2. Expiration sounds are heard longer than inspiration In What area?
Focused
# of packs per day x # of years smoked
The medication will not affect the patient's breathing.
Broncial (heard over trachea)

3. Kussamaul respirations describe

4. Intermittent claudication is caused by?
Wandering
Snap - crackle - pops; velcro - bubble wrap
Decreased arterial perfusion
To simulate eating motions with the hands

5. Why are young children at greater risk for respiratory infection?
Broncial (heard over trachea)
Defining a baseline of cognitive function - any changes or deviations from norm.
Immature immune system - structures close together lends to easy spreading from on area to another.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

6. What are the components of a mental status exam that are not part of a regular assessment?
Confusion Assessment Method
Secondary
Learning - memory and adaptation to stress
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

7. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Pt's underlying feelings
A personal experience that does whatever the person in pain says it does
Adolescence

8. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Vesicular (peripheral lung areas)
An 80 y/o patient that has emergency surgery
Fast and deep respirations seen in patient's with acidosis
Level of stress - risk for violence - anxiety level - patient unmet needs

9. When a patient has increased neutrophils - this may indicate what?
Paradoxical reaction
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Bacterial infection
School age childen

10. Inspiration sounds are heard longer than expiration sounds In What area?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Hygeine - DOB - work hx
Serves to expedite dx and tx of actual and potential health problems
Vesicular (peripheral lung areas)

11. Factors that may reduce the efficacy of pulse oximetry include
Risk of falls increases
Defining a baseline of cognitive function - any changes or deviations from norm.
Fluid volume deficit related to poor intake
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

12. Sleep deprivation can effect
School age childen
Focused
Learning - memory and adaptation to stress
Immature immune system - structures close together lends to easy spreading from on area to another.

13. In Which part of the nursing process will you find delegation?
Objective
Immature immune system - structures close together lends to easy spreading from on area to another.
Capillaries
Implementation

14. The path of blood from the lungs to the heart is
Bacterial infection
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Sensory motor
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

15. An example of a secondary source is
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Family - spouse - someone other than a healthcare worker - previous medical records.
Fast and deep respirations seen in patient's with acidosis
Nurse

16. An example of a nursing dx would be
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Fluid volume deficit related to poor intake
Daily
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

17. What is the formula for determining pack years?
# of packs per day x # of years smoked
Communicate using hands and eyes.
Double check equip and patient
Viral infection

18. What do rhonchi sound like?
Fast and deep respirations seen in patient's with acidosis
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Serves to expedite dx and tx of actual and potential health problems
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

19. Types of hearing loss include
Focused
Decreased sense of taste
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Tricuspid - mitral and the aortic

20. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Hearing loss
Non - opiod (ex: NSAID/acetominaphen)
Capillaries
Upper airways

21. What are the ABCDE's of pain management?
Confusion Assessment Method
Fast and deep respirations seen in patient's with acidosis
Pt's with oxygenation and perfusion problems
Ask - Believe - Choose - Deliver - Empower

22. When dealing with a confused patient - should the nurse acknowledge the patient's underlying feelings or the content of the delusion?

23. When using restraints in a confused patient
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Risk of falls increases
Communicate using hands and eyes.
Toddler

24. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Pt's with oxygenation and perfusion problems
An 80 y/o patient that has emergency surgery
Decision assessment

25. What is a chochlear implant?
Hemoglobin
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Inattention and acute increase/decrease in cognitive function
The medication will not affect the patient's breathing.

26. QUESTT is a tool for What type of an assessment?
A false - fixed belief that cannot be corrected through reasoning.
Learning - memory and adaptation to stress
Pain
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

27. Subjective data could include
Learning - memory and adaptation to stress
Broncial (heard over trachea)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Symptoms

28. Would a nursing dx be part of the primary or secondary dx?
Knowing What to do/how to make a decision based upon available data.
Secondary
Secondary soureces (family - friends)
The result is accurate patient dB

29. The order of air flow into the lungs is
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Pt's with oxygenation and perfusion problems
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

30. What are the steps of the nursing process?
Nursing dx
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Level of stress - risk for violence - anxiety level - patient unmet needs
Decreased arterial perfusion

31. What is the purpose of the nursing process?
Pain
The process of storing - learning - retrieving - and using info.
No
Serves to expedite dx and tx of actual and potential health problems

32. Nursing interventions should be based on who's theory?
Maslow
Pt's underlying feelings
Ask - Believe - Choose - Deliver - Empower
Communicate using hands and eyes.

33. When speaking with a patient with moderate hearing loss the RN should
The process of storing - learning - retrieving - and using info.
Communicate using hands and eyes.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

34. Data validation assures
The result is accurate patient dB
Nursing dx
Immature immune system - structures close together lends to easy spreading from on area to another.
Objective

35. At What age do you begin to use decision making?
Upper airways
Focused
The result is accurate patient dB
Adolescence

36. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Daily
Nurse
Fast and deep respirations seen in patient's with acidosis
Tricuspid - mitral and the aortic

37. What is pain?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
A personal experience that does whatever the person in pain says it does
Initial assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

38. What are Piaget's stages of cognitive development
Wandering
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Decision assessment

39. Fluid volume deficit is a __________ dx
Pain in legs assoc w walking
Nursing
Double check equip and patient
A false - fixed belief that cannot be corrected through reasoning.

40. An ongoing assessment is performed
Decision assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
Daily
A false - fixed belief that cannot be corrected through reasoning.

41. What is intermittent claudication?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pain in legs assoc w walking
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Secondary soureces (family - friends)

42. The fifth vital sign is
Trauma or illness
A false - fixed belief that cannot be corrected through reasoning.
Decision assessment
Pain

43. Are changes in vital signs a reliable indicator of chronic pain?
Viral infection
No
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Medical

44. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Irregular respirations (fast/slow) often seen at end of life
Daily
Family - spouse - someone other than a healthcare worker - previous medical records.

45. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Secondary
Irregular respirations (fast/slow) often seen at end of life
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Wandering

46. What is responsible for transporting O2 in the blood
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Hemoglobin

47. Where can you hear bronchovesicular breath sounds?
Decision assessment
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Knowing What to do/how to make a decision based upon available data.
Pain

48. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
The result is accurate patient dB
Pt's underlying feelings
Abstract thinking
Capillaries

49. Ongoing assessments are useful in

50. What is the formula for cardiac output?