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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. Would a nursing dx be part of the primary or secondary dx?
Secondary
8.4
Capillaries
The result is accurate patient dB

2. Ongoing assessments are useful in

3. What is pain?
The patient
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Non - opiod (ex: NSAID/acetominaphen)
A personal experience that does whatever the person in pain says it does

4. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
8.4
Loss of taste
Medical

5. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Decreased arterial perfusion
Level of stress - risk for violence - anxiety level - patient unmet needs
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Secondary

6. Factors that may reduce the efficacy of pulse oximetry include
No
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
The process of storing - learning - retrieving - and using info.

7. What is the formula for determining pack years?
Viral infection
# of packs per day x # of years smoked
Loss of taste
Secondary

8. What is the correct approach when dealing with older adults?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
A false - fixed belief that cannot be corrected through reasoning.
Non - opiod (ex: NSAID/acetominaphen)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

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

10. Name the 5 'W's' of assessing a change in LOC
Learning - memory and adaptation to stress
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
# of packs per day x # of years smoked
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

11. Hypogeusis is
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Decreased sense of taste
Objective
The medication will not affect the patient's breathing.

12. What are the steps of the nursing process?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Initial assessment
Knowing What to do/how to make a decision based upon available data.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

13. A nursing dx is best described as
Upper airways
The process of storing - learning - retrieving - and using info.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Knowing What to do/how to make a decision based upon available data.

14. What would cause changes in congitive development later in life (middle adulthood)?
Vesicular (peripheral lung areas)
Nurse
Trauma or illness
Pain on inspiration and expiration; superficial squeaking or grating

15. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Double check equip and patient
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Implementation

16. Where can you hear bronchovesicular breath sounds?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Wandering
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

17. What scale is used to determine eating and feeding issues in adults with confusion
An 80 y/o patient that has emergency surgery
Hearing loss
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
EdFED- Q

18. An example of a primary source is
The patient
Secondary
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

19. The basis for a plan of care comes for which stage of the nursing process?
Hemoglobin
Assess over all health status and identify the problem
Knowing What to do/how to make a decision based upon available data.
Nursing dx

20. Side effects of putting confused pts in restraints include
Stroke volume x's heart rate
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Broncial (heard over trachea)
Trend assessment (shift report)

21. Fluid volume deficit is a __________ dx
Fluid volume deficit related to poor intake
8.4
Nursing
Confusion Assessment Method

22. What are the components of a mental status exam that are not part of a regular assessment?
Decreased arterial perfusion
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
# of packs per day x # of years smoked
An 80 y/o patient that has emergency surgery

23. Examples of personal information
Family - spouse - someone other than a healthcare worker - previous medical records.
Fluid volume deficit related to poor intake
Hygeine - DOB - work hx
Initial assessment

24. QUESTT is a tool for What type of an assessment?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain
Tricuspid - mitral and the aortic
An 80 y/o patient that has emergency surgery

25. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Wandering
EdFED- Q
Upper airways
Abstract thinking

26. An infant is in which Paiget stage?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Objective
Sensory motor
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

27. At What age do you begin to use logical thought process?
Broncial (heard over trachea)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
School age childen

28. Expiration sounds are heard longer than inspiration In What area?
Family - spouse - someone other than a healthcare worker - previous medical records.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Broncial (heard over trachea)
An 80 y/o patient that has emergency surgery

29. What is the difference between a nursing dx and a med dx?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Irregular respirations (fast/slow) often seen at end of life
Nursing

30. What are the components of an assessment?
Irregular respirations (fast/slow) often seen at end of life
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Serves to expedite dx and tx of actual and potential health problems
Ask - Believe - Choose - Deliver - Empower

31. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Level of stress - risk for violence - anxiety level - patient unmet needs
Family - spouse - someone other than a healthcare worker - previous medical records.
Pain in legs assoc w walking

32. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Double check equip and patient
Edema
Stroke volume x's heart rate

33. Why are young children at greater risk for respiratory infection?
Decision assessment
Bacterial infection
Immature immune system - structures close together lends to easy spreading from on area to another.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

34. The site where gas exchange occurs is
Capillaries
Decreased sense of taste
Fast and deep respirations seen in patient's with acidosis
Pain

35. If an abnormal finding is revealed during assessment - the nurse should
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Double check equip and patient
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decreased sense of taste

36. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Non - opiod (ex: NSAID/acetominaphen)
Pain on inspiration and expiration; superficial squeaking or grating
Knowing What to do/how to make a decision based upon available data.

37. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Tricuspid - mitral and the aortic
The process of storing - learning - retrieving - and using info.
Pain on inspiration and expiration; superficial squeaking or grating

38. What does CAM stand for
Non - opiod (ex: NSAID/acetominaphen)
Ask - Believe - Choose - Deliver - Empower
Confusion Assessment Method
Pt's underlying feelings

39. What are Piaget's stages of cognitive development
Decreased arterial perfusion
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Level of stress - risk for violence - anxiety level - patient unmet needs
8.4

40. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Nurse
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Assess over all health status and identify the problem

41. What do rhonchi sound like?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Vesicular (peripheral lung areas)
Nursing
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

42. Data gathered via instrumention (pulse ox) is considered
Objective
Secondary soureces (family - friends)
A false - fixed belief that cannot be corrected through reasoning.
Fluid volume deficit related to poor intake

43. An example of a secondary source is
Secondary soureces (family - friends)
Family - spouse - someone other than a healthcare worker - previous medical records.
Risk of falls increases
Bacterial infection

44. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
To ID the problem
Trauma or illness
Ongoing assessment

45. At patient that state their shoes are tighter at the end of the day may be experiencing
Pain
Edema
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
The patient

46. In Which part of the nursing process will you find delegation?
Have them do simple math problems
Implementation
To ID the problem
Tricuspid - mitral and the aortic

47. Another term for a focused assessment is
8.4
Confusion Assessment Method
Defining a baseline of cognitive function - any changes or deviations from norm.
Ongoing assessment

48. Two indicators that are REQUIRED for classification via the CAM tool include
Pain
Inattention and acute increase/decrease in cognitive function
Abstract thinking
The process of storing - learning - retrieving - and using info.

49. What is cognition?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Toddler
Learning - memory and adaptation to stress
The process of storing - learning - retrieving - and using info.

50. Where can wheezes best be heard?
Double check equip and patient
Upper airways
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Inattention and acute increase/decrease in cognitive function