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. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nurse
Pain
Surgically implanted device for deaf or hard or hearing - also called bionic ear.


2. The purpose of an initial assessment is
Family - spouse - someone other than a healthcare worker - previous medical records.
To ID the problem
Tricuspid - mitral and the aortic
A false - fixed belief that cannot be corrected through reasoning.


3. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Broncial (heard over trachea)
Nursing
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)


4. The path of blood from the lungs to the heart is
Secondary
Pain on inspiration and expiration; superficial squeaking or grating
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve


5. Diabetes is a _________ dx
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decreased arterial perfusion
Medical
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)


6. Expiration sounds are heard longer than inspiration In What area?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Maslow
Broncial (heard over trachea)
Nurse


7. What are the components of a mental status exam that are not part of a regular assessment?
Viral infection
Upper airways
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
A false - fixed belief that cannot be corrected through reasoning.


8. When a patient has increased lymphocytes - this may indicate what?
Secondary soureces (family - friends)
Viral infection
Preschool is cause and effect - school age begins to use logical thought process.
An 80 y/o patient that has emergency surgery


9. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Interventions for which the nurse is accountable
Pain in legs assoc w walking
Nursing dx


10. Examples of personal information
Tricuspid - mitral and the aortic
Decision assessment
Hygeine - DOB - work hx
No


11. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
To ID the problem
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)


12. What is the formula for cardiac output?

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13. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Pain
Defining a baseline of cognitive function - any changes or deviations from norm.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Abstract thinking


14. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Irregular respirations (fast/slow) often seen at end of life
Vesicular (peripheral lung areas)
Decreased arterial perfusion


15. Data that is recorded for an immediate need (code blue or fall) would be included in
Focused
Fast and deep respirations seen in patient's with acidosis
Paradoxical reaction
Decision assessment


16. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Bacterial infection


17. Kussamaul respirations describe

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18. Where can wheezes best be heard?
Implementation
Upper airways
Decision assessment
Broncial (heard over trachea)


19. What is the cognitive difference between a preschooler and schoolage child?
Medical
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Preschool is cause and effect - school age begins to use logical thought process.
# of packs per day x # of years smoked


20. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Risk of falls increases
Pain in legs assoc w walking
Snap - crackle - pops; velcro - bubble wrap
Wandering


21. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Having to use more than one pillow when sleeping
Daily
Knowing What to do/how to make a decision based upon available data.


22. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Loss of taste
Upper airways
A personal experience that does whatever the person in pain says it does


23. 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
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Nursing dx
Stroke volume x's heart rate


24. A patient that is easily fatigued may have a HgB lab value of?
Focused
8.4
Secondary soureces (family - friends)
The patient


25. What is responsible for transporting O2 in the blood
Hemoglobin
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Daily
Trauma or illness


26. What is cognition?
The process of storing - learning - retrieving - and using info.
Focused
Paradoxical reaction
Decision assessment


27. ABG's would be an important lab value for What types of patient's?

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28. Describe the purpose of a mental status exam
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Defining a baseline of cognitive function - any changes or deviations from norm.
Stroke volume x's heart rate
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


29. At What age do you begin to use logical thought process?
School age childen
Interventions for which the nurse is accountable
Maslow
Upper airways


30. Data validation assures
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
EdFED- Q
The result is accurate patient dB
A false - fixed belief that cannot be corrected through reasoning.


31. Types of hearing loss include
Bacterial infection
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Medical
An 80 y/o patient that has emergency surgery


32. Acceptable sources of assessment data when evaluating a confused patient would be
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Secondary soureces (family - friends)
Toddler
Confusion Assessment Method


33. What do rales sound like?
Initial assessment
Snap - crackle - pops; velcro - bubble wrap
Disorganized thinking and altered LOC
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.


34. Would a nursing dx be part of the primary or secondary dx?
Adolescence
Secondary
Learning - memory and adaptation to stress
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


35. What is the purpose of the nursing process?
Upper airways
Serves to expedite dx and tx of actual and potential health problems
Disorganized thinking and altered LOC
Toddler


36. An ongoing assessment is performed
Interventions for which the nurse is accountable
Pt's with oxygenation and perfusion problems
Daily
Risk of falls increases


37. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Risk of falls increases
Non - opiod (ex: NSAID/acetominaphen)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Implementation


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

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39. Sleep deprivation can effect
Learning - memory and adaptation to stress
Symptoms
Daily
Tricuspid - mitral and the aortic


40. When using restraints in a confused patient
Disorganized thinking and altered LOC
Risk of falls increases
Focused
Communicate using hands and eyes.


41. An example of a secondary source is
Symptoms
Non - opiod (ex: NSAID/acetominaphen)
Family - spouse - someone other than a healthcare worker - previous medical records.
Loss of taste


42. One way to test a person's cognitive ability and abstract thinking ability would be to
Viral infection
Snap - crackle - pops; velcro - bubble wrap
Knowing What to do/how to make a decision based upon available data.
Have them do simple math problems


43. Name the 5 'W's' of assessing a change in LOC
Communicate using hands and eyes.
Pain
Defining a baseline of cognitive function - any changes or deviations from norm.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)


44. A nursing dx is best described as
The patient
Bacterial infection
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Risk of falls increases


45. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

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46. What is the difference between a nursing dx and a med dx?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Immature immune system - structures close together lends to easy spreading from on area to another.
Adolescence


47. What do rhonchi sound like?
Secondary
Stroke volume x's heart rate
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)


48. What is a component of the cognitive part of critical thinking skills?
Knowing What to do/how to make a decision based upon available data.
Communicate using hands and eyes.
Double check equip and patient
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve


49. What factors may indicate plural rub?
8.4
Ongoing assessment
Nursing dx
Pain on inspiration and expiration; superficial squeaking or grating


50. What are the steps of the nursing process?
Bacterial infection
Assess over all health status and identify the problem
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nursing dx