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. An ongoing assessment is performed
Daily
Medical
Nurse
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation


2. What would cause changes in congitive development later in life (middle adulthood)?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Trauma or illness


3. Where can wheezes best be heard?
ID'ing status of exisiting problems and locating new issues
Upper airways
Learning - memory and adaptation to stress
Nursing


4. What is the formula for cardiac output?

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5. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Double check equip and patient
Hemoglobin


6. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Secondary
Abstract thinking
Hygeine - DOB - work hx


7. Ageusia is
Loss of taste
Trend assessment (shift report)
The patient
Confusion Assessment Method


8. What is the difference between a nursing dx and a med dx?
Toddler
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Focused
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts


9. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Viral infection
Trauma or illness
To ID the problem


10. When speaking with a patient with moderate hearing loss the RN should
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Implementation
Communicate using hands and eyes.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.


11. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Non - opiod (ex: NSAID/acetominaphen)
Maslow
Knowing What to do/how to make a decision based upon available data.


12. Where can you hear bronchovesicular breath sounds?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Irregular respirations (fast/slow) often seen at end of life


13. Which patient would be most likely to experience sensory overload?
Risk of falls increases
An 80 y/o patient that has emergency surgery
To simulate eating motions with the hands
Sensory motor


14. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Edema
Secondary
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.


15. At What age do you begin to put thoughts into words?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Toddler
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli


16. 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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17. What are Piaget's stages of cognitive development
Trauma or illness
Inattention and acute increase/decrease in cognitive function
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve


18. Data from the last 24/48 hours that included patterns would be a part of
The result is accurate patient dB
Trend assessment (shift report)
Nurse
Bacterial infection


19. Intermittent claudication is caused by?
Decreased arterial perfusion
Paradoxical reaction
Having to use more than one pillow when sleeping
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli


20. At What age do you begin to use decision making?
Medical
Adolescence
Hearing loss
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)


21. Expiration sounds are heard longer than inspiration In What area?
Decreased sense of taste
Broncial (heard over trachea)
Nurse
Eye hygeine - accomodating factors - what was the level of decline - how long has it been


22. What is the cognitive difference between a preschooler and schoolage child?
Loss of taste
Preschool is cause and effect - school age begins to use logical thought process.
Secondary
The result is accurate patient dB


23. What are the components of a mental status exam that are not part of a regular assessment?
8.4
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
Sensory motor


24. What are Cheyne Stokes?
A personal experience that does whatever the person in pain says it does
Irregular respirations (fast/slow) often seen at end of life
Edema
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts


25. What are the steps of the nursing process?
Knowing What to do/how to make a decision based upon available data.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensory motor
Family - spouse - someone other than a healthcare worker - previous medical records.


26. Factors that may reduce the efficacy of pulse oximetry include
Preschool is cause and effect - school age begins to use logical thought process.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Assess over all health status and identify the problem
Adolescence


27. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Nursing
Toddler
Confusion Assessment Method
Wandering


28. When a patient has increased neutrophils - this may indicate what?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Bacterial infection
Pt's with oxygenation and perfusion problems
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


29. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Implementation
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.


30. Name the 5 'W's' of assessing a change in LOC
Hemoglobin
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Knowing What to do/how to make a decision based upon available data.


31. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain
To ID the problem


32. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Focused
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response


33. Ongoing assessments are useful in

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34. An example of a nursing dx would be
Adolescence
Defining a baseline of cognitive function - any changes or deviations from norm.
Fluid volume deficit related to poor intake
Data collection - data validation - data organization - data analysis - and data reporting/recording.


35. Are changes in vital signs a reliable indicator of chronic pain?
No
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Family - spouse - someone other than a healthcare worker - previous medical records.
Ask - Believe - Choose - Deliver - Empower


36. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Objective


37. Data validation assures
Level of stress - risk for violence - anxiety level - patient unmet needs
Communicate using hands and eyes.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The result is accurate patient dB


38. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Pt's underlying feelings
Communicate using hands and eyes.
Serves to expedite dx and tx of actual and potential health problems


39. Other factors that may indicate confusion using the CAM tool could be
Nurse
Bacterial infection
Defining a baseline of cognitive function - any changes or deviations from norm.
Disorganized thinking and altered LOC


40. What is the nursing process?
Ask - Believe - Choose - Deliver - Empower
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Toddler
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


41. The basis for a plan of care comes for which stage of the nursing process?
Capillaries
Secondary soureces (family - friends)
Preschool is cause and effect - school age begins to use logical thought process.
Nursing dx


42. Types of hearing loss include
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
ID'ing status of exisiting problems and locating new issues
A false - fixed belief that cannot be corrected through reasoning.


43. The purpose of an initial assessment is
Medical
Edema
To ID the problem
The patient


44. What do rhonchi sound like?
Hemoglobin
Implementation
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins


45. Another term for a focused assessment is
Having to use more than one pillow when sleeping
Paradoxical reaction
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ongoing assessment


46. An example of a primary source is
The patient
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Initial assessment
Inattention and acute increase/decrease in cognitive function


47. Describe the purpose of a mental status exam
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Defining a baseline of cognitive function - any changes or deviations from norm.
Preschool is cause and effect - school age begins to use logical thought process.
Focused


48. Kussamaul respirations describe

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49. What is pain?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
A personal experience that does whatever the person in pain says it does
Symptoms
School age childen


50. 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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