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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. Intermittent claudication is caused by?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Decreased arterial perfusion
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

2. What factors may indicate plural rub?
Capillaries
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Decreased arterial perfusion
Pain on inspiration and expiration; superficial squeaking or grating

3. Data that is recorded for an immediate need (code blue or fall) would be included in
Initial assessment
Decision assessment
Pain on inspiration and expiration; superficial squeaking or grating
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

4. The assessment that includes the patient's overhall health status
Pt's with oxygenation and perfusion problems
Initial assessment
Interventions for which the nurse is accountable
Preschool is cause and effect - school age begins to use logical thought process.

5. A patient that is easily fatigued may have a HgB lab value of?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Edema
Preschool is cause and effect - school age begins to use logical thought process.
8.4

6. In Which part of the nursing process will you find delegation?
Ongoing assessment
Non - opiod (ex: NSAID/acetominaphen)
EdFED- Q
Implementation

7. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Hemoglobin
Upper airways
Nursing dx

8. Diabetes is a _________ dx
Abstract thinking
Fast and deep respirations seen in patient's with acidosis
Inattention and acute increase/decrease in cognitive function
Medical

9. What is the correct approach when dealing with older adults?
Stroke volume x's heart rate
The medication will not affect the patient's breathing.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

10. At What age do you begin to use logical thought process?
Pt's underlying feelings
Pain
School age childen
Fast and deep respirations seen in patient's with acidosis

11. What do rhonchi sound like?
Learning - memory and adaptation to stress
Nurse
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Trend assessment (shift report)

12. Factors that may reduce the efficacy of pulse oximetry include
Tricuspid - mitral and the aortic
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The result is accurate patient dB
Hearing loss

13. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Loss of taste
Ask - Believe - Choose - Deliver - Empower
Fluid volume deficit related to poor intake

14. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Pain in legs assoc w walking
Knowing What to do/how to make a decision based upon available data.
Pain on inspiration and expiration; superficial squeaking or grating

15. The path of blood from the lungs to the heart is
Level of stress - risk for violence - anxiety level - patient unmet needs
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Paradoxical reaction
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

16. An example of a secondary source is
Disorganized thinking and altered LOC
Level of stress - risk for violence - anxiety level - patient unmet needs
Fast and deep respirations seen in patient's with acidosis
Family - spouse - someone other than a healthcare worker - previous medical records.

17. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Daily
Ongoing assessment
Have them do simple math problems

18. What are the ABCDE's of pain management?
EdFED- Q
Learning - memory and adaptation to stress
Ask - Believe - Choose - Deliver - Empower
Decreased arterial perfusion

19. 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)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Loss of taste
Decreased arterial perfusion

20. Ageusia is
Medical
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Trauma or illness
Loss of taste

21. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nurse
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Serves to expedite dx and tx of actual and potential health problems

22. Are changes in vital signs a reliable indicator of chronic pain?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
No
Initial assessment
Double check equip and patient

23. Which patient would be most likely to experience sensory overload?
8.4
An 80 y/o patient that has emergency surgery
Tricuspid - mitral and the aortic
Upper airways

24. Orthopnea is described as?
Secondary soureces (family - friends)
Having to use more than one pillow when sleeping
# of packs per day x # of years smoked
Implementation

25. Expiration sounds are heard longer than inspiration In What area?
Interventions for which the nurse is accountable
Broncial (heard over trachea)
Daily
Risk of falls increases

26. An example of a nursing dx would be
The patient
Fluid volume deficit related to poor intake
Vesicular (peripheral lung areas)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

27. Would a nursing dx be part of the primary or secondary dx?
Fast and deep respirations seen in patient's with acidosis
Objective
Secondary
Capillaries

28. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Decreased arterial perfusion
Medical
Upper airways

29. When using restraints in a confused patient
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Risk of falls increases
Objective
Focused

30. What would cause changes in congitive development later in life (middle adulthood)?
Sensory motor
Decreased sense of taste
Trauma or illness
Defining a baseline of cognitive function - any changes or deviations from norm.

31. Describe the purpose of a mental status exam
Pain
Defining a baseline of cognitive function - any changes or deviations from norm.
Adolescence
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

32. What are the components of an assessment?
8.4
Trend assessment (shift report)
Symptoms
Data collection - data validation - data organization - data analysis - and data reporting/recording.

33. Kussamaul respirations describe

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34. At What age do you begin to use decision making?
Abstract thinking
Preschool is cause and effect - school age begins to use logical thought process.
ID'ing status of exisiting problems and locating new issues
Adolescence

35. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Snap - crackle - pops; velcro - bubble wrap
Upper airways
Communicate using hands and eyes.

36. Where can wheezes best be heard?
Upper airways
Objective
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

37. What is a component of the cognitive part of critical thinking skills?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Knowing What to do/how to make a decision based upon available data.
Decreased arterial perfusion
Implementation

38. What is cognition?
The process of storing - learning - retrieving - and using info.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Symptoms

39. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain in legs assoc w walking
Nursing dx

40. 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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41. What is the formula for determining pack years?
The result is accurate patient dB
Fast and deep respirations seen in patient's with acidosis
To simulate eating motions with the hands
# of packs per day x # of years smoked

42. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Implementation
Daily
Adolescence

43. QUESTT is a tool for What type of an assessment?
Daily
Pain
Fast and deep respirations seen in patient's with acidosis
Nursing

44. What is the purpose of the nursing process?
Loss of taste
Double check equip and patient
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Serves to expedite dx and tx of actual and potential health problems

45. Two indicators that are REQUIRED for classification via the CAM tool include
Decision assessment
Defining a baseline of cognitive function - any changes or deviations from norm.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Inattention and acute increase/decrease in cognitive function

46. At What age do you begin to put thoughts into words?
Sensory motor
Toddler
Pain
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

47. What is pain?
A personal experience that does whatever the person in pain says it does
Nursing
8.4
To simulate eating motions with the hands

48. All body system data is not necessary which type of assessment
Focused
Fast and deep respirations seen in patient's with acidosis
Secondary soureces (family - friends)
Decision assessment

49. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Confusion Assessment Method
Symptoms
# of packs per day x # of years smoked

50. When a patient has increased lymphocytes - this may indicate what?
Double check equip and patient
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Viral infection
Trauma or illness