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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. Data gathered via instrumention (pulse ox) is considered
Objective
Toddler
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Edema

2. What are the components of an assessment?
Stroke volume x's heart rate
Medical
Edema
Data collection - data validation - data organization - data analysis - and data reporting/recording.

3. The basis for a plan of care comes for which stage 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)
Fast and deep respirations seen in patient's with acidosis
Medical
Nursing dx

4. Other factors that may indicate confusion using the CAM tool could be
No
Trend assessment (shift report)
Implementation
Disorganized thinking and altered LOC

5. Fluid volume deficit is a __________ dx
Fast and deep respirations seen in patient's with acidosis
Nursing
Disorganized thinking and altered LOC
Nurse

6. An infant is in which Paiget stage?
To ID the problem
Sensory motor
Decreased sense of taste
To simulate eating motions with the hands

7. The site where gas exchange occurs is
Capillaries
Having to use more than one pillow when sleeping
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Inattention and acute increase/decrease in cognitive function

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
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Immature immune system - structures close together lends to easy spreading from on area to another.

9. Data from the last 24/48 hours that included patterns would be a part of
Pain on inspiration and expiration; superficial squeaking or grating
Hygeine - DOB - work hx
Trend assessment (shift report)
The medication will not affect the patient's breathing.

10. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The medication will not affect the patient's breathing.
To simulate eating motions with the hands
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

11. Would a nursing dx be part of the primary or secondary dx?
Secondary
Symptoms
Medical
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

12. What are the ABCDE's of pain management?
8.4
Pt's with oxygenation and perfusion problems
Maslow
Ask - Believe - Choose - Deliver - Empower

13. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pt's underlying feelings
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

14. If an abnormal finding is revealed during assessment - the nurse should
Fluid volume deficit related to poor intake
Decreased arterial perfusion
Broncial (heard over trachea)
Double check equip and patient

15. Acceptable sources of assessment data when evaluating a confused patient would be
Pain
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pain on inspiration and expiration; superficial squeaking or grating
Secondary soureces (family - friends)

16. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
An 80 y/o patient that has emergency surgery
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

17. Where can wheezes best be heard?
Upper airways
Objective
Broncial (heard over trachea)
Ask - Believe - Choose - Deliver - Empower

18. When a patient has increased neutrophils - this may indicate what?
A false - fixed belief that cannot be corrected through reasoning.
Focused
Stroke volume x's heart rate
Bacterial infection

19. Orthopnea is described as?
Broncial (heard over trachea)
Having to use more than one pillow when sleeping
Objective
Interventions for which the nurse is accountable

20. What is a chochlear implant?
Having to use more than one pillow when sleeping
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Stroke volume x's heart rate
Toddler

21. Inspiration sounds are heard longer than expiration sounds In What area?
Family - spouse - someone other than a healthcare worker - previous medical records.
Initial assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Vesicular (peripheral lung areas)

22. What does CAM stand for
Confusion Assessment Method
Pt's with oxygenation and perfusion problems
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

23. What is the nursing process?
Risk of falls increases
Daily
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Edema

24. Side effects of putting confused pts in restraints include
No
Objective
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Decreased arterial perfusion

25. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Ask - Believe - Choose - Deliver - Empower
Symptoms
No

26. Types of hearing loss include
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Loss of taste

27. Ongoing assessments are useful in

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28. The path of blood from the lungs to the heart is
A false - fixed belief that cannot be corrected through reasoning.
Decreased sense of taste
Preschool is cause and effect - school age begins to use logical thought process.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

29. What is the purpose of the nursing process?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Serves to expedite dx and tx of actual and potential health problems
Abstract thinking
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

30. What are the steps of the nursing process?
Hearing loss
Level of stress - risk for violence - anxiety level - patient unmet needs
Pain on inspiration and expiration; superficial squeaking or grating
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

31. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
The medication will not affect the patient's breathing.
Wandering
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

32. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
To simulate eating motions with the hands
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nurse
# of packs per day x # of years smoked

33. What scale is used to determine eating and feeding issues in adults with confusion
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
To ID the problem
EdFED- Q

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

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35. Are changes in vital signs a reliable indicator of chronic pain?
No
8.4
The process of storing - learning - retrieving - and using info.
Implementation

36. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Tricuspid - mitral and the aortic
Initial assessment
Pt's with oxygenation and perfusion problems

37. What do rhonchi sound like?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Loss of taste
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Inattention and acute increase/decrease in cognitive function

38. Two indicators that are REQUIRED for classification via the CAM tool include
Trend assessment (shift report)
Edema
Inattention and acute increase/decrease in cognitive function
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

39. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
A personal experience that does whatever the person in pain says it does
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Loss of taste
Non - opiod (ex: NSAID/acetominaphen)

40. In Which part of the nursing process will you find delegation?
Symptoms
Implementation
Pt's with oxygenation and perfusion problems
Decreased arterial perfusion

41. Nursing interventions should be based on who's theory?
Maslow
Wandering
Viral infection
The patient

42. What factors may indicate plural rub?
Fluid volume deficit related to poor intake
Symptoms
Fast and deep respirations seen in patient's with acidosis
Pain on inspiration and expiration; superficial squeaking or grating

43. What do rales sound like?
Bacterial infection
Medical
Snap - crackle - pops; velcro - bubble wrap
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

44. Nursing dx provides basis of
Medical
Interventions for which the nurse is accountable
Fast and deep respirations seen in patient's with acidosis
Fluid volume deficit related to poor intake

45. When using restraints in a confused patient
Pain
School age childen
Risk of falls increases
Capillaries

46. What is pain?
Trend assessment (shift report)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
EdFED- Q
A personal experience that does whatever the person in pain says it does

47. What would cause changes in congitive development later in life (middle adulthood)?
Disorganized thinking and altered LOC
Ongoing assessment
Secondary
Trauma or illness

48. Diabetes is a _________ dx
Risk of falls increases
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
To simulate eating motions with the hands

49. Why are young children at greater risk for respiratory infection?
Knowing What to do/how to make a decision based upon available data.
Nursing dx
Immature immune system - structures close together lends to easy spreading from on area to another.
Sensory motor

50. At What age do you begin to use logical thought process?
8.4
School age childen
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Serves to expedite dx and tx of actual and potential health problems