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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. When using restraints in a confused patient
Immature immune system - structures close together lends to easy spreading from on area to another.
Risk of falls increases
The patient
Fast and deep respirations seen in patient's with acidosis

2. The site where gas exchange occurs is
Knowing What to do/how to make a decision based upon available data.
Capillaries
Paradoxical reaction
Pain on inspiration and expiration; superficial squeaking or grating

3. What is responsible for transporting O2 in the blood
A false - fixed belief that cannot be corrected through reasoning.
Interventions for which the nurse is accountable
Hemoglobin
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

4. When speaking with a patient with moderate hearing loss the RN should
Maslow
Paradoxical reaction
Communicate using hands and eyes.
Initial assessment

5. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Ongoing assessment
Level of stress - risk for violence - anxiety level - patient unmet needs
Viral infection

6. Sleep deprivation can effect
Learning - memory and adaptation to stress
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pt's with oxygenation and perfusion problems
Viral infection

7. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
A false - fixed belief that cannot be corrected through reasoning.
Pain
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

8. At What age do you begin to use logical thought process?
Nurse
Assess over all health status and identify the problem
Maslow
School age childen

9. What is the cognitive difference between a preschooler and schoolage child?
Viral infection
Hygeine - DOB - work hx
Bacterial infection
Preschool is cause and effect - school age begins to use logical thought process.

10. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Have them do simple math problems
Abstract thinking
Bacterial infection
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

11. Data gathered via instrumention (pulse ox) is considered
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Bacterial infection
Objective
Trauma or illness

12. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Snap - crackle - pops; velcro - bubble wrap
Pt's with oxygenation and perfusion problems
Bacterial infection

13. 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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14. What is the nursing process?
Pt's with oxygenation and perfusion problems
Toddler
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.

15. What does CAM stand for
Objective
Confusion Assessment Method
Pt's underlying feelings
The process of storing - learning - retrieving - and using info.

16. A nursing dx is best described as
Fluid volume deficit related to poor intake
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
ID'ing status of exisiting problems and locating new issues
Bacterial infection

17. What would cause changes in congitive development later in life (middle adulthood)?
Maslow
Trauma or illness
Pt's underlying feelings
Data collection - data validation - data organization - data analysis - and data reporting/recording.

18. One way to test a person's cognitive ability and abstract thinking ability would be to
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Have them do simple math problems
Paradoxical reaction
Family - spouse - someone other than a healthcare worker - previous medical records.

19. 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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20. What are Cheyne Stokes?
Learning - memory and adaptation to stress
Loss of taste
Irregular respirations (fast/slow) often seen at end of life
Hygeine - DOB - work hx

21. What is the difference between a nursing dx and a med dx?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Hearing loss
A personal experience that does whatever the person in pain says it does
Trend assessment (shift report)

22. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pt's with oxygenation and perfusion problems
Learning - memory and adaptation to stress
To ID the problem

23. What are the components of an assessment?
Medical
Interventions for which the nurse is accountable
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Fast and deep respirations seen in patient's with acidosis

24. What is the formula for determining pack years?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
# of packs per day x # of years smoked
Tricuspid - mitral and the aortic

25. At What age do you begin to use decision making?
Pt's with oxygenation and perfusion problems
Adolescence
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Upper airways

26. Ongoing assessments are useful in

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27. What scale is used to determine eating and feeding issues in adults with confusion
Family - spouse - someone other than a healthcare worker - previous medical records.
Ask - Believe - Choose - Deliver - Empower
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
EdFED- Q

28. When a patient has increased neutrophils - this may indicate what?
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
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Level of stress - risk for violence - anxiety level - patient unmet needs

29. Acceptable sources of assessment data when evaluating a confused patient would be
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nursing
Secondary soureces (family - friends)
Ongoing assessment

30. The assessment that includes the patient's overhall health status
Pain on inspiration and expiration; superficial squeaking or grating
Ask - Believe - Choose - Deliver - Empower
Fluid volume deficit related to poor intake
Initial assessment

31. Types of hearing loss include
Pain in legs assoc w walking
Ask - Believe - Choose - Deliver - Empower
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
A personal experience that does whatever the person in pain says it does

32. What do rales sound like?
Ask - Believe - Choose - Deliver - Empower
The medication will not affect the patient's breathing.
Snap - crackle - pops; velcro - bubble wrap
ID'ing status of exisiting problems and locating new issues

33. An infant is in which Paiget stage?
Trend assessment (shift report)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
EdFED- Q
Sensory motor

34. The order of air flow into the lungs is
Stroke volume x's heart rate
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pt's underlying feelings

35. What is pain?
Irregular respirations (fast/slow) often seen at end of life
A personal experience that does whatever the person in pain says it does
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Inattention and acute increase/decrease in cognitive function

36. Ageusia is
A personal experience that does whatever the person in pain says it does
Loss of taste
Trauma or illness
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

37. Kussamaul respirations describe

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38. 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
Nursing
Pain in legs assoc w walking
Risk of falls increases

39. Diabetes is a _________ dx
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensory motor
Upper airways
Medical

40. An ongoing assessment is performed
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Daily
Sensory motor

41. Fluid volume deficit is a __________ dx
Hygeine - DOB - work hx
Defining a baseline of cognitive function - any changes or deviations from norm.
Nursing
School age childen

42. Data validation assures
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The result is accurate patient dB
Broncial (heard over trachea)
Adolescence

43. Nursing interventions should be based on who's theory?
Maslow
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Have them do simple math problems
Paradoxical reaction

44. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Edema
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Paradoxical reaction

45. Data from the last 24/48 hours that included patterns would be a part of
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Preschool is cause and effect - school age begins to use logical thought process.
Trend assessment (shift report)
Family - spouse - someone other than a healthcare worker - previous medical records.

46. Nursing dx provides basis of
Maslow
Nurse
Risk of falls increases
Interventions for which the nurse is accountable

47. If an abnormal finding is revealed during assessment - the nurse should
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Double check equip and patient
No
Sensory motor

48. What are the steps of the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Non - opiod (ex: NSAID/acetominaphen)
Trauma or illness
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

49. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
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.
Focused

50. Another term for a focused assessment is
Ongoing assessment
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -