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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. The path of blood from the lungs to the heart is
Toddler
Focused
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

2. At What age do you begin to use decision making?
Pain on inspiration and expiration; superficial squeaking or grating
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Adolescence
To simulate eating motions with the hands

3. 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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4. All body system data is not necessary which type of assessment
Irregular respirations (fast/slow) often seen at end of life
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Preschool is cause and effect - school age begins to use logical thought process.
Focused

5. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Sensory motor
8.4
Risk of falls increases
Nurse

6. What is the correct approach when dealing with older adults?
Viral infection
# of packs per day x # of years smoked
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
School age childen

7. Would a nursing dx be part of the primary or secondary dx?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Learning - memory and adaptation to stress
Secondary

8. Side effects of putting confused pts in restraints include
Level of stress - risk for violence - anxiety level - patient unmet needs
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Toddler
Nursing

9. Types of hearing loss include
Having to use more than one pillow when sleeping
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
ID'ing status of exisiting problems and locating new issues

10. Intermittent claudication is caused by?
Decreased arterial perfusion
Adolescence
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Double check equip and patient

11. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Decision assessment
Paradoxical reaction
# of packs per day x # of years smoked

12. One way to test a person's cognitive ability and abstract thinking ability would be to
Medical
Preschool is cause and effect - school age begins to use logical thought process.
Have them do simple math problems
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

13. What is responsible for transporting O2 in the blood
The medication will not affect the patient's breathing.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Hemoglobin
Disorganized thinking and altered LOC

14. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
8.4
Assess over all health status and identify the problem
Risk of falls increases

15. What is a chochlear implant?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
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

16. When a patient has increased lymphocytes - this may indicate what?
Communicate using hands and eyes.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Viral infection
Medical

17. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
The result is accurate patient dB
Risk of falls increases

18. 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
EdFED- Q
Secondary soureces (family - friends)
Fast and deep respirations seen in patient's with acidosis

19. When noticing a patient with dementia has stopped eating - the RN's first response is?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
To simulate eating motions with the hands
Pain

20. What factors may indicate plural rub?
Capillaries
Pain on inspiration and expiration; superficial squeaking or grating
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pain

21. An example of a primary source is
Decreased arterial perfusion
Symptoms
Tricuspid - mitral and the aortic
The patient

22. Data gathered via instrumention (pulse ox) is considered
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Objective
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Medical

23. An infant is in which Paiget stage?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Sensory motor
Capillaries
Knowing What to do/how to make a decision based upon available data.

24. When using restraints in a confused patient
Paradoxical reaction
Risk of falls increases
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Confusion Assessment Method

25. Expiration sounds are heard longer than inspiration In What area?
Viral infection
The process of storing - learning - retrieving - and using info.
Broncial (heard over trachea)
Paradoxical reaction

26. What are the components of an assessment?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Broncial (heard over trachea)
Vesicular (peripheral lung areas)

27. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Having to use more than one pillow when sleeping
Pt's underlying feelings
Snap - crackle - pops; velcro - bubble wrap

28. What is intermittent claudication?
Pain in legs assoc w walking
Stroke volume x's heart rate
Confusion Assessment Method
Decision assessment

29. What would cause changes in congitive development later in life (middle adulthood)?
Serves to expedite dx and tx of actual and potential health problems
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Upper airways
Trauma or illness

30. Two indicators that are REQUIRED for classification via the CAM tool include
Focused
Inattention and acute increase/decrease in cognitive function
Initial assessment
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

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

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32. What is a definition of a delusion?
Communicate using hands and eyes.
Having to use more than one pillow when sleeping
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
A false - fixed belief that cannot be corrected through reasoning.

33. Diabetes is a _________ dx
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nurse
Medical
Knowing What to do/how to make a decision based upon available data.

34. Data that is recorded for an immediate need (code blue or fall) would be included in
Disorganized thinking and altered LOC
Trauma or illness
Decision assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

35. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Vesicular (peripheral lung areas)
Preschool is cause and effect - school age begins to use logical thought process.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

36. Orthopnea is described as?
Ongoing assessment
Having to use more than one pillow when sleeping
Interventions for which the nurse is accountable
Secondary

37. Nursing dx provides basis of
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Confusion Assessment Method
Hearing loss
Interventions for which the nurse is accountable

38. An ongoing assessment is performed
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Assess over all health status and identify the problem
Symptoms
Daily

39. An example of a secondary source is
Abstract thinking
Trauma or illness
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Family - spouse - someone other than a healthcare worker - previous medical records.

40. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Secondary soureces (family - friends)
Secondary

41. Data from the last 24/48 hours that included patterns would be a part of
Wandering
A personal experience that does whatever the person in pain says it does
Trend assessment (shift report)
EdFED- Q

42. Are changes in vital signs a reliable indicator of chronic pain?
Non - opiod (ex: NSAID/acetominaphen)
No
To ID the problem
Ongoing assessment

43. Where can you hear bronchovesicular breath sounds?
Hemoglobin
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
School age childen

44. Fluid volume deficit is a __________ dx
Nursing
Capillaries
The process of storing - learning - retrieving - and using info.
Loss of taste

45. What is the purpose of the nursing process?
Viral infection
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
Risk of falls increases

46. Subjective data could include
Symptoms
EdFED- Q
Broncial (heard over trachea)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

47. The purpose of an intitial assement serves to?
Pain
# of packs per day x # of years smoked
Assess over all health status and identify the problem
Fast and deep respirations seen in patient's with acidosis

48. In Which part of the nursing process will you find delegation?
Upper airways
The medication will not affect the patient's breathing.
Implementation
EdFED- Q

49. 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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50. What does CAM stand for
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Confusion Assessment Method
Adolescence
Medical