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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. What is the correct approach when dealing with older adults?
Maslow
The result is accurate patient dB
Sensory motor
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

2. Where can wheezes best be heard?
Upper airways
Fluid volume deficit related to poor intake
The medication will not affect the patient's breathing.
Tricuspid - mitral and the aortic

3. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Have them do simple math problems
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Nursing
Non - opiod (ex: NSAID/acetominaphen)

4. What is the cognitive difference between a preschooler and schoolage child?
Learning - memory and adaptation to stress
Hearing loss
Pain
Preschool is cause and effect - school age begins to use logical thought process.

5. The basis for a plan of care comes for which stage of the nursing process?
Capillaries
Bacterial infection
Tricuspid - mitral and the aortic
Nursing dx

6. What is intermittent claudication?
Pain in legs assoc w walking
Sensory motor
The result is accurate patient dB
The process of storing - learning - retrieving - and using info.

7. What do rales sound like?
Toddler
Snap - crackle - pops; velcro - bubble wrap
Vesicular (peripheral lung areas)
Loss of taste

8. Another term for a focused assessment is
A personal experience that does whatever the person in pain says it does
Risk of falls increases
Ongoing assessment
Pt's with oxygenation and perfusion problems

9. What is a component of the cognitive part of critical thinking skills?
Disorganized thinking and altered LOC
Pain
Knowing What to do/how to make a decision based upon available data.
Implementation

10. A nursing dx is best described as
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Family - spouse - someone other than a healthcare worker - previous medical records.
Toddler
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

11. The purpose of an intitial assement serves to?
Learning - memory and adaptation to stress
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Assess over all health status and identify the problem
Preschool is cause and effect - school age begins to use logical thought process.

12. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Paradoxical reaction
Nursing
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

13. Sleep deprivation can effect
Stroke volume x's heart rate
Hearing loss
Inattention and acute increase/decrease in cognitive function
Learning - memory and adaptation to stress

14. Fluid volume deficit is a __________ dx
Trauma or illness
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nursing
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

15. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Disorganized thinking and altered LOC
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Focused

16. What is the difference between hallucination and delirium?
Ask - Believe - Choose - Deliver - Empower
Viral infection
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Double check equip and patient

17. All body system data is not necessary which type of assessment
The result is accurate patient dB
Focused
Trauma or illness
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

18. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Sensory motor
A false - fixed belief that cannot be corrected through reasoning.
Focused

19. The path of blood from the heart to the lungs is
Daily
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Family - spouse - someone other than a healthcare worker - previous medical records.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

20. Two indicators that are REQUIRED for classification via the CAM tool include
Communicate using hands and eyes.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Inattention and acute increase/decrease in cognitive function

21. Orthopnea is described as?
Pain
Having to use more than one pillow when sleeping
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Symptoms

22. What do rhonchi sound like?
Abstract thinking
Daily
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Toddler

23. Expiration sounds are heard longer than inspiration In What area?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Sensory motor
Broncial (heard over trachea)

24. Nursing dx provides basis of
Snap - crackle - pops; velcro - bubble wrap
Viral infection
Interventions for which the nurse is accountable
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

25. In Which part of the nursing process will you find delegation?
Implementation
Fluid volume deficit related to poor intake
Hygeine - DOB - work hx
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

26. What are the ABCDE's of pain management?
Preschool is cause and effect - school age begins to use logical thought 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)
Capillaries
Ask - Believe - Choose - Deliver - Empower

27. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Fast and deep respirations seen in patient's with acidosis
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Edema

28. Would a nursing dx be part of the primary or secondary dx?
Non - opiod (ex: NSAID/acetominaphen)
Disorganized thinking and altered LOC
Have them do simple math problems
Secondary

29. The purpose of an initial assessment is
To ID the problem
Having to use more than one pillow when sleeping
Secondary soureces (family - friends)
Non - opiod (ex: NSAID/acetominaphen)

30. Are changes in vital signs a reliable indicator of chronic pain?
Tricuspid - mitral and the aortic
Maslow
Capillaries
No

31. What is the difference between a nursing dx and a med dx?
Decreased sense of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Family - spouse - someone other than a healthcare worker - previous medical records.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

32. Data gathered via instrumention (pulse ox) is considered
Objective
Implementation
Fast and deep respirations seen in patient's with acidosis
Stroke volume x's heart rate

33. Name the 5 'W's' of assessing a change in LOC
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
ID'ing status of exisiting problems and locating new issues
# of packs per day x # of years smoked
Trauma or illness

34. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Pt's underlying feelings

35. Data from the last 24/48 hours that included patterns would be a part of
Trauma or illness
Snap - crackle - pops; velcro - bubble wrap
Confusion Assessment Method
Trend assessment (shift report)

36. Ongoing assessments are useful in

37. What does CAM stand for
Secondary
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Confusion Assessment Method

38. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

39. Describe the purpose of a mental status exam
The patient
8.4
Wandering
Defining a baseline of cognitive function - any changes or deviations from norm.

40. What is a chochlear implant?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pain

41. Factors that may reduce the efficacy of pulse oximetry include
Symptoms
Snap - crackle - pops; velcro - bubble wrap
A personal experience that does whatever the person in pain says it does
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

42. What is pain?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pt's with oxygenation and perfusion problems
A personal experience that does whatever the person in pain says it does
Secondary soureces (family - friends)

43. An example of a secondary source is
Vesicular (peripheral lung areas)
Family - spouse - someone other than a healthcare worker - previous medical records.
Toddler
Focused

44. The site where gas exchange occurs is
Loss of taste
Capillaries
Medical
Focused

45. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Pt's underlying feelings
Secondary
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Level of stress - risk for violence - anxiety level - patient unmet needs

46. An example of a primary source is
Pain in legs assoc w walking
The patient
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Trauma or illness

47. When a patient has increased neutrophils - this may indicate what?
To simulate eating motions with the hands
No
Objective
Bacterial infection

48. Data that is recorded for an immediate need (code blue or fall) would be included in
The result is accurate patient dB
Pt's underlying feelings
Decision assessment
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

49. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Toddler
Stroke volume x's heart rate

50. A patient that is easily fatigued may have a HgB lab value of?
8.4
The patient
Objective
Pain in legs assoc w walking