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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. In Which part of the nursing process will you find delegation?
The result is accurate patient dB
Upper airways
Implementation
Data collection - data validation - data organization - data analysis - and data reporting/recording.

2. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Hemoglobin
No
School age childen

3. At What age do you begin to use decision making?
Adolescence
Assess over all health status and identify the problem
Pain on inspiration and expiration; superficial squeaking or grating
Knowing What to do/how to make a decision based upon available data.

4. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
Ask - Believe - Choose - Deliver - Empower
Pain in legs assoc w walking
Family - spouse - someone other than a healthcare worker - previous medical records.

5. Hypogeusis is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Have them do simple math problems
Decreased sense of taste
Implementation

6. Ageusia is
Nurse
Loss of taste
Risk of falls increases
Trauma or illness

7. 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)
Hemoglobin
Capillaries
8.4

8. When speaking with a patient with moderate hearing loss the RN should
Interventions for which the nurse is accountable
Daily
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Communicate using hands and eyes.

9. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Fast and deep respirations seen in patient's with acidosis
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Capillaries

10. Subjective data could include
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Decreased arterial perfusion
Symptoms
Toddler

11. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Wandering
Focused

12. An example of a nursing dx would be
Fluid volume deficit related to poor intake
The medication will not affect the patient's breathing.
Secondary
Inattention and acute increase/decrease in cognitive function

13. What is cognition?
The process of storing - learning - retrieving - and using info.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Initial assessment

14. The assessment that includes the patient's overhall health status
Fast and deep respirations seen in patient's with acidosis
Focused
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Initial assessment

15. Another term for a focused assessment is
8.4
The process of storing - learning - retrieving - and using info.
Ongoing assessment
Decreased arterial perfusion

16. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Medical
A false - fixed belief that cannot be corrected through reasoning.
Capillaries

17. The path of blood from the lungs to the heart is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Fluid volume deficit related to poor intake
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

18. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Nursing dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Have them do simple math problems
Decision assessment

19. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Adolescence
Pain
Upper airways

20. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Viral infection
Pain in legs assoc w walking
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Nurse

21. Data from the last 24/48 hours that included patterns would be a part of
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain in legs assoc w walking
Trend assessment (shift report)
Ask - Believe - Choose - Deliver - Empower

22. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Level of stress - risk for violence - anxiety level - patient unmet needs
Nursing
Adolescence

23. What is pain?
Learning - memory and adaptation to stress
Snap - crackle - pops; velcro - bubble wrap
A personal experience that does whatever the person in pain says it does
To ID the problem

24. Describe the purpose of a mental status exam
Hemoglobin
Having to use more than one pillow when sleeping
Snap - crackle - pops; velcro - bubble wrap
Defining a baseline of cognitive function - any changes or deviations from norm.

25. Nursing dx provides basis of
Adolescence
Daily
Loss of taste
Interventions for which the nurse is accountable

26. Diabetes is a _________ dx
Ask - Believe - Choose - Deliver - Empower
Level of stress - risk for violence - anxiety level - patient unmet needs
Defining a baseline of cognitive function - any changes or deviations from norm.
Medical

27. What is the difference between hallucination and delirium?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Objective
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

28. An example of a primary source is
The result is accurate patient dB
The patient
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Data collection - data validation - data organization - data analysis - and data reporting/recording.

29. Which patient would be most likely to experience sensory overload?
Toddler
Having to use more than one pillow when sleeping
An 80 y/o patient that has emergency surgery
Medical

30. Data validation assures
Broncial (heard over trachea)
The result is accurate patient dB
Having to use more than one pillow when sleeping
Pt's underlying feelings

31. When a patient has increased lymphocytes - this may indicate what?
The process of storing - learning - retrieving - and using info.
Decision assessment
Pain
Viral infection

32. All body system data is not necessary which type of assessment
Medical
Trauma or illness
Focused
Non - opiod (ex: NSAID/acetominaphen)

33. A nursing dx is best described as
ID'ing status of exisiting problems and locating new issues
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
The patient
To simulate eating motions with the hands

34. Acceptable sources of assessment data when evaluating a confused patient would be
Preschool is cause and effect - school age begins to use logical thought process.
Wandering
Secondary soureces (family - friends)
Hearing loss

35. Two indicators that are REQUIRED for classification via the CAM tool include
To ID the problem
Inattention and acute increase/decrease in cognitive function
Decreased sense of taste
# of packs per day x # of years smoked

36. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Vesicular (peripheral lung areas)
Pt's underlying feelings
The patient

37. A patient that is easily fatigued may have a HgB lab value of?
Decision assessment
8.4
The process of storing - learning - retrieving - and using info.
Hygeine - DOB - work hx

38. What is the nursing process?
Pain
Trauma or illness
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

39. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Pain in legs assoc w walking
Focused
The process of storing - learning - retrieving - and using info.
Level of stress - risk for violence - anxiety level - patient unmet needs

40. Orthopnea is described as?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Having to use more than one pillow when sleeping
Decreased arterial perfusion
Hygeine - DOB - work hx

41. When using restraints in a confused patient
Risk of falls increases
Paradoxical reaction
Family - spouse - someone other than a healthcare worker - previous medical records.
Symptoms

42. 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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43. What does CAM stand for
Family - spouse - someone other than a healthcare worker - previous medical records.
Fast and deep respirations seen in patient's with acidosis
Have them do simple math problems
Confusion Assessment Method

44. An example of a secondary source is
Capillaries
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Wandering
Family - spouse - someone other than a healthcare worker - previous medical records.

45. Nursing interventions should be based on who's theory?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Edema
Maslow
Fast and deep respirations seen in patient's with acidosis

46. What is a definition of a delusion?
Non - opiod (ex: NSAID/acetominaphen)
Pain in legs assoc w walking
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
A false - fixed belief that cannot be corrected through reasoning.

47. Intermittent claudication is caused by?
Decreased arterial perfusion
Pt's with oxygenation and perfusion problems
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Defining a baseline of cognitive function - any changes or deviations from norm.

48. Data that is recorded for an immediate need (code blue or fall) would be included in
A personal experience that does whatever the person in pain says it does
Decision assessment
To simulate eating motions with the hands
Hemoglobin

49. What do rales sound like?
Snap - crackle - pops; velcro - bubble wrap
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Serves to expedite dx and tx of actual and potential health problems
Have them do simple math problems

50. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Family - spouse - someone other than a healthcare worker - previous medical records.
Trauma or illness
Hygeine - DOB - work hx