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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?
School age childen
EdFED- Q
Implementation
Fast and deep respirations seen in patient's with acidosis

2. What does CAM stand for
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Immature immune system - structures close together lends to easy spreading from on area to another.
Knowing What to do/how to make a decision based upon available data.
Confusion Assessment Method

3. The path of blood from the heart to the lungs is
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Learning - memory and adaptation to stress
8.4
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

4. At patient that state their shoes are tighter at the end of the day may be experiencing
The patient
Decision assessment
Edema
Learning - memory and adaptation to stress

5. Examples of personal information
Hygeine - DOB - work hx
Toddler
Interventions for which the nurse is accountable
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

6. A potential adverse rx of chemically restraining a confused patient would be
Nursing dx
Paradoxical reaction
Toddler
Defining a baseline of cognitive function - any changes or deviations from norm.

7. The purpose of an initial assessment is
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Double check equip and patient
To ID the problem
Daily

8. An example of a primary source is
The patient
Nursing dx
Capillaries
Inattention and acute increase/decrease in cognitive function

9. Side effects of putting confused pts in restraints include
Hygeine - DOB - work hx
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Disorganized thinking and altered LOC
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

10. An infant is in which Paiget stage?
Inattention and acute increase/decrease in cognitive function
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Sensory motor

11. Describe the purpose of a mental status exam
Edema
Trend assessment (shift report)
Defining a baseline of cognitive function - any changes or deviations from norm.
Irregular respirations (fast/slow) often seen at end of life

12. Inspiration sounds are heard longer than expiration sounds In What area?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Vesicular (peripheral lung areas)
Implementation
The patient

13. Data validation assures
Pain
Level of stress - risk for violence - anxiety level - patient unmet needs
The result is accurate patient dB
Nursing dx

14. What factors may indicate plural rub?
Viral infection
Immature immune system - structures close together lends to easy spreading from on area to another.
Pain on inspiration and expiration; superficial squeaking or grating
Assess over all health status and identify the problem

15. The basis for a plan of care comes for which stage of the nursing process?
Nursing
Hemoglobin
Serves to expedite dx and tx of actual and potential health problems
Nursing dx

16. What is the formula for determining pack years?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
# of packs per day x # of years smoked
Daily
Serves to expedite dx and tx of actual and potential health problems

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

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18. An example of a secondary source is
# of packs per day x # of years smoked
Family - spouse - someone other than a healthcare worker - previous medical records.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Edema

19. Another term for a focused assessment is
Ongoing assessment
To simulate eating motions with the hands
Nurse
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

20. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Serves to expedite dx and tx of actual and potential health problems
Having to use more than one pillow when sleeping

21. What is the purpose of the nursing process?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Disorganized thinking and altered LOC
Serves to expedite dx and tx of actual and potential health problems

22. Where can you hear bronchovesicular breath sounds?
Nursing
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Sensory motor
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

23. Which patient would be most likely to experience sensory overload?
Loss of taste
To simulate eating motions with the hands
An 80 y/o patient that has emergency surgery
# of packs per day x # of years smoked

24. What is a component of the cognitive part of critical thinking skills?
Implementation
An 80 y/o patient that has emergency surgery
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Knowing What to do/how to make a decision based upon available data.

25. What is a definition of a delusion?
Objective
A false - fixed belief that cannot be corrected through reasoning.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain

26. All body system data is not necessary which type of assessment
Focused
Stroke volume x's heart rate
Pt's underlying feelings
The medication will not affect the patient's breathing.

27. When speaking with a patient with moderate hearing loss the RN should
Disorganized thinking and altered LOC
Communicate using hands and eyes.
Preschool is cause and effect - school age begins to use logical thought process.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

28. When a patient has increased lymphocytes - this may indicate what?
Loss of taste
Decreased arterial perfusion
Viral infection
A personal experience that does whatever the person in pain says it does

29. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Trauma or illness
Daily
Vesicular (peripheral lung areas)

30. What is the correct approach when dealing with older adults?
Objective
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Communicate using hands and eyes.

31. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
EdFED- Q
Nurse
Vesicular (peripheral lung areas)

32. Two indicators that are REQUIRED for classification via the CAM tool include
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Inattention and acute increase/decrease in cognitive function
Capillaries

33. A nursing dx is best described as
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Pt's with oxygenation and perfusion problems
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain

34. A patient that is easily fatigued may have a HgB lab value of?
Family - spouse - someone other than a healthcare worker - previous medical records.
Abstract thinking
Hygeine - DOB - work hx
8.4

35. What do rales sound like?
Sensory motor
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Fast and deep respirations seen in patient's with acidosis
Snap - crackle - pops; velcro - bubble wrap

36. Data gathered via instrumention (pulse ox) is considered
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Objective
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Implementation

37. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
A personal experience that does whatever the person in pain says it does
Level of stress - risk for violence - anxiety level - patient unmet needs
The process of storing - learning - retrieving - and using info.

38. What are the components of an assessment?
Medical
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Hemoglobin
Maslow

39. What are the ABCDE's of pain management?
Decreased arterial perfusion
To simulate eating motions with the hands
Ask - Believe - Choose - Deliver - Empower
Inattention and acute increase/decrease in cognitive function

40. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Medical
To ID the problem
An 80 y/o patient that has emergency surgery

41. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
The medication will not affect the patient's breathing.
Confusion Assessment Method
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

42. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Ongoing assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Abstract thinking

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

44. Diabetes is a _________ dx
Medical
The medication will not affect the patient's breathing.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Decreased arterial perfusion

45. Types of hearing loss include
Assess over all health status and identify the problem
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Non - opiod (ex: NSAID/acetominaphen)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

46. What is the cognitive difference between a preschooler and schoolage child?
An 80 y/o patient that has emergency surgery
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Daily
Preschool is cause and effect - school age begins to use logical thought process.

47. Intermittent claudication is caused by?
Hemoglobin
To simulate eating motions with the hands
Decreased arterial perfusion
Bacterial infection

48. What is the nursing process?
Hemoglobin
Daily
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

49. At What age do you begin to use logical thought process?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Implementation
Hearing loss
School age childen

50. The purpose of an intitial assement serves to?
Nursing dx
Pt's underlying feelings
Assess over all health status and identify the problem
Preschool is cause and effect - school age begins to use logical thought process.