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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 responsible for transporting O2 in the blood
Hemoglobin
Level of stress - risk for violence - anxiety level - patient unmet needs
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Implementation

2. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Hygeine - DOB - work hx
The medication will not affect the patient's breathing.

3. Kussamaul respirations describe

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4. Ageusia is
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Loss of taste
Ask - Believe - Choose - Deliver - Empower
Decision assessment

5. What do rhonchi sound like?
Immature immune system - structures close together lends to easy spreading from on area to another.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Decision assessment
Family - spouse - someone other than a healthcare worker - previous medical records.

6. All body system data is not necessary which type of assessment
Hemoglobin
Focused
Serves to expedite dx and tx of actual and potential health problems
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

7. Data validation assures
The result is accurate patient dB
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Viral infection
Assess over all health status and identify the problem

8. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Learning - memory and adaptation to stress
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Viral infection

9. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Decreased arterial perfusion
Defining a baseline of cognitive function - any changes or deviations from norm.
Adolescence

10. The purpose of an initial assessment is
Trauma or illness
Capillaries
To ID the problem
Daily

11. Where can wheezes best be heard?
Upper airways
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Capillaries
Fast and deep respirations seen in patient's with acidosis

12. What are Cheyne Stokes?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Irregular respirations (fast/slow) often seen at end of life
Pain in legs assoc w walking
Pain

13. What is the difference between hallucination and delirium?
Pain on inspiration and expiration; superficial squeaking or grating
Family - spouse - someone other than a healthcare worker - previous medical records.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The medication will not affect the patient's breathing.

14. What is the cognitive difference between a preschooler and schoolage child?
Vesicular (peripheral lung areas)
Focused
To simulate eating motions with the hands
Preschool is cause and effect - school age begins to use logical thought process.

15. Side effects of putting confused pts in restraints include
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Interventions for which the nurse is accountable
Tricuspid - mitral and the aortic
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

16. Factors that may reduce the efficacy of pulse oximetry include
Trauma or illness
Knowing What to do/how to make a decision based upon available data.
To ID the problem
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

17. An ongoing assessment is performed
Daily
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Secondary
Initial assessment

18. 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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19. What is pain?
Daily
Hemoglobin
Sensory motor
A personal experience that does whatever the person in pain says it does

20. What does CAM stand for
The process of storing - learning - retrieving - and using info.
Preschool is cause and effect - school age begins to use logical thought process.
Tricuspid - mitral and the aortic
Confusion Assessment Method

21. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Communicate using hands and eyes.
Family - spouse - someone other than a healthcare worker - previous medical records.
Disorganized thinking and altered LOC

22. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Inattention and acute increase/decrease in cognitive function
School age childen
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

23. An example of a nursing dx would be
Assess over all health status and identify the problem
Capillaries
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Fluid volume deficit related to poor intake

24. What is the purpose of the nursing process?
Edema
Nursing dx
Family - spouse - someone other than a healthcare worker - previous medical records.
Serves to expedite dx and tx of actual and potential health problems

25. An example of a secondary source is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Family - spouse - someone other than a healthcare worker - previous medical records.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

26. Another term for a focused assessment is
Nurse
Ongoing assessment
EdFED- Q
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

27. What is the formula for cardiac output?

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28. At What age do you begin to put thoughts into words?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Capillaries
Knowing What to do/how to make a decision based upon available data.
Toddler

29. The basis for a plan of care comes for which stage of the nursing process?
Risk of falls increases
Objective
Pain
Nursing dx

30. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Wandering
Sensory motor
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

31. Acceptable sources of assessment data when evaluating a confused patient would be
Decision assessment
Secondary soureces (family - friends)
Non - opiod (ex: NSAID/acetominaphen)
Toddler

32. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Tricuspid - mitral and the aortic
Secondary soureces (family - friends)
Non - opiod (ex: NSAID/acetominaphen)
Pain on inspiration and expiration; superficial squeaking or grating

33. Diabetes is a _________ dx
Edema
Decreased arterial perfusion
Medical
Objective

34. Fluid volume deficit is a __________ dx
Bacterial infection
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nursing
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

35. What is the formula for determining pack years?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
ID'ing status of exisiting problems and locating new issues
# of packs per day x # of years smoked
Daily

36. In Which part of the nursing process will you find delegation?
Implementation
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Irregular respirations (fast/slow) often seen at end of life
The result is accurate patient dB

37. Examples of personal information
Fast and deep respirations seen in patient's with acidosis
Focused
No
Hygeine - DOB - work hx

38. When speaking with a patient with moderate hearing loss the RN should
Have them do simple math problems
Secondary soureces (family - friends)
Communicate using hands and eyes.
Fast and deep respirations seen in patient's with acidosis

39. 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
The process of storing - learning - retrieving - and using info.
Having to use more than one pillow when sleeping
Ongoing assessment

40. Data that is recorded for an immediate need (code blue or fall) would be included in
Toddler
Preschool is cause and effect - school age begins to use logical thought process.
Pain in legs assoc w walking
Decision assessment

41. What is cognition?
Disorganized thinking and altered LOC
The process of storing - learning - retrieving - and using info.
Irregular respirations (fast/slow) often seen at end of life
Defining a baseline of cognitive function - any changes or deviations from norm.

42. What is a chochlear implant?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Maslow
Family - spouse - someone other than a healthcare worker - previous medical records.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

43. Are changes in vital signs a reliable indicator of chronic pain?
The patient
School age childen
A false - fixed belief that cannot be corrected through reasoning.
No

44. Inspiration sounds are heard longer than expiration sounds In What area?
Daily
To ID the problem
Vesicular (peripheral lung areas)
A personal experience that does whatever the person in pain says it does

45. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Irregular respirations (fast/slow) often seen at end of life
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Hearing loss
Decision assessment

46. What do rales sound like?
Broncial (heard over trachea)
Family - spouse - someone other than a healthcare worker - previous medical records.
Inattention and acute increase/decrease in cognitive function
Snap - crackle - pops; velcro - bubble wrap

47. What is the difference between a nursing dx and a med dx?
Communicate using hands and eyes.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Non - opiod (ex: NSAID/acetominaphen)
Decision assessment

48. Nursing dx provides basis of
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Capillaries
Pain in legs assoc w walking
Interventions for which the nurse is accountable

49. The fifth vital sign is
Pain
Secondary soureces (family - friends)
Nursing
Inattention and acute increase/decrease in cognitive function

50. A nursing dx is best described as
Focused
Snap - crackle - pops; velcro - bubble wrap
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli