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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?
Immature immune system - structures close together lends to easy spreading from on area to another.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

2. The basis for a plan of care comes for which stage of the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nursing dx
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

3. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Decreased sense of taste
Pain
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

4. The purpose of an initial assessment is
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Symptoms
To ID the problem

5. What is the difference between a nursing dx and a med dx?
Snap - crackle - pops; velcro - bubble wrap
Wandering
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

6. Acceptable sources of assessment data when evaluating a confused patient would be
Inattention and acute increase/decrease in cognitive function
Pain on inspiration and expiration; superficial squeaking or grating
Trend assessment (shift report)
Secondary soureces (family - friends)

7. At What age do you begin to use decision making?
Pt's with oxygenation and perfusion problems
The patient
Adolescence
Pt's underlying feelings

8. What is the purpose of the nursing process?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Non - opiod (ex: NSAID/acetominaphen)
Serves to expedite dx and tx of actual and potential health problems
Nurse

9. Are changes in vital signs a reliable indicator of chronic pain?
Have them do simple math problems
No
The patient
Trauma or illness

10. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Level of stress - risk for violence - anxiety level - patient unmet needs
Double check equip and patient
Tricuspid - mitral and the aortic

11. Factors that may reduce the efficacy of pulse oximetry include
Sensory motor
School age childen
Fluid volume deficit related to poor intake
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

12. 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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13. Blood passes through the heart valves In what order?
Risk of falls increases
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Knowing What to do/how to make a decision based upon available data.
Tricuspid - mitral and the aortic

14. At patient that state their shoes are tighter at the end of the day may be experiencing
Tricuspid - mitral and the aortic
Irregular respirations (fast/slow) often seen at end of life
Edema
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

15. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Decreased arterial perfusion
Viral infection
Double check equip and patient

16. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Viral infection
Trend assessment (shift report)
Stroke volume x's heart rate

17. 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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18. Examples of personal information
Assess over all health status and identify the problem
An 80 y/o patient that has emergency surgery
Maslow
Hygeine - DOB - work hx

19. The path of blood from the lungs to the heart is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The result is accurate patient dB
Pain on inspiration and expiration; superficial squeaking or grating
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

20. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Secondary soureces (family - friends)

21. The fifth vital sign is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Decision assessment
Pain
No

22. What are the steps of the nursing process?
Trend assessment (shift report)
Ongoing assessment
Secondary soureces (family - friends)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

23. In Which part of the nursing process will you find delegation?
Knowing What to do/how to make a decision based upon available data.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Toddler
Implementation

24. What is the formula for determining pack years?
Trend assessment (shift report)
Nursing dx
# of packs per day x # of years smoked
No

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

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26. 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.
Symptoms
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

27. Nursing interventions should be based on who's theory?
School age childen
Assess over all health status and identify the problem
Maslow
Loss of taste

28. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Learning - memory and adaptation to stress
# of packs per day x # of years smoked
Nurse
Loss of taste

29. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain in legs assoc w walking
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Fast and deep respirations seen in patient's with acidosis

30. The site where gas exchange occurs is
Snap - crackle - pops; velcro - bubble wrap
Confusion Assessment Method
An 80 y/o patient that has emergency surgery
Capillaries

31. Expiration sounds are heard longer than inspiration In What area?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Vesicular (peripheral lung areas)
Broncial (heard over trachea)
Adolescence

32. Kussamaul respirations describe

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33. Where can you hear bronchovesicular breath sounds?
Abstract thinking
Vesicular (peripheral lung areas)
Disorganized thinking and altered LOC
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

34. When speaking with a patient with moderate hearing loss the RN should
A false - fixed belief that cannot be corrected through reasoning.
Communicate using hands and eyes.
Toddler
Hemoglobin

35. An example of a secondary source is
Trend assessment (shift report)
The result is accurate patient dB
Family - spouse - someone other than a healthcare worker - previous medical records.
Objective

36. A nursing dx is best described as
Ask - Believe - Choose - Deliver - Empower
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Assess over all health status and identify the problem
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

37. What is the nursing process?
Broncial (heard over trachea)
8.4
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

38. If an abnormal finding is revealed during assessment - the nurse should
Objective
Inattention and acute increase/decrease in cognitive function
Double check equip and patient
Initial assessment

39. At What age do you begin to use logical thought process?
School age childen
Daily
An 80 y/o patient that has emergency surgery
Loss of taste

40. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Toddler
Having to use more than one pillow when sleeping
Capillaries

41. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Edema
Pt's underlying feelings

42. When a patient has increased lymphocytes - this may indicate what?
Viral infection
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

43. Would a nursing dx be part of the primary or secondary dx?
Trend assessment (shift report)
Secondary
Broncial (heard over trachea)
Level of stress - risk for violence - anxiety level - patient unmet needs

44. An infant is in which Paiget stage?
Sensory motor
Capillaries
Medical
Nursing dx

45. When using restraints in a confused patient
Risk of falls increases
Fluid volume deficit related to poor intake
The medication will not affect the patient's breathing.
EdFED- Q

46. When a patient has increased neutrophils - this may indicate what?
Knowing What to do/how to make a decision based upon available data.
Bacterial infection
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Toddler

47. What does CAM stand for
Adolescence
Confusion Assessment Method
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

48. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
8.4
EdFED- Q
Abstract thinking
Decreased arterial perfusion

49. Two indicators that are REQUIRED for classification via the CAM tool include
Inattention and acute increase/decrease in cognitive function
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Having to use more than one pillow when sleeping
Maslow

50. An example of a primary source is
Edema
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
The patient
Abstract thinking