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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. Where can you hear bronchovesicular breath sounds?
Focused
Pt's underlying feelings
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Have them do simple math problems

2. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Maslow
No
The result is accurate patient dB
Wandering

3. The order of air flow into the lungs is
Snap - crackle - pops; velcro - bubble wrap
Nursing dx
Decision assessment
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

4. Orthopnea is described as?
Paradoxical reaction
Nursing dx
Having to use more than one pillow when sleeping
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

5. At What age do you begin to put thoughts into words?
The process of storing - learning - retrieving - and using info.
Vesicular (peripheral lung areas)
Ask - Believe - Choose - Deliver - Empower
Toddler

6. In Which part of the nursing process will you find delegation?
Pain in legs assoc w walking
Implementation
Fast and deep respirations seen in patient's with acidosis
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

7. An infant is in which Paiget stage?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Maslow
Nursing dx
Sensory motor

8. 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.
ID'ing status of exisiting problems and locating new issues
To simulate eating motions with the hands
Vesicular (peripheral lung areas)

9. The assessment that includes the patient's overhall health status
Capillaries
Initial assessment
Fluid volume deficit related to poor intake
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

10. Subjective data could include
Pt's with oxygenation and perfusion problems
Symptoms
Serves to expedite dx and tx of actual and potential health problems
Secondary

11. What is cognition?
Assess over all health status and identify the problem
To simulate eating motions with the hands
The process of storing - learning - retrieving - and using info.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

12. Blood passes through the heart valves In what order?
Nursing dx
Viral infection
Pt's underlying feelings
Tricuspid - mitral and the aortic

13. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Serves to expedite dx and tx of actual and potential health problems
Tricuspid - mitral and the aortic
The medication will not affect the patient's breathing.

14. QUESTT is a tool for What type of an assessment?
Pain
Pain on inspiration and expiration; superficial squeaking or grating
Secondary
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

15. Factors that may reduce the efficacy of pulse oximetry include
Nursing dx
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Inattention and acute increase/decrease in cognitive function
Edema

16. What would cause changes in congitive development later in life (middle adulthood)?
Nursing
Broncial (heard over trachea)
Trauma or illness
Defining a baseline of cognitive function - any changes or deviations from norm.

17. Describe the purpose of a mental status exam
Family - spouse - someone other than a healthcare worker - previous medical records.
The process of storing - learning - retrieving - and using info.
Defining a baseline of cognitive function - any changes or deviations from norm.
School age childen

18. Data gathered via instrumention (pulse ox) is considered
Interventions for which the nurse is accountable
Capillaries
# of packs per day x # of years smoked
Objective

19. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Viral infection
Fluid volume deficit related to poor intake
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

20. Fluid volume deficit is a __________ dx
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Hemoglobin
Nursing
To ID the problem

21. What is a chochlear implant?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Stroke volume x's heart rate
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

22. What are the steps of the nursing process?
Have them do simple math problems
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Loss of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

23. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Family - spouse - someone other than a healthcare worker - previous medical records.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Abstract thinking

24. When a patient has increased neutrophils - this may indicate what?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Bacterial infection
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decreased sense of taste

25. What is pain?
A personal experience that does whatever the person in pain says it does
ID'ing status of exisiting problems and locating new issues
Paradoxical reaction
Hygeine - DOB - work hx

26. What is intermittent claudication?
Pain in legs assoc w walking
Pt's with oxygenation and perfusion problems
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The result is accurate patient dB

27. Types of hearing loss include
Symptoms
Nursing
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

28. The site where gas exchange occurs is
Capillaries
Fast and deep respirations seen in patient's with acidosis
Stroke volume x's heart rate
Viral infection

29. What is the formula for determining pack years?
Objective
Learning - memory and adaptation to stress
# of packs per day x # of years smoked
Sensory motor

30. When speaking with a patient with moderate hearing loss the RN should
A false - fixed belief that cannot be corrected through reasoning.
Stroke volume x's heart rate
Communicate using hands and eyes.
Preschool is cause and effect - school age begins to use logical thought process.

31. What is responsible for transporting O2 in the blood
Having to use more than one pillow when sleeping
ID'ing status of exisiting problems and locating new issues
Wandering
Hemoglobin

32. What do rales sound like?
Snap - crackle - pops; velcro - bubble wrap
# of packs per day x # of years smoked
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Daily

33. What scale is used to determine eating and feeding issues in adults with confusion
Nurse
EdFED- Q
Objective
Upper airways

34. What does CAM stand for
Having to use more than one pillow when sleeping
Confusion Assessment Method
Stroke volume x's heart rate
Bacterial infection

35. Other factors that may indicate confusion using the CAM tool could be
Vesicular (peripheral lung areas)
Disorganized thinking and altered LOC
The process of storing - learning - retrieving - and using info.
Broncial (heard over trachea)

36. 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.
To simulate eating motions with the hands
Trauma or illness
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

37. What factors may indicate plural rub?
Assess over all health status and identify the problem
Decision assessment
A personal experience that does whatever the person in pain says it does
Pain on inspiration and expiration; superficial squeaking or grating

38. When using restraints in a confused patient
Hygeine - DOB - work hx
Risk of falls increases
Vesicular (peripheral lung areas)
Knowing What to do/how to make a decision based upon available data.

39. The purpose of an initial assessment is
Edema
To ID the problem
The result is accurate patient dB
Stroke volume x's heart rate

40. Nursing interventions should be based on who's theory?
Secondary soureces (family - friends)
No
Maslow
Irregular respirations (fast/slow) often seen at end of life

41. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Inattention and acute increase/decrease in cognitive function
Abstract thinking
Wandering
Objective

42. What is the formula for cardiac output?

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43. Intermittent claudication is caused by?
Decreased sense of taste
Decreased arterial perfusion
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Stroke volume x's heart rate

44. What is the difference between a nursing dx and a med dx?
Nurse
Defining a baseline of cognitive function - any changes or deviations from norm.
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

45. 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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46. Nursing dx provides basis of
Interventions for which the nurse is accountable
ID'ing status of exisiting problems and locating new issues
Level of stress - risk for violence - anxiety level - patient unmet needs
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

47. Side effects of putting confused pts in restraints include
Decreased arterial perfusion
Symptoms
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Serves to expedite dx and tx of actual and potential health problems

48. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Focused
Non - opiod (ex: NSAID/acetominaphen)
Hearing loss
Hygeine - DOB - work hx

49. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Irregular respirations (fast/slow) often seen at end of life
Nurse
Hearing loss

50. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Paradoxical reaction
Knowing What to do/how to make a decision based upon available data.
Secondary