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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. The basis for a plan of care comes for which stage of the nursing process?
Upper airways
Nursing dx
Initial assessment
Capillaries

2. Inspiration sounds are heard longer than expiration sounds In What area?
Having to use more than one pillow when sleeping
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Vesicular (peripheral lung areas)
Tricuspid - mitral and the aortic

3. What are the components of an assessment?
Pain in legs assoc w walking
Fluid volume deficit related to poor intake
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Nursing dx

4. The site where gas exchange occurs is
Pain in legs assoc w walking
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Capillaries
Ask - Believe - Choose - Deliver - Empower

5. A nursing dx is best described as
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Preschool is cause and effect - school age begins to use logical thought process.
Pain
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

6. Data gathered via instrumention (pulse ox) is considered
Having to use more than one pillow when sleeping
Objective
Symptoms
Pain in legs assoc w walking

7. Subjective data could include
The medication will not affect the patient's breathing.
Symptoms
Abstract thinking
Ongoing assessment

8. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Upper airways
Viral infection
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Inattention and acute increase/decrease in cognitive function

9. A patient that is easily fatigued may have a HgB lab value of?
ID'ing status of exisiting problems and locating new issues
Serves to expedite dx and tx of actual and potential health problems
8.4
An 80 y/o patient that has emergency surgery

10. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Stroke volume x's heart rate
Preschool is cause and effect - school age begins to use logical thought process.
Fast and deep respirations seen in patient's with acidosis

11. The order of air flow into the lungs is
Fast and deep respirations seen in patient's with acidosis
Symptoms
Capillaries
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

12. 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
Pain
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Decreased sense of taste

13. Nursing interventions should be based on who's theory?
Capillaries
Maslow
Decreased sense of taste
Vesicular (peripheral lung areas)

14. In Which part of the nursing process will you find delegation?
Confusion Assessment Method
Implementation
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

15. At What age do you begin to put thoughts into words?
Toddler
Secondary soureces (family - friends)
Ask - Believe - Choose - Deliver - Empower
Decreased arterial perfusion

16. Sleep deprivation can effect
Communicate using hands and eyes.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Learning - memory and adaptation to stress
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

17. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
To simulate eating motions with the hands
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A false - fixed belief that cannot be corrected through reasoning.

18. What is pain?
Capillaries
Hearing loss
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A personal experience that does whatever the person in pain says it does

19. What do rhonchi sound like?
Decreased sense of taste
Initial assessment
Risk of falls increases
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

20. What is cognition?
Broncial (heard over trachea)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
The process of storing - learning - retrieving - and using info.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

21. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
The medication will not affect the patient's breathing.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Stroke volume x's heart rate

22. An example of a nursing dx would be
Pt's underlying feelings
Fluid volume deficit related to poor intake
Abstract thinking
Double check equip and patient

23. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Confusion Assessment Method
Non - opiod (ex: NSAID/acetominaphen)

24. What do rales sound like?
Toddler
Daily
Immature immune system - structures close together lends to easy spreading from on area to another.
Snap - crackle - pops; velcro - bubble wrap

25. When a patient has increased lymphocytes - this may indicate what?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Viral infection
The patient
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

26. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Defining a baseline of cognitive function - any changes or deviations from norm.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nurse

27. What would cause changes in congitive development later in life (middle adulthood)?
Sensory motor
Ongoing assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Trauma or illness

28. One way to test a person's cognitive ability and abstract thinking ability would be to
Pt's underlying feelings
Have them do simple math problems
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Inattention and acute increase/decrease in cognitive function

29. Data that is recorded for an immediate need (code blue or fall) would be included in
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Secondary soureces (family - friends)
Abstract thinking
Decision assessment

30. Where can wheezes best be heard?
ID'ing status of exisiting problems and locating new issues
To ID the problem
Capillaries
Upper airways

31. What is intermittent claudication?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pain on inspiration and expiration; superficial squeaking or grating
Pain in legs assoc w walking
Wandering

32. The assessment that includes the patient's overhall health status
Wandering
Maslow
To ID the problem
Initial assessment

33. What does CAM stand for
Pt's underlying feelings
Upper airways
Confusion Assessment Method
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

34. Factors that may reduce the efficacy of pulse oximetry include
Wandering
Assess over all health status and identify the problem
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Knowing What to do/how to make a decision based upon available data.

35. If an abnormal finding is revealed during assessment - the nurse should
To ID the problem
Level of stress - risk for violence - anxiety level - patient unmet needs
Double check equip and patient
Having to use more than one pillow when sleeping

36. At patient that state their shoes are tighter at the end of the day may be experiencing
Hygeine - DOB - work hx
Fluid volume deficit related to poor intake
Edema
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

37. 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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38. Blood passes through the heart valves In what order?
Stroke volume x's heart rate
Tricuspid - mitral and the aortic
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Secondary soureces (family - friends)

39. The purpose of an initial assessment is
To ID the problem
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hearing loss
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

40. The fifth vital sign is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain
Medical
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

41. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Decision assessment
Symptoms
# of packs per day x # of years smoked

42. Would a nursing dx be part of the primary or secondary dx?
Secondary
No
Risk of falls increases
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

43. Data validation assures
The result is accurate patient dB
Trauma or illness
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decreased sense of taste

44. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Sensory motor
Abstract thinking
Secondary soureces (family - friends)
No

45. Acceptable sources of assessment data when evaluating a confused patient would be
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Focused
Trauma or illness
Secondary soureces (family - friends)

46. What is the difference between hallucination and delirium?
Bacterial infection
Hearing loss
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The process of storing - learning - retrieving - and using info.

47. Kussamaul respirations describe

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48. Expiration sounds are heard longer than inspiration In What area?
Edema
Defining a baseline of cognitive function - any changes or deviations from norm.
Broncial (heard over trachea)
Ongoing assessment

49. QUESTT is a tool for What type of an assessment?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pt's with oxygenation and perfusion problems
Pain
Pt's underlying feelings

50. Nursing dx provides basis of
Snap - crackle - pops; velcro - bubble wrap
Interventions for which the nurse is accountable
Loss of taste
Secondary