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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 path of blood from the heart to the lungs is
Broncial (heard over trachea)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Risk of falls increases
Interventions for which the nurse is accountable

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

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3. Types of hearing loss include
Decision assessment
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Wandering
Daily

4. The purpose of an intitial assement serves to?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Assess over all health status and identify the problem
Maslow
Pain in legs assoc w walking

5. Sleep deprivation can effect
Preschool is cause and effect - school age begins to use logical thought process.
Learning - memory and adaptation to stress
Non - opiod (ex: NSAID/acetominaphen)
Assess over all health status and identify the problem

6. 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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7. Ongoing assessments are useful in

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8. In Which part of the nursing process will you find delegation?
Decision assessment
8.4
Defining a baseline of cognitive function - any changes or deviations from norm.
Implementation

9. Other factors that may indicate confusion using the CAM tool could be
Have them do simple math problems
The process of storing - learning - retrieving - and using info.
The patient
Disorganized thinking and altered LOC

10. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Immature immune system - structures close together lends to easy spreading from on area to another.
Having to use more than one pillow when sleeping

11. QUESTT is a tool for What type of an assessment?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
School age childen
Pain
Nurse

12. All body system data is not necessary which type of assessment
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Trauma or illness
Focused
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

13. At patient that state their shoes are tighter at the end of the day may be experiencing
The result is accurate patient dB
Edema
A personal experience that does whatever the person in pain says it does
Decision assessment

14. What is the correct approach when dealing with older adults?
Implementation
ID'ing status of exisiting problems and locating new issues
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Immature immune system - structures close together lends to easy spreading from on area to another.

15. Fluid volume deficit is a __________ dx
Preschool is cause and effect - school age begins to use logical thought process.
Stroke volume x's heart rate
Nursing
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

16. What are the components of a mental status exam that are not part of a regular assessment?
Snap - crackle - pops; velcro - bubble wrap
Bacterial infection
Having to use more than one pillow when sleeping
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

17. Diabetes is a _________ dx
Focused
Trend assessment (shift report)
Medical
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

18. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Fluid volume deficit related to poor intake
8.4
Double check equip and patient

19. Data gathered via instrumention (pulse ox) is considered
Pain in legs assoc w walking
Decreased arterial perfusion
Hygeine - DOB - work hx
Objective

20. If an abnormal finding is revealed during assessment - the nurse should
Trauma or illness
School age childen
Double check equip and patient
Fast and deep respirations seen in patient's with acidosis

21. When noticing a patient with dementia has stopped eating - the RN's first response is?
Pt's underlying feelings
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
To simulate eating motions with the hands
Stroke volume x's heart rate

22. What is cognition?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Abstract thinking
Nurse
The process of storing - learning - retrieving - and using info.

23. One way to test a person's cognitive ability and abstract thinking ability would be to
Hemoglobin
Have them do simple math problems
Focused
Decision assessment

24. Would a nursing dx be part of the primary or secondary dx?
Pain
Have them do simple math problems
Pt's underlying feelings
Secondary

25. Where can wheezes best be heard?
Trend assessment (shift report)
Upper airways
Learning - memory and adaptation to stress
Irregular respirations (fast/slow) often seen at end of life

26. Examples of personal information
Abstract thinking
Nursing
Hygeine - DOB - work hx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

27. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
School age childen
Level of stress - risk for violence - anxiety level - patient unmet needs
The medication will not affect the patient's breathing.
Interventions for which the nurse is accountable

28. Which patient would be most likely to experience sensory overload?
No
The patient
Pain
An 80 y/o patient that has emergency surgery

29. The fifth vital sign is
Pain
Non - opiod (ex: NSAID/acetominaphen)
Decreased arterial perfusion
Inattention and acute increase/decrease in cognitive function

30. When a patient has increased lymphocytes - this may indicate what?
Interventions for which the nurse is accountable
Viral infection
8.4
Defining a baseline of cognitive function - any changes or deviations from norm.

31. What is a component of the cognitive part of critical thinking skills?
Confusion Assessment Method
Knowing What to do/how to make a decision based upon available data.
Paradoxical reaction
Pain

32. Side effects of putting confused pts in restraints include
Nursing
# of packs per day x # of years smoked
Decreased arterial perfusion
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

33. What is a chochlear implant?
Decision assessment
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pain in legs assoc w walking
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

34. What is the formula for determining pack years?
# of packs per day x # of years smoked
Interventions for which the nurse is accountable
The result is accurate patient dB
Upper airways

35. The assessment that includes the patient's overhall health status
School age childen
Decreased arterial perfusion
Initial assessment
Ongoing assessment

36. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Nursing dx
Have them do simple math problems
Defining a baseline of cognitive function - any changes or deviations from norm.

37. Name the 5 'W's' of assessing a change in LOC
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Data collection - data validation - data organization - data analysis - and data reporting/recording.

38. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Upper airways
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Capillaries

39. Data validation assures
The result is accurate patient dB
Decreased sense of taste
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
The medication will not affect the patient's breathing.

40. The purpose of an initial assessment is
To ID the problem
Family - spouse - someone other than a healthcare worker - previous medical records.
Medical
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

41. 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
Trend assessment (shift report)
A personal experience that does whatever the person in pain says it does
Having to use more than one pillow when sleeping

42. The order of air flow into the lungs is
Double check equip and patient
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Confusion Assessment Method
Capillaries

43. Where can you hear bronchovesicular breath sounds?
Hemoglobin
8.4
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

44. Are changes in vital signs a reliable indicator of chronic pain?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Implementation
No
Focused

45. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Level of stress - risk for violence - anxiety level - patient unmet needs
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Hearing loss

46. What is the nursing process?
Wandering
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Risk of falls increases
Confusion Assessment Method

47. Data that is recorded for an immediate need (code blue or fall) would be included in
Initial assessment
Secondary
Vesicular (peripheral lung areas)
Decision assessment

48. An infant is in which Paiget stage?
Sensory motor
Communicate using hands and eyes.
Hemoglobin
EdFED- Q

49. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Medical

50. A potential adverse rx of chemically restraining a confused patient would be
Ask - Believe - Choose - Deliver - Empower
Symptoms
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Paradoxical reaction