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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. Blood passes through the heart valves In what order?
Nurse
Loss of taste
Tricuspid - mitral and the aortic
Confusion Assessment Method

2. What is the difference between hallucination and delirium?
Tricuspid - mitral and the aortic
Medical
Fast and deep respirations seen in patient's with acidosis
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

3. Where can you hear bronchovesicular breath sounds?
Upper airways
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pain in legs assoc w walking
Trend assessment (shift report)

4. What scale is used to determine eating and feeding issues in adults with confusion
Decreased sense of taste
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
EdFED- Q
The patient

5. What are the components of an assessment?
Daily
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
# of packs per day x # of years smoked

6. Sleep deprivation can effect
Non - opiod (ex: NSAID/acetominaphen)
An 80 y/o patient that has emergency surgery
Loss of taste
Learning - memory and adaptation to stress

7. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Objective
No
The process of storing - learning - retrieving - and using info.

8. Ongoing assessments are useful in

9. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Irregular respirations (fast/slow) often seen at end of life
A false - fixed belief that cannot be corrected through reasoning.
The medication will not affect the patient's breathing.

10. The purpose of an intitial assement serves to?
The medication will not affect the patient's breathing.
Wandering
Assess over all health status and identify the problem
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

11. When speaking with a patient with moderate hearing loss the RN should
To ID the problem
Medical
The process of storing - learning - retrieving - and using info.
Communicate using hands and eyes.

12. An ongoing assessment is performed
No
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
8.4
Daily

13. The purpose of an initial assessment is
Adolescence
Symptoms
To ID the problem
Decreased arterial perfusion

14. Another term for a focused assessment is
Ongoing assessment
Objective
Hemoglobin
Secondary

15. Describe the purpose of a mental status exam
Loss of taste
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

16. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Fluid volume deficit related to poor intake
Trend assessment (shift report)

17. What is the formula for determining pack years?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Medical
# of packs per day x # of years smoked
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

18. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Family - spouse - someone other than a healthcare worker - previous medical records.
Viral infection
Wandering

19. What is the formula for cardiac output?

20. The site where gas exchange occurs is
Capillaries
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
8.4

21. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Non - opiod (ex: NSAID/acetominaphen)
Nursing dx
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

22. 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
Abstract thinking
Maslow
Loss of taste

23. An example of a secondary source is
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Family - spouse - someone other than a healthcare worker - previous medical records.
Objective
Inattention and acute increase/decrease in cognitive function

24. Examples of personal information
Irregular respirations (fast/slow) often seen at end of life
The process of storing - learning - retrieving - and using info.
Hygeine - DOB - work hx
Paradoxical reaction

25. The assessment that includes the patient's overhall health status
The patient
Viral infection
Immature immune system - structures close together lends to easy spreading from on area to another.
Initial assessment

26. Data that is recorded for an immediate need (code blue or fall) would be included in
School age childen
Decision assessment
Non - opiod (ex: NSAID/acetominaphen)
Interventions for which the nurse is accountable

27. What is a chochlear implant?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Level of stress - risk for violence - anxiety level - patient unmet needs
Pt's underlying feelings

28. Two indicators that are REQUIRED for classification via the CAM tool include
Inattention and acute increase/decrease in cognitive function
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 in legs assoc w walking
EdFED- Q

29. Why are young children at greater risk for respiratory infection?
Broncial (heard over trachea)
Nursing
Immature immune system - structures close together lends to easy spreading from on area to another.
Loss of taste

30. What does CAM stand for
The process of storing - learning - retrieving - and using info.
Pt's with oxygenation and perfusion problems
Confusion Assessment Method
Trend assessment (shift report)

31. What is a definition of a delusion?
Hearing loss
Trauma or illness
A false - fixed belief that cannot be corrected through reasoning.
Pain on inspiration and expiration; superficial squeaking or grating

32. The path of blood from the heart to the lungs is
Pain in legs assoc w walking
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Snap - crackle - pops; velcro - bubble wrap
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

33. Side effects of putting confused pts in restraints include
Trend assessment (shift report)
Loss of taste
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Learning - memory and adaptation to stress

34. At What age do you begin to put thoughts into words?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Vesicular (peripheral lung areas)
Toddler
Hygeine - DOB - work hx

35. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

36. A potential adverse rx of chemically restraining a confused patient would be
Knowing What to do/how to make a decision based upon available data.
Paradoxical reaction
Pt's with oxygenation and perfusion problems
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

37. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
A false - fixed belief that cannot be corrected through reasoning.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Have them do simple math problems
Level of stress - risk for violence - anxiety level - patient unmet needs

38. All body system data is not necessary which type of assessment
Ask - Believe - Choose - Deliver - Empower
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The process of storing - learning - retrieving - and using info.
Focused

39. What is the correct approach when dealing with older adults?
Decreased sense of taste
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Level of stress - risk for violence - anxiety level - patient unmet needs
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

40. Where can wheezes best be heard?
Upper airways
Pain on inspiration and expiration; superficial squeaking or grating
Objective
Knowing What to do/how to make a decision based upon available data.

41. Data from the last 24/48 hours that included patterns would be a part of
Hygeine - DOB - work hx
Pt's underlying feelings
Family - spouse - someone other than a healthcare worker - previous medical records.
Trend assessment (shift report)

42. An infant is in which Paiget stage?
Decreased sense of taste
Sensory motor
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Hearing loss

43. Fluid volume deficit is a __________ dx
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Nursing
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
To simulate eating motions with the hands

44. When noticing a patient with dementia has stopped eating - the RN's first response is?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
To simulate eating motions with the hands
Interventions for which the nurse is accountable
Objective

45. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Ask - Believe - Choose - Deliver - Empower
Upper airways
Stroke volume x's heart rate

46. What is a component of the cognitive part of critical thinking skills?
Knowing What to do/how to make a decision based upon available data.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Learning - memory and adaptation to stress
A personal experience that does whatever the person in pain says it does

47. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Family - spouse - someone other than a healthcare worker - previous medical records.
Stroke volume x's heart rate

48. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Preschool is cause and effect - school age begins to use logical thought process.
The result is accurate patient dB
The medication will not affect the patient's breathing.

49. When a patient has increased lymphocytes - this may indicate what?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
School age childen
Viral infection
Medical

50. What is the difference between a nursing dx and a med dx?
The patient
Having to use more than one pillow when sleeping
Pain in legs assoc w walking
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital