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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. When dealing with a confused patient - should the nurse acknowledge the patient's underlying feelings or the content of the delusion?

2. Would a nursing dx be part of the primary or secondary dx?
Secondary
Bacterial infection
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
The patient

3. The purpose of an intitial assement serves to?
Toddler
Assess over all health status and identify the problem
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Daily

4. A potential adverse rx of chemically restraining a confused patient would be
Disorganized thinking and altered LOC
Stroke volume x's heart rate
Ask - Believe - Choose - Deliver - Empower
Paradoxical reaction

5. Where can wheezes best be heard?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Have them do simple math problems
Upper airways

6. Two indicators that are REQUIRED for classification via the CAM tool include
Vesicular (peripheral lung areas)
Inattention and acute increase/decrease in cognitive function
Daily
Learning - memory and adaptation to stress

7. The order of air flow into the lungs is
Maslow
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
8.4
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

8. Which patient would be most likely to experience sensory overload?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
An 80 y/o patient that has emergency surgery
Trauma or illness

9. If an abnormal finding is revealed during assessment - the nurse should
Interventions for which the nurse is accountable
Having to use more than one pillow when sleeping
Double check equip and patient
Medical

10. What is pain?
A personal experience that does whatever the person in pain says it does
Toddler
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Hearing loss

11. Intermittent claudication is caused by?
Nurse
Medical
Pain
Decreased arterial perfusion

12. A patient that is easily fatigued may have a HgB lab value of?
Pt's with oxygenation and perfusion problems
8.4
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)

13. What do rales sound like?
Secondary soureces (family - friends)
The result is accurate patient dB
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Snap - crackle - pops; velcro - bubble wrap

14. Data that is recorded for an immediate need (code blue or fall) would be included in
Immature immune system - structures close together lends to easy spreading from on area to another.
Decision assessment
Fast and deep respirations seen in patient's with acidosis
An 80 y/o patient that has emergency surgery

15. Inspiration sounds are heard longer than expiration sounds In What area?
Risk of falls increases
Level of stress - risk for violence - anxiety level - patient unmet needs
Vesicular (peripheral lung areas)
Hygeine - DOB - work hx

16. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Fast and deep respirations seen in patient's with acidosis
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Abstract thinking

17. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Focused
Pain on inspiration and expiration; superficial squeaking or grating
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

18. Ageusia is
Loss of taste
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Toddler
Irregular respirations (fast/slow) often seen at end of life

19. The path of blood from the lungs to the heart is
Decreased sense of taste
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Communicate using hands and eyes.

20. At What age do you begin to use logical thought process?
The process of storing - learning - retrieving - and using info.
Objective
School age childen
To simulate eating motions with the hands

21. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Objective
Abstract thinking
Vesicular (peripheral lung areas)

22. Data validation assures
The result is accurate patient dB
Tricuspid - mitral and the aortic
Assess over all health status and identify the problem
EdFED- Q

23. Sleep deprivation can effect
Pain
To ID the problem
Learning - memory and adaptation to stress
School age childen

24. Nursing interventions should be based on who's theory?
Maslow
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Learning - memory and adaptation to stress
To simulate eating motions with the hands

25. A nursing dx is best described as
Disorganized thinking and altered LOC
Abstract thinking
Objective
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

26. Nursing dx provides basis of
Ask - Believe - Choose - Deliver - Empower
Interventions for which the nurse is accountable
To simulate eating motions with the hands
Hygeine - DOB - work hx

27. Orthopnea is described as?
Decision assessment
Having to use more than one pillow when sleeping
8.4
Upper airways

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

29. What does CAM stand for
Maslow
Medical
Communicate using hands and eyes.
Confusion Assessment Method

30. What is responsible for transporting O2 in the blood
Pain
Hemoglobin
Hygeine - DOB - work hx
Trend assessment (shift report)

31. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Level of stress - risk for violence - anxiety level - patient unmet needs
Snap - crackle - pops; velcro - bubble wrap
Double check equip and patient

32. The purpose of an initial assessment is
Immature immune system - structures close together lends to easy spreading from on area to another.
Serves to expedite dx and tx of actual and potential health problems
To ID the problem
Tricuspid - mitral and the aortic

33. The fifth vital sign is
To simulate eating motions with the hands
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Non - opiod (ex: NSAID/acetominaphen)
Pain

34. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Assess over all health status and identify the problem
The medication will not affect the patient's breathing.
Pain

35. Expiration sounds are heard longer than inspiration In What area?
A personal experience that does whatever the person in pain says it does
Broncial (heard over trachea)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Symptoms

36. Types of hearing loss include
Level of stress - risk for violence - anxiety level - patient unmet needs
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Stroke volume x's heart rate

37. What is cognition?
The process of storing - learning - retrieving - and using info.
An 80 y/o patient that has emergency surgery
Pain
Data collection - data validation - data organization - data analysis - and data reporting/recording.

38. What is the formula for cardiac output?

39. The assessment that includes the patient's overhall health status
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
8.4
Learning - memory and adaptation to stress
Initial assessment

40. Hypogeusis is
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Secondary
Decreased sense of taste
Vesicular (peripheral lung areas)

41. In Which part of the nursing process will you find delegation?
Non - opiod (ex: NSAID/acetominaphen)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Implementation
Fluid volume deficit related to poor intake

42. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Immature immune system - structures close together lends to easy spreading from on area to another.
Fast and deep respirations seen in patient's with acidosis
Pain on inspiration and expiration; superficial squeaking or grating

43. Ongoing assessments are useful in

44. What is a definition of a delusion?
Vesicular (peripheral lung areas)
The patient
Wandering
A false - fixed belief that cannot be corrected through reasoning.

45. What are the steps of the nursing process?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Irregular respirations (fast/slow) often seen at end of life
Trauma or illness

46. An ongoing assessment is performed
Sensory motor
To simulate eating motions with the hands
Daily
To ID the problem

47. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Level of stress - risk for violence - anxiety level - patient unmet needs
School age childen
Pt's underlying feelings

48. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Nursing
Family - spouse - someone other than a healthcare worker - previous medical records.
Bacterial infection

49. What is the formula for determining pack years?
Serves to expedite dx and tx of actual and potential health problems
# of packs per day x # of years smoked
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Capillaries

50. When speaking with a patient with moderate hearing loss the RN should
Decreased sense of taste
Communicate using hands and eyes.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hygeine - DOB - work hx