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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. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Tricuspid - mitral and the aortic
The process of storing - learning - retrieving - and using info.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

2. Orthopnea is described as?
Having to use more than one pillow when sleeping
A personal experience that does whatever the person in pain says it does
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

3. At patient that state their shoes are tighter at the end of the day may be experiencing
Edema
Objective
Capillaries
Abstract thinking

4. The path of blood from the lungs to the heart is
Level of stress - risk for violence - anxiety level - patient unmet needs
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Fast and deep respirations seen in patient's with acidosis

5. The site where gas exchange occurs is
Capillaries
Interventions for which the nurse is accountable
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Toddler

6. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Defining a baseline of cognitive function - any changes or deviations from norm.

7. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Hygeine - DOB - work hx
Level of stress - risk for violence - anxiety level - patient unmet needs
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

8. Subjective data could include
Nursing
Symptoms
Pt's underlying feelings
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

9. Types of hearing loss include
Daily
Upper airways
Bacterial infection
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

10. The purpose of an initial assessment is
8.4
Stroke volume x's heart rate
To ID the problem
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

11. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
Pain on inspiration and expiration; superficial squeaking or grating
Hearing loss
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

12. Where can wheezes best be heard?
Trend assessment (shift report)
Upper airways
Serves to expedite dx and tx of actual and potential health problems
Stroke volume x's heart rate

13. What is intermittent claudication?
Ask - Believe - Choose - Deliver - Empower
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pain in legs assoc w walking

14. 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.
ID'ing status of exisiting problems and locating new issues
# of packs per day x # of years smoked
Immature immune system - structures close together lends to easy spreading from on area to another.

15. What does CAM stand for
Family - spouse - someone other than a healthcare worker - previous medical records.
Level of stress - risk for violence - anxiety level - patient unmet needs
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Confusion Assessment Method

16. If an abnormal finding is revealed during assessment - the nurse should
EdFED- Q
ID'ing status of exisiting problems and locating new issues
Pain in legs assoc w walking
Double check equip and patient

17. All body system data is not necessary which type of assessment
Preschool is cause and effect - school age begins to use logical thought process.
An 80 y/o patient that has emergency surgery
Tricuspid - mitral and the aortic
Focused

18. An example of a primary source is
Secondary soureces (family - friends)
Risk of falls increases
The patient
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

19. Which patient would be most likely to experience sensory overload?
The result is accurate patient dB
Initial assessment
An 80 y/o patient that has emergency surgery
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

20. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Snap - crackle - pops; velcro - bubble wrap
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

21. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Focused
To ID the problem
Decreased sense of taste

22. Expiration sounds are heard longer than inspiration In What area?
Secondary soureces (family - friends)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
School age childen
Broncial (heard over trachea)

23. Ongoing assessments are useful in

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24. Would a nursing dx be part of the primary or secondary dx?
Upper airways
Trauma or illness
Secondary
Family - spouse - someone other than a healthcare worker - previous medical records.

25. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Fluid volume deficit related to poor intake
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Level of stress - risk for violence - anxiety level - patient unmet needs

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

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27. 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)
School age childen

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

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29. When noticing a patient with dementia has stopped eating - the RN's first response is?
Ask - Believe - Choose - Deliver - Empower
Viral infection
Hearing loss
To simulate eating motions with the hands

30. Examples of personal information
ID'ing status of exisiting problems and locating new issues
Nurse
Hygeine - DOB - work hx
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

31. At What age do you begin to put thoughts into words?
Medical
Ask - Believe - Choose - Deliver - Empower
Toddler
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

32. The order of air flow into the lungs is
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nursing
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
8.4

33. The path of blood from the heart to the lungs is
Nurse
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.
Vesicular (peripheral lung areas)

34. At What age do you begin to use decision making?
Fluid volume deficit related to poor intake
Adolescence
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Ongoing assessment

35. Ageusia is
Loss of taste
Medical
Trauma or illness
Nurse

36. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Hemoglobin
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

37. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Medical
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Focused

38. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Having to use more than one pillow when sleeping
The patient
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Non - opiod (ex: NSAID/acetominaphen)

39. What is the difference between hallucination and delirium?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Viral infection
Hemoglobin

40. Data gathered via instrumention (pulse ox) is considered
Objective
Tricuspid - mitral and the aortic
Immature immune system - structures close together lends to easy spreading from on area to another.
Having to use more than one pillow when sleeping

41. What is responsible for transporting O2 in the blood
Loss of taste
Pain
Hemoglobin
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

42. Acceptable sources of assessment data when evaluating a confused patient would be
Non - opiod (ex: NSAID/acetominaphen)
Confusion Assessment Method
Secondary soureces (family - friends)
Decision assessment

43. What scale is used to determine eating and feeding issues in adults with confusion
The process of storing - learning - retrieving - and using info.
Decision assessment
Assess over all health status and identify the problem
EdFED- Q

44. Fluid volume deficit is a __________ dx
Learning - memory and adaptation to stress
Secondary soureces (family - friends)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Nursing

45. A patient that is easily fatigued may have a HgB lab value of?
Communicate using hands and eyes.
8.4
Secondary
Sensory motor

46. In Which part of the nursing process will you find delegation?
Pain in legs assoc w walking
Level of stress - risk for violence - anxiety level - patient unmet needs
Adolescence
Implementation

47. What is the purpose of the nursing process?
Pain
Serves to expedite dx and tx of actual and potential health problems
To simulate eating motions with the hands
Knowing What to do/how to make a decision based upon available data.

48. At What age do you begin to use logical thought process?
School age childen
Family - spouse - someone other than a healthcare worker - previous medical records.
Learning - memory and adaptation to stress
Ask - Believe - Choose - Deliver - Empower

49. Two indicators that are REQUIRED for classification via the CAM tool include
Adolescence
Inattention and acute increase/decrease in cognitive function
Bacterial infection
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

50. 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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