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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. Data validation assures
The result is accurate patient dB
Stroke volume x's heart rate
ID'ing status of exisiting problems and locating new issues
Focused

2. Side effects of putting confused pts in restraints include
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Knowing What to do/how to make a decision based upon available data.
Having to use more than one pillow when sleeping
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

3. The path of blood from the lungs to the heart is
Level of stress - risk for violence - anxiety level - patient unmet needs
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
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

4. The path of blood from the heart to the lungs is
Learning - memory and adaptation to stress
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Focused

5. If an abnormal finding is revealed during assessment - the nurse should
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Pain
Family - spouse - someone other than a healthcare worker - previous medical records.
Double check equip and patient

6. Intermittent claudication is caused by?
Hearing loss
Decreased arterial perfusion
Non - opiod (ex: NSAID/acetominaphen)
Fast and deep respirations seen in patient's with acidosis

7. What factors may indicate plural rub?
Tricuspid - mitral and the aortic
Medical
Ongoing assessment
Pain on inspiration and expiration; superficial squeaking or grating

8. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Nurse
Loss of taste
Upper airways

9. Fluid volume deficit is a __________ dx
The result is accurate patient dB
Nursing
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Non - opiod (ex: NSAID/acetominaphen)

10. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Risk of falls increases

11. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Tricuspid - mitral and the aortic
Paradoxical reaction

12. When a patient has increased lymphocytes - this may indicate what?
Pt's underlying feelings
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Viral infection
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

13. Two indicators that are REQUIRED for classification via the CAM tool include
Hearing loss
Inattention and acute increase/decrease in cognitive function
Sensory motor
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

14. What is a definition of a delusion?
Having to use more than one pillow when sleeping
Pain
A false - fixed belief that cannot be corrected through reasoning.
Double check equip and patient

15. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Toddler
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

16. 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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17. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hearing loss
No
Assess over all health status and identify the problem

18. The basis for a plan of care comes for which stage of the nursing process?
Adolescence
Nursing dx
Loss of taste
Pain on inspiration and expiration; superficial squeaking or grating

19. Expiration sounds are heard longer than inspiration In What area?
Hearing loss
Edema
Broncial (heard over trachea)
Vesicular (peripheral lung areas)

20. One way to test a person's cognitive ability and abstract thinking ability would be to
Non - opiod (ex: NSAID/acetominaphen)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Have them do simple math problems

21. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
School age childen
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

22. Are changes in vital signs a reliable indicator of chronic pain?
Have them do simple math problems
The process of storing - learning - retrieving - and using info.
No
Nursing dx

23. Name the 5 'W's' of assessing a change in LOC
Pain
Preschool is cause and effect - school age begins to use logical thought process.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Toddler

24. The fifth vital sign is
The patient
Pain
Decision assessment
Hearing loss

25. Acceptable sources of assessment data when evaluating a confused patient would be
No
Secondary soureces (family - friends)
Non - opiod (ex: NSAID/acetominaphen)
Assess over all health status and identify the problem

26. The purpose of an intitial assement serves to?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Assess over all health status and identify the problem
Abstract thinking
Stroke volume x's heart rate

27. At What age do you begin to put thoughts into words?
Secondary
Loss of taste
Toddler
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

28. Subjective data could include
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Symptoms
Assess over all health status and identify the problem
Double check equip and patient

29. Sleep deprivation can effect
Immature immune system - structures close together lends to easy spreading from on area to another.
Learning - memory and adaptation to stress
Ongoing assessment
Symptoms

30. An example of a nursing dx would be
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Decision assessment
Fluid volume deficit related to poor intake

31. What is the formula for determining pack years?
A false - fixed belief that cannot be corrected through reasoning.
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 dx
# of packs per day x # of years smoked

32. Diabetes is a _________ dx
Upper airways
To simulate eating motions with the hands
Decreased arterial perfusion
Medical

33. 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
Nursing dx
Serves to expedite dx and tx of actual and potential health problems
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

34. Hypogeusis is
Decreased sense of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
To simulate eating motions with the hands
Irregular respirations (fast/slow) often seen at end of life

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

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36. When speaking with a patient with moderate hearing loss the RN should
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Have them do simple math problems
Communicate using hands and eyes.

37. A patient that is easily fatigued may have a HgB lab value of?
Secondary soureces (family - friends)
8.4
No
Wandering

38. What does CAM stand for
Paradoxical reaction
Confusion Assessment Method
An 80 y/o patient that has emergency surgery
Wandering

39. The order of air flow into the lungs is
8.4
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
To simulate eating motions with the hands

40. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
Having to use more than one pillow when sleeping
Trauma or illness
8.4

41. Inspiration sounds are heard longer than expiration sounds In What area?
Immature immune system - structures close together lends to easy spreading from on area to another.
Paradoxical reaction
Vesicular (peripheral lung areas)
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

42. Data gathered via instrumention (pulse ox) is considered
8.4
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Objective
Pain

43. Where can you hear bronchovesicular breath sounds?
Edema
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Knowing What to do/how to make a decision based upon available data.
Stroke volume x's heart rate

44. An example of a primary source is
The patient
Confusion Assessment Method
Implementation
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

45. At What age do you begin to use decision making?
Maslow
Adolescence
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sensory motor

46. What is responsible for transporting O2 in the blood
Viral infection
Trauma or illness
Hemoglobin
Toddler

47. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
To simulate eating motions with the hands
Wandering
Family - spouse - someone other than a healthcare worker - previous medical records.

48. 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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49. When noticing a patient with dementia has stopped eating - the RN's first response is?
Maslow
To simulate eating motions with the hands
Wandering
Disorganized thinking and altered LOC

50. Nursing dx provides basis of
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Paradoxical reaction
Interventions for which the nurse is accountable
Sensory motor