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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?
Bacterial infection
Family - spouse - someone other than a healthcare worker - previous medical records.
Tricuspid - mitral and the aortic
Risk of falls increases

2. What is a component of the cognitive part of critical thinking skills?
To simulate eating motions with the hands
To ID the problem
Confusion Assessment Method
Knowing What to do/how to make a decision based upon available data.

3. What are the components of an assessment?
EdFED- Q
Ongoing assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Defining a baseline of cognitive function - any changes or deviations from norm.

4. An example of a nursing dx would be
The medication will not affect the patient's breathing.
Fluid volume deficit related to poor intake
No
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

5. 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
Adolescence
Wandering
Nursing dx

6. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Capillaries
Irregular respirations (fast/slow) often seen at end of life
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

7. Why are young children at greater risk for respiratory infection?
Medical
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.
Pain

8. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
8.4
Snap - crackle - pops; velcro - bubble wrap
Vesicular (peripheral lung areas)

9. Nursing interventions should be based on who's theory?
Maslow
Paradoxical reaction
Edema
No

10. Factors that may reduce the efficacy of pulse oximetry include
Pain on inspiration and expiration; superficial squeaking or grating
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

11. Data that is recorded for an immediate need (code blue or fall) would be included in
Medical
Decision assessment
Decreased arterial perfusion
ID'ing status of exisiting problems and locating new issues

12. The purpose of an intitial assement serves to?
Abstract thinking
Disorganized thinking and altered LOC
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Assess over all health status and identify the problem

13. The order of air flow into the lungs is
Edema
Vesicular (peripheral lung areas)
Upper airways
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

14. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
The patient
Level of stress - risk for violence - anxiety level - patient unmet needs
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

15. A patient that is easily fatigued may have a HgB lab value of?
8.4
Secondary
Confusion Assessment Method
Decreased sense of taste

16. Ageusia is
Communicate using hands and eyes.
Loss of taste
Pain
Pain

17. The fifth vital sign is
Focused
Sensory motor
Pain
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

18. What are the components of a mental status exam that are not part of a regular assessment?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decreased arterial perfusion
Initial assessment
Snap - crackle - pops; velcro - bubble wrap

19. Ongoing assessments are useful in

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20. What scale is used to determine eating and feeding issues in adults with confusion
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
EdFED- Q
Trauma or illness

21. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Pain
Trend assessment (shift report)
Inattention and acute increase/decrease in cognitive function

22. What factors may indicate plural rub?
Daily
Trend assessment (shift report)
Capillaries
Pain on inspiration and expiration; superficial squeaking or grating

23. What do rhonchi sound like?
Defining a baseline of cognitive function - any changes or deviations from norm.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Non - opiod (ex: NSAID/acetominaphen)
Sensory motor

24. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Interventions for which the nurse is accountable
The result is accurate patient dB
Confusion Assessment Method

25. What is the formula for determining pack years?
Bacterial infection
Objective
# of packs per day x # of years smoked
Broncial (heard over trachea)

26. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Level of stress - risk for violence - anxiety level - patient unmet needs
Nursing

27. QUESTT is a tool for What type of an assessment?
Confusion Assessment Method
Bacterial infection
Adolescence
Pain

28. An ongoing assessment is performed
Double check equip and patient
Decision assessment
Daily
Ask - Believe - Choose - Deliver - Empower

29. What is the formula for cardiac output?

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30. Orthopnea is described as?
Level of stress - risk for violence - anxiety level - patient unmet needs
Disorganized thinking and altered LOC
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Having to use more than one pillow when sleeping

31. When speaking with a patient with moderate hearing loss the RN should
Interventions for which the nurse is accountable
ID'ing status of exisiting problems and locating new issues
Communicate using hands and eyes.
An 80 y/o patient that has emergency surgery

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

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33. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Secondary soureces (family - friends)
Hearing loss
Maslow
Broncial (heard over trachea)

34. Sleep deprivation can effect
Have them do simple math problems
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Learning - memory and adaptation to stress
Assess over all health status and identify the problem

35. What are Cheyne Stokes?
Pt's with oxygenation and perfusion problems
Non - opiod (ex: NSAID/acetominaphen)
Irregular respirations (fast/slow) often seen at end of life
Objective

36. What is a definition of a delusion?
Hemoglobin
Symptoms
Having to use more than one pillow when sleeping
A false - fixed belief that cannot be corrected through reasoning.

37. What is the difference between a nursing dx and a med dx?
The patient
Pt's underlying feelings
Irregular respirations (fast/slow) often seen at end of life
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

38. Two indicators that are REQUIRED for classification via the CAM tool include
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Inattention and acute increase/decrease in cognitive function
Toddler
Trauma or illness

39. What is the purpose of the nursing process?
Fast and deep respirations seen in patient's with acidosis
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Serves to expedite dx and tx of actual and potential health problems

40. Intermittent claudication is caused by?
To simulate eating motions with the hands
Knowing What to do/how to make a decision based upon available data.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decreased arterial perfusion

41. Fluid volume deficit is a __________ dx
Focused
Nursing
Stroke volume x's heart rate
Pain

42. Data gathered via instrumention (pulse ox) is considered
A false - fixed belief that cannot be corrected through reasoning.
Knowing What to do/how to make a decision based upon available data.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Objective

43. If an abnormal finding is revealed during assessment - the nurse should
Pain on inspiration and expiration; superficial squeaking or grating
Edema
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Double check equip and patient

44. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Tricuspid - mitral and the aortic
The result is accurate patient dB
Non - opiod (ex: NSAID/acetominaphen)

45. The assessment that includes the patient's overhall health status
Having to use more than one pillow when sleeping
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Secondary soureces (family - friends)
Initial assessment

46. One way to test a person's cognitive ability and abstract thinking ability would be to
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
The patient
Objective
Have them do simple math problems

47. Data validation assures
The result is accurate patient dB
Non - opiod (ex: NSAID/acetominaphen)
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

48. Where can you hear bronchovesicular breath sounds?
Pt's underlying feelings
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
An 80 y/o patient that has emergency surgery

49. 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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50. A nursing dx is best described as
The medication will not affect the patient's breathing.
The process of storing - learning - retrieving - and using info.
Decreased arterial perfusion
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.