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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 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
Hemoglobin
Decision assessment
8.4

2. What is responsible for transporting O2 in the blood
Have them do simple math problems
Hemoglobin
Broncial (heard over trachea)
Implementation

3. Inspiration sounds are heard longer than expiration sounds In What area?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Vesicular (peripheral lung areas)
Loss of taste
Pain

4. What is a component of the cognitive part of critical thinking skills?
No
Secondary soureces (family - friends)
Knowing What to do/how to make a decision based upon available data.
Serves to expedite dx and tx of actual and potential health problems

5. When using restraints in a confused patient
A personal experience that does whatever the person in pain says it does
Double check equip and patient
Risk of falls increases
Fluid volume deficit related to poor intake

6. When noticing a patient with dementia has stopped eating - the RN's first response is?
Implementation
Adolescence
Family - spouse - someone other than a healthcare worker - previous medical records.
To simulate eating motions with the hands

7. Expiration sounds are heard longer than inspiration In What area?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Broncial (heard over trachea)
Have them do simple math problems
Abstract thinking

8. What is pain?
Nurse
Double check equip and patient
Nursing dx
A personal experience that does whatever the person in pain says it does

9. Orthopnea is described as?
Objective
Non - opiod (ex: NSAID/acetominaphen)
Assess over all health status and identify the problem
Having to use more than one pillow when sleeping

10. An example of a primary source is
Wandering
Maslow
The patient
Defining a baseline of cognitive function - any changes or deviations from norm.

11. A nursing dx is best described as
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Learning - memory and adaptation to stress
Nursing dx
To simulate eating motions with the hands

12. What is intermittent claudication?
Hearing loss
Secondary
Stroke volume x's heart rate
Pain in legs assoc w walking

13. Examples of personal information
Communicate using hands and eyes.
Pain
Defining a baseline of cognitive function - any changes or deviations from norm.
Hygeine - DOB - work hx

14. The order of air flow into the lungs is
Hygeine - DOB - work hx
Serves to expedite dx and tx of actual and potential health problems
Pt's with oxygenation and perfusion problems
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

15. At What age do you begin to use logical thought process?
Ask - Believe - Choose - Deliver - Empower
Irregular respirations (fast/slow) often seen at end of life
Preschool is cause and effect - school age begins to use logical thought process.
School age childen

16. What factors may indicate plural rub?
Pain in legs assoc w walking
Objective
Pain on inspiration and expiration; superficial squeaking or grating
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

17. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Hearing loss

18. Hypogeusis is
Decreased sense of taste
Irregular respirations (fast/slow) often seen at end of life
Secondary soureces (family - friends)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

19. Ongoing assessments are useful in

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20. What is a chochlear implant?
Interventions for which the nurse is accountable
The medication will not affect the patient's breathing.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Abstract thinking

21. What is the formula for determining pack years?
# of packs per day x # of years smoked
Initial assessment
Capillaries
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

22. Data from the last 24/48 hours that included patterns would be a part of
Hemoglobin
Trend assessment (shift report)
Double check equip and patient
Pain on inspiration and expiration; superficial squeaking or grating

23. In Which part of the nursing process will you find delegation?
Paradoxical reaction
Having to use more than one pillow when sleeping
Implementation
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

24. When a patient has increased lymphocytes - this may indicate what?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Viral infection
Pt's with oxygenation and perfusion problems
Data collection - data validation - data organization - data analysis - and data reporting/recording.

25. What is the difference between a nursing dx and a med dx?
Assess over all health status and identify the problem
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Vesicular (peripheral lung areas)

26. Factors that may reduce the efficacy of pulse oximetry include
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Hemoglobin
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Trauma or illness

27. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Hemoglobin
Data collection - data validation - data organization - data analysis - and data reporting/recording.
ID'ing status of exisiting problems and locating new issues
Level of stress - risk for violence - anxiety level - patient unmet needs

28. Are changes in vital signs a reliable indicator of chronic pain?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
The process of storing - learning - retrieving - and using info.
No

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

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30. Nursing dx provides basis of
Symptoms
Interventions for which the nurse is accountable
ID'ing status of exisiting problems and locating new issues
8.4

31. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
# of packs per day x # of years smoked
Abstract thinking
Wandering
Objective

32. What is the purpose of the nursing process?
Toddler
Serves to expedite dx and tx of actual and potential health problems
Viral infection
Pain

33. What is the correct approach when dealing with older adults?
8.4
Secondary soureces (family - friends)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

34. What are the steps of the nursing process?
The process of storing - learning - retrieving - and using info.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensory motor
Trauma or illness

35. Nursing interventions should be based on who's theory?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Maslow
The medication will not affect the patient's breathing.
Medical

36. Another term for a focused assessment is
Ongoing assessment
Nurse
Wandering
Snap - crackle - pops; velcro - bubble wrap

37. The purpose of an initial assessment is
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
A personal experience that does whatever the person in pain says it does
Decision assessment
To ID the problem

38. Other factors that may indicate confusion using the CAM tool could be
Family - spouse - someone other than a healthcare worker - previous medical records.
Disorganized thinking and altered LOC
Abstract thinking
Nursing dx

39. The path of blood from the heart to the lungs is
The patient
Broncial (heard over trachea)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Inattention and acute increase/decrease in cognitive function

40. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Upper airways
Level of stress - risk for violence - anxiety level - patient unmet needs
Vesicular (peripheral lung areas)

41. All body system data is not necessary which type of assessment
Focused
Pain
Symptoms
Adolescence

42. The purpose of an intitial assement serves to?
Irregular respirations (fast/slow) often seen at end of life
Pain on inspiration and expiration; superficial squeaking or grating
Assess over all health status and identify the problem
Pain

43. An example of a nursing dx would be
Assess over all health status and identify the problem
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Fluid volume deficit related to poor intake

44. Types of hearing loss include
Pt's underlying feelings
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
Immature immune system - structures close together lends to easy spreading from on area to another.

45. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Implementation
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
A personal experience that does whatever the person in pain says it does

46. What are Cheyne Stokes?
Immature immune system - structures close together lends to easy spreading from on area to another.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Irregular respirations (fast/slow) often seen at end of life
Implementation

47. What is the formula for cardiac output?

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48. Which patient would be most likely to experience sensory overload?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decreased arterial perfusion
Level of stress - risk for violence - anxiety level - patient unmet needs
An 80 y/o patient that has emergency surgery

49. What is the difference between hallucination and delirium?
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.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain on inspiration and expiration; superficial squeaking or grating

50. Sleep deprivation can effect
Fast and deep respirations seen in patient's with acidosis
Pt's underlying feelings
Family - spouse - someone other than a healthcare worker - previous medical records.
Learning - memory and adaptation to stress