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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. A nursing dx is best described as
Snap - crackle - pops; velcro - bubble wrap
Pain
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Decreased sense of taste

2. If an abnormal finding is revealed during assessment - the nurse should
Stroke volume x's heart rate
No
Fluid volume deficit related to poor intake
Double check equip and patient

3. Sleep deprivation can effect
Fast and deep respirations seen in patient's with acidosis
The process of storing - learning - retrieving - and using info.
Learning - memory and adaptation to stress
Interventions for which the nurse is accountable

4. When using restraints in a confused patient
Interventions for which the nurse is accountable
8.4
Risk of falls increases
Assess over all health status and identify the problem

5. QUESTT is a tool for What type of an assessment?
Inattention and acute increase/decrease in cognitive function
Decreased arterial perfusion
Pain
To ID the problem

6. A patient that is easily fatigued may have a HgB lab value of?
8.4
Having to use more than one pillow when sleeping
Decreased sense of taste
Learning - memory and adaptation to stress

7. When a patient has increased neutrophils - this may indicate what?
Fast and deep respirations seen in patient's with acidosis
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Non - opiod (ex: NSAID/acetominaphen)
Bacterial infection

8. A potential adverse rx of chemically restraining a confused patient would be
Family - spouse - someone other than a healthcare worker - previous medical records.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Symptoms
Paradoxical reaction

9. Intermittent claudication is caused by?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Decreased arterial perfusion
Interventions for which the nurse is accountable

10. What is responsible for transporting O2 in the blood
Hemoglobin
Decision assessment
Stroke volume x's heart rate
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

11. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Decision assessment
Toddler
# of packs per day x # of years smoked

12. What are the steps of the nursing process?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Disorganized thinking and altered LOC
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

13. 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
Sensory motor
Medical
Focused

14. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Sensory motor
Disorganized thinking and altered LOC
Ongoing assessment

15. Examples of personal information
Preschool is cause and effect - school age begins to use logical thought process.
Capillaries
Decreased sense of taste
Hygeine - DOB - work hx

16. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Capillaries
Adolescence
Decreased arterial perfusion
Abstract thinking

17. What are the ABCDE's of pain management?
Defining a baseline of cognitive function - any changes or deviations from norm.
Ask - Believe - Choose - Deliver - Empower
Assess over all health status and identify the problem
Trend assessment (shift report)

18. Two indicators that are REQUIRED for classification via the CAM tool include
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
The process of storing - learning - retrieving - and using info.
Decreased sense of taste
Inattention and acute increase/decrease in cognitive function

19. The site where gas exchange occurs is
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Pt's underlying feelings
Capillaries
Decreased arterial perfusion

20. What factors may indicate plural rub?
Decision assessment
Implementation
Ask - Believe - Choose - Deliver - Empower
Pain on inspiration and expiration; superficial squeaking or grating

21. When speaking with a patient with moderate hearing loss the RN should
Fluid volume deficit related to poor intake
Learning - memory and adaptation to stress
Nurse
Communicate using hands and eyes.

22. In Which part of the nursing process will you find delegation?
Implementation
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pt's with oxygenation and perfusion problems
Paradoxical reaction

23. Nursing interventions should be based on who's theory?
Serves to expedite dx and tx of actual and potential health problems
Edema
Maslow
School age childen

24. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Hearing loss
Wandering
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Bacterial infection

25. Data that is recorded for an immediate need (code blue or fall) would be included in
EdFED- Q
Knowing What to do/how to make a decision based upon available data.
Have them do simple math problems
Decision assessment

26. Factors that may reduce the efficacy of pulse oximetry include
Assess over all health status and identify the problem
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
School age childen
Pt's with oxygenation and perfusion problems

27. An example of a primary source is
Objective
Decision assessment
The patient
Pain in legs assoc w walking

28. What are Piaget's stages of cognitive development
To simulate eating motions with the hands
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Abstract thinking
The medication will not affect the patient's breathing.

29. Ageusia is
No
Ask - Believe - Choose - Deliver - Empower
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Loss of taste

30. Fluid volume deficit is a __________ dx
Nursing
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Interventions for which the nurse is accountable
Learning - memory and adaptation to stress

31. What is a definition of a delusion?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
A false - fixed belief that cannot be corrected through reasoning.
Immature immune system - structures close together lends to easy spreading from on area to another.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

32. Why are young children at greater risk for respiratory infection?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Immature immune system - structures close together lends to easy spreading from on area to another.
Communicate using hands and eyes.
# of packs per day x # of years smoked

33. Name the 5 'W's' of assessing a change in LOC
No
Pt's with oxygenation and perfusion problems
The process of storing - learning - retrieving - and using info.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

34. What scale is used to determine eating and feeding issues in adults with confusion
A personal experience that does whatever the person in pain says it does
EdFED- Q
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Objective

35. What is a component of the cognitive part of critical thinking skills?
# of packs per day x # of years smoked
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Knowing What to do/how to make a decision based upon available data.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

36. Are changes in vital signs a reliable indicator of chronic pain?
Nurse
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
No
Having to use more than one pillow when sleeping

37. What is pain?
A personal experience that does whatever the person in pain says it does
The patient
The result is accurate patient dB
ID'ing status of exisiting problems and locating new issues

38. Types of hearing loss include
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
No
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
A false - fixed belief that cannot be corrected through reasoning.

39. Blood passes through the heart valves In what order?
Initial assessment
Adolescence
Family - spouse - someone other than a healthcare worker - previous medical records.
Tricuspid - mitral and the aortic

40. What is the difference between a nursing dx and a med dx?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Loss of taste
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Adolescence

41. The purpose of an initial assessment is
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
To ID the problem
Pain on inspiration and expiration; superficial squeaking or grating
Abstract thinking

42. Ongoing assessments are useful in

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43. Where can wheezes best be heard?
Upper airways
Trend assessment (shift report)
No
Capillaries

44. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Decision assessment
Maslow

45. At What age do you begin to put thoughts into words?
Nursing dx
Toddler
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
To ID the problem

46. Would a nursing dx be part of the primary or secondary dx?
Secondary
Pain
Tricuspid - mitral and the aortic
EdFED- Q

47. Subjective data could include
Adolescence
Objective
Symptoms
Upper airways

48. The basis for a plan of care comes for which stage of the nursing process?
Confusion Assessment Method
Tricuspid - mitral and the aortic
Nursing dx
Secondary

49. All body system data is not necessary which type of assessment
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Inattention and acute increase/decrease in cognitive function
Family - spouse - someone other than a healthcare worker - previous medical records.
Focused

50. What do rales sound like?
Loss of taste
Snap - crackle - pops; velcro - bubble wrap
Trauma or illness
8.4