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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. QUESTT is a tool for What type of an assessment?
Pain
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Decreased arterial perfusion
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

2. Fluid volume deficit is a __________ dx
Nursing
EdFED- Q
Decreased sense of taste
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

3. Acceptable sources of assessment data when evaluating a confused patient would be
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Double check equip and patient
Secondary soureces (family - friends)
Have them do simple math problems

4. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Trend assessment (shift report)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Paradoxical reaction

5. Would a nursing dx be part of the primary or secondary dx?
Secondary
Symptoms
Defining a baseline of cognitive function - any changes or deviations from norm.
Focused

6. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Inattention and acute increase/decrease in cognitive function
Pt's with oxygenation and perfusion problems
Non - opiod (ex: NSAID/acetominaphen)
Defining a baseline of cognitive function - any changes or deviations from norm.

7. When a patient has increased neutrophils - this may indicate what?
Learning - memory and adaptation to stress
Hemoglobin
Bacterial infection
Trend assessment (shift report)

8. What are Cheyne Stokes?
Tricuspid - mitral and the aortic
Irregular respirations (fast/slow) often seen at end of life
Upper airways
The process of storing - learning - retrieving - and using info.

9. A patient that is easily fatigued may have a HgB lab value of?
8.4
Nurse
Stroke volume x's heart rate
Communicate using hands and eyes.

10. What is cognition?
The process of storing - learning - retrieving - and using info.
Broncial (heard over trachea)
Pain
Having to use more than one pillow when sleeping

11. What are the components of an assessment?
Communicate using hands and eyes.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The result is accurate patient dB

12. Sleep deprivation can effect
Non - opiod (ex: NSAID/acetominaphen)
Learning - memory and adaptation to stress
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Stroke volume x's heart rate

13. Where can you hear bronchovesicular breath sounds?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
To ID the problem
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Trauma or illness

14. Blood passes through the heart valves In what order?
Double check equip and patient
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Preschool is cause and effect - school age begins to use logical thought process.
Tricuspid - mitral and the aortic

15. Two indicators that are REQUIRED for classification via the CAM tool include
Decreased sense of taste
Objective
Inattention and acute increase/decrease in cognitive function
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

16. Factors that may reduce the efficacy of pulse oximetry include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Double check equip and patient
Sensory motor

17. Data that is recorded for an immediate need (code blue or fall) would be included in
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Trend assessment (shift report)
Decision assessment
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

18. The site where gas exchange occurs is
Decreased arterial perfusion
Capillaries
The result is accurate patient dB
The patient

19. An example of a nursing dx would be
Abstract thinking
Broncial (heard over trachea)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Fluid volume deficit related to poor intake

20. The order of air flow into the lungs is
School age childen
Symptoms
Risk of falls increases
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

21. An example of a primary source is
Risk of falls increases
Pain on inspiration and expiration; superficial squeaking or grating
The patient
To simulate eating motions with the hands

22. A nursing dx is best described as
Fluid volume deficit related to poor intake
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

23. An ongoing assessment is performed
# of packs per day x # of years smoked
Ask - Believe - Choose - Deliver - Empower
The process of storing - learning - retrieving - and using info.
Daily

24. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Fast and deep respirations seen in patient's with acidosis
Pain
Adolescence

25. What is the correct approach when dealing with older adults?
Decreased sense of taste
Implementation
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Decreased arterial perfusion

26. The path of blood from the heart to the lungs is
Objective
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ask - Believe - Choose - Deliver - Empower
Hearing loss

27. The purpose of an initial assessment is
Hygeine - DOB - work hx
Interventions for which the nurse is accountable
The process of storing - learning - retrieving - and using info.
To ID the problem

28. What is the formula for cardiac output?

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29. At patient that state their shoes are tighter at the end of the day may be experiencing
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Edema
Pain

30. What factors may indicate plural rub?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain on inspiration and expiration; superficial squeaking or grating
Secondary soureces (family - friends)
Medical

31. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Stroke volume x's heart rate
To ID the problem
Nurse
Sensory motor

32. The basis for a plan of care comes for which stage of the nursing process?
Preschool is cause and effect - school age begins to use logical thought process.
Nursing
Nursing dx
Objective

33. What is responsible for transporting O2 in the blood
Hemoglobin
Abstract thinking
A false - fixed belief that cannot be corrected through reasoning.
Pain in legs assoc w walking

34. Ageusia is
Inattention and acute increase/decrease in cognitive function
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Loss of taste
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

35. When noticing a patient with dementia has stopped eating - the RN's first response is?
Initial assessment
Viral infection
To simulate eating motions with the hands
Hearing loss

36. Inspiration sounds are heard longer than expiration sounds In What area?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
No
Level of stress - risk for violence - anxiety level - patient unmet needs
Vesicular (peripheral lung areas)

37. If an abnormal finding is revealed during assessment - the nurse should
The result is accurate patient dB
Having to use more than one pillow when sleeping
Double check equip and patient
Level of stress - risk for violence - anxiety level - patient unmet needs

38. In Which part of the nursing process will you find delegation?
To ID the problem
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Symptoms
Implementation

39. An infant is in which Paiget stage?
Sensory motor
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
To ID the problem

40. Subjective data could include
Symptoms
The medication will not affect the patient's breathing.
Non - opiod (ex: NSAID/acetominaphen)
Abstract thinking

41. Orthopnea is described as?
Abstract thinking
Family - spouse - someone other than a healthcare worker - previous medical records.
Knowing What to do/how to make a decision based upon available data.
Having to use more than one pillow when sleeping

42. Which patient would be most likely to experience sensory overload?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
To ID the problem
An 80 y/o patient that has emergency surgery

43. Data gathered via instrumention (pulse ox) is considered
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Objective
Inattention and acute increase/decrease in cognitive function

44. Types of hearing loss include
Wandering
Interventions for which the nurse is accountable
The patient
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

45. 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
Pain
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
# of packs per day x # of years smoked

46. When using restraints in a confused patient
The process of storing - learning - retrieving - and using info.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Tricuspid - mitral and the aortic
Risk of falls increases

47. What do rales sound like?
Secondary soureces (family - friends)
Snap - crackle - pops; velcro - bubble wrap
Defining a baseline of cognitive function - any changes or deviations from norm.
Bacterial infection

48. The fifth vital sign is
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain
Decreased sense of taste
Preschool is cause and effect - school age begins to use logical thought process.

49. 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
Confusion Assessment Method
Paradoxical reaction
Assess over all health status and identify the problem

50. What is the difference between a nursing dx and a med dx?
Abstract thinking
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain in legs assoc w walking