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. Two indicators that are REQUIRED for classification via the CAM tool include
Inattention and acute increase/decrease in cognitive function
To ID the problem
Symptoms
Ongoing assessment


2. The purpose of an initial assessment is
To ID the problem
Knowing What to do/how to make a decision based upon available data.
Initial assessment
Snap - crackle - pops; velcro - bubble wrap


3. Where can you hear bronchovesicular breath sounds?
Knowing What to do/how to make a decision based upon available data.
Level of stress - risk for violence - anxiety level - patient unmet needs
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli


4. What is pain?
Capillaries
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
A personal experience that does whatever the person in pain says it does
The result is accurate patient dB


5. In Which part of the nursing process will you find delegation?
Family - spouse - someone other than a healthcare worker - previous medical records.
Implementation
Nursing dx
EdFED- Q


6. Another term for a focused assessment is
Nursing
Pain in legs assoc w walking
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Ongoing assessment


7. What do rales sound like?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Pain
Stroke volume x's heart rate
Snap - crackle - pops; velcro - bubble wrap


8. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Tricuspid - mitral and the aortic
Irregular respirations (fast/slow) often seen at end of life
Family - spouse - someone other than a healthcare worker - previous medical records.


9. Examples of personal information
Learning - memory and adaptation to stress
Wandering
Level of stress - risk for violence - anxiety level - patient unmet needs
Hygeine - DOB - work hx


10. Ongoing assessments are useful in

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11. What factors may indicate plural rub?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
School age childen
Communicate using hands and eyes.
Pain on inspiration and expiration; superficial squeaking or grating


12. The assessment that includes the patient's overhall health status
Capillaries
EdFED- Q
Initial assessment
Nurse


13. What is the nursing process?
Wandering
Disorganized thinking and altered LOC
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Double check equip and patient


14. What is the correct approach when dealing with older adults?
EdFED- Q
Learning - memory and adaptation to stress
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pain on inspiration and expiration; superficial squeaking or grating


15. Hypogeusis is
Adolescence
Medical
Communicate using hands and eyes.
Decreased sense of taste


16. Side effects of putting confused pts in restraints include
Communicate using hands and eyes.
Double check equip and patient
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy


17. What is intermittent claudication?
Viral infection
Abstract thinking
Pain in legs assoc w walking
Edema


18. What is the formula for cardiac output?

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19. Data gathered via instrumention (pulse ox) is considered
Loss of taste
An 80 y/o patient that has emergency surgery
Maslow
Objective


20. 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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21. At patient that state their shoes are tighter at the end of the day may be experiencing
Symptoms
Secondary
Learning - memory and adaptation to stress
Edema


22. Describe the purpose of a mental status exam
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
The process of storing - learning - retrieving - and using info.
Objective
Defining a baseline of cognitive function - any changes or deviations from norm.


23. What is a chochlear implant?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Inattention and acute increase/decrease in cognitive function
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Interventions for which the nurse is accountable


24. Expiration sounds are heard longer than inspiration In What area?
No
Having to use more than one pillow when sleeping
Nursing
Broncial (heard over trachea)


25. When a patient has increased lymphocytes - this may indicate what?
Secondary soureces (family - friends)
Trend assessment (shift report)
Viral infection
Vesicular (peripheral lung areas)


26. Other factors that may indicate confusion using the CAM tool could be
Pt's underlying feelings
Having to use more than one pillow when sleeping
Disorganized thinking and altered LOC
EdFED- Q


27. When speaking with a patient with moderate hearing loss the RN should
Having to use more than one pillow when sleeping
Communicate using hands and eyes.
Double check equip and patient
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response


28. Where can wheezes best be heard?
Learning - memory and adaptation to stress
ID'ing status of exisiting problems and locating new issues
Upper airways
Nursing dx


29. When using restraints in a confused patient
A false - fixed belief that cannot be corrected through reasoning.
Having to use more than one pillow when sleeping
Risk of falls increases
Daily


30. When noticing a patient with dementia has stopped eating - the RN's first response is?
Pain on inspiration and expiration; superficial squeaking or grating
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The medication will not affect the patient's breathing.
To simulate eating motions with the hands


31. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Trend assessment (shift report)
Risk of falls increases
Viral infection
Nurse


32. What is the cognitive difference between a preschooler and schoolage child?
Immature immune system - structures close together lends to easy spreading from on area to another.
Learning - memory and adaptation to stress
Family - spouse - someone other than a healthcare worker - previous medical records.
Preschool is cause and effect - school age begins to use logical thought process.


33. The order of air flow into the lungs is
Nurse
Hygeine - DOB - work hx
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Implementation


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

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35. 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
Pain
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Irregular respirations (fast/slow) often seen at end of life


36. Would a nursing dx be part of the primary or secondary dx?
Secondary
Pain on inspiration and expiration; superficial squeaking or grating
Ongoing assessment
The patient


37. What is the formula for determining pack years?
A false - fixed belief that cannot be corrected through reasoning.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
# of packs per day x # of years smoked
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.


38. What is responsible for transporting O2 in the blood
Hemoglobin
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Abstract thinking
Focused


39. What scale is used to determine eating and feeding issues in adults with confusion
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
EdFED- Q
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
The process of storing - learning - retrieving - and using info.


40. What are the steps of the nursing process?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Having to use more than one pillow when sleeping
Decreased sense of taste
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation


41. Types of hearing loss include
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
To ID the problem
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Trend assessment (shift report)


42. Data validation assures
Trend assessment (shift report)
Risk of falls increases
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
The result is accurate patient dB


43. What is a component of the cognitive part of critical thinking skills?
Objective
Knowing What to do/how to make a decision based upon available data.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Medical


44. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Irregular respirations (fast/slow) often seen at end of life
Level of stress - risk for violence - anxiety level - patient unmet needs
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve


45. Kussamaul respirations describe

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46. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
A personal experience that does whatever the person in pain says it does
Fast and deep respirations seen in patient's with acidosis
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -


47. An infant is in which Paiget stage?
Stroke volume x's heart rate
Pain in legs assoc w walking
Irregular respirations (fast/slow) often seen at end of life
Sensory motor


48. At What age do you begin to use decision making?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
An 80 y/o patient that has emergency surgery
Adolescence
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.


49. Subjective data could include
Medical
Symptoms
Snap - crackle - pops; velcro - bubble wrap
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli


50. The purpose of an intitial assement serves to?
Having to use more than one pillow when sleeping
Assess over all health status and identify the problem
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Paradoxical reaction