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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. Data gathered via instrumention (pulse ox) is considered
Decreased arterial perfusion
Irregular respirations (fast/slow) often seen at end of life
Objective
Preschool is cause and effect - school age begins to use logical thought process.

2. Kussamaul respirations describe

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3. Would a nursing dx be part of the primary or secondary dx?
Adolescence
Secondary
Pain
Immature immune system - structures close together lends to easy spreading from on area to another.

4. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
The process of storing - learning - retrieving - and using info.
Level of stress - risk for violence - anxiety level - patient unmet needs
Decreased arterial perfusion
Hemoglobin

5. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Pt's with oxygenation and perfusion problems
Initial assessment
Family - spouse - someone other than a healthcare worker - previous medical records.

6. All body system data is not necessary which type of assessment
The result is accurate patient dB
Double check equip and patient
Focused
Pain on inspiration and expiration; superficial squeaking or grating

7. What factors may indicate plural rub?
Vesicular (peripheral lung areas)
Trend assessment (shift report)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pain on inspiration and expiration; superficial squeaking or grating

8. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pain in legs assoc w walking
Irregular respirations (fast/slow) often seen at end of life
The result is accurate patient dB

9. 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.
Disorganized thinking and altered LOC
Defining a baseline of cognitive function - any changes or deviations from norm.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

10. Types of hearing loss include
Objective
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Decreased sense of taste
Hearing loss

11. What are Cheyne Stokes?
Serves to expedite dx and tx of actual and potential health problems
Level of stress - risk for violence - anxiety level - patient unmet needs
Irregular respirations (fast/slow) often seen at end of life
Fluid volume deficit related to poor intake

12. What are Piaget's stages of cognitive development
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Snap - crackle - pops; velcro - bubble wrap
Maslow

13. The site where gas exchange occurs is
Capillaries
Objective
To simulate eating motions with the hands
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

14. What is a definition of a delusion?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
A false - fixed belief that cannot be corrected through reasoning.
Maslow
Fluid volume deficit related to poor intake

15. Ongoing assessments are useful in

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16. Describe the purpose of a mental status exam
EdFED- Q
Capillaries
Sensory motor
Defining a baseline of cognitive function - any changes or deviations from norm.

17. Inspiration sounds are heard longer than expiration sounds In What area?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Wandering
Capillaries
Vesicular (peripheral lung areas)

18. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Implementation
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Abstract thinking

19. Sleep deprivation can effect
Learning - memory and adaptation to stress
To simulate eating motions with the hands
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Have them do simple math problems

20. What is the formula for cardiac output?

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21. Other factors that may indicate confusion using the CAM tool could be
Fast and deep respirations seen in patient's with acidosis
Disorganized thinking and altered LOC
Vesicular (peripheral lung areas)
8.4

22. When dealing with a confused patient - should the nurse acknowledge the patient's underlying feelings or the content of the delusion?

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23. What is pain?
A personal experience that does whatever the person in pain says it does
Nurse
Ongoing assessment
The patient

24. An ongoing assessment is performed
Interventions for which the nurse is accountable
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Immature immune system - structures close together lends to easy spreading from on area to another.
Daily

25. One way to test a person's cognitive ability and abstract thinking ability would be to
Wandering
Initial assessment
Have them do simple math problems
Family - spouse - someone other than a healthcare worker - previous medical records.

26. Subjective data could include
Trauma or illness
Symptoms
Abstract thinking
Immature immune system - structures close together lends to easy spreading from on area to another.

27. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Preschool is cause and effect - school age begins to use logical thought process.
Hemoglobin
Communicate using hands and eyes.

28. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Level of stress - risk for violence - anxiety level - patient unmet needs
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

29. What is responsible for transporting O2 in the blood
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Hemoglobin
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nursing

30. Diabetes is a _________ dx
Communicate using hands and eyes.
Medical
Secondary soureces (family - friends)
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

31. The purpose of an initial assessment is
Capillaries
The process of storing - learning - retrieving - and using info.
ID'ing status of exisiting problems and locating new issues
To ID the problem

32. 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
Disorganized thinking and altered LOC
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Capillaries

33. Examples of personal information
Hygeine - DOB - work hx
Learning - memory and adaptation to stress
Stroke volume x's heart rate
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

34. What is the correct approach when dealing with older adults?
Capillaries
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Risk of falls increases
Assess over all health status and identify the problem

35. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Maslow
Bacterial infection
Toddler
Nurse

36. What is a chochlear implant?
# of packs per day x # of years smoked
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Non - opiod (ex: NSAID/acetominaphen)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

37. Data validation assures
The process of storing - learning - retrieving - and using info.
Upper airways
The result is accurate patient dB
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

38. At What age do you begin to use logical thought process?
Focused
School age childen
Decreased arterial perfusion
Pt's underlying feelings

39. The path of blood from the heart to the lungs is
Symptoms
Hearing loss
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

40. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Secondary
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Implementation

41. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Communicate using hands and eyes.
Hearing loss
Ask - Believe - Choose - Deliver - Empower
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

42. What is cognition?
The process of storing - learning - retrieving - and using info.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Decreased arterial perfusion
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

43. Nursing dx provides basis of
Interventions for which the nurse is accountable
The patient
Decision assessment
Communicate using hands and eyes.

44. Which patient would be most likely to experience sensory overload?
Disorganized thinking and altered LOC
An 80 y/o patient that has emergency surgery
Nursing dx
Hemoglobin

45. Nursing interventions should be based on who's theory?
Double check equip and patient
Maslow
Snap - crackle - pops; velcro - bubble wrap
Pain in legs assoc w walking

46. Data from the last 24/48 hours that included patterns would be a part of
Fluid volume deficit related to poor intake
Pt's with oxygenation and perfusion problems
Trend assessment (shift report)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

47. QUESTT is a tool for What type of an assessment?
Fluid volume deficit related to poor intake
Snap - crackle - pops; velcro - bubble wrap
Decreased sense of taste
Pain

48. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Level of stress - risk for violence - anxiety level - patient unmet needs
Pain in legs assoc w walking
Wandering
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

49. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Vesicular (peripheral lung areas)
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Fast and deep respirations seen in patient's with acidosis
Non - opiod (ex: NSAID/acetominaphen)

50. The assessment that includes the patient's overhall health status
Nursing
School age childen
Risk of falls increases
Initial assessment