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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. What is responsible for transporting O2 in the blood
Pt's underlying feelings
Fluid volume deficit related to poor intake
Decreased arterial perfusion
Hemoglobin

2. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Bacterial infection
Having to use more than one pillow when sleeping
Level of stress - risk for violence - anxiety level - patient unmet needs

3. What is a definition of a delusion?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
A false - fixed belief that cannot be corrected through reasoning.
Vesicular (peripheral lung areas)
Hearing loss

4. When a patient has increased neutrophils - this may indicate what?
Capillaries
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Bacterial infection
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

5. Orthopnea is described as?
Fluid volume deficit related to poor intake
Having to use more than one pillow when sleeping
Medical
Broncial (heard over trachea)

6. The site where gas exchange occurs is
Capillaries
Risk of falls increases
To simulate eating motions with the hands
Secondary soureces (family - friends)

7. Diabetes is a _________ dx
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 patient
Nursing dx
Medical

8. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Confusion Assessment Method
A personal experience that does whatever the person in pain says it does
Edema
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

9. An ongoing assessment is performed
Daily
Irregular respirations (fast/slow) often seen at end of life
Loss of taste
EdFED- Q

10. The assessment that includes the patient's overhall health status
Initial assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Objective

11. Would a nursing dx be part of the primary or secondary dx?
Secondary
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Trauma or illness
Immature immune system - structures close together lends to easy spreading from on area to another.

12. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

13. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Paradoxical reaction
Risk of falls increases
Decision assessment

14. What is the correct approach when dealing with older adults?
Ask - Believe - Choose - Deliver - Empower
Interventions for which the nurse is accountable
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pt's with oxygenation and perfusion problems

15. At What age do you begin to use decision making?
Learning - memory and adaptation to stress
Adolescence
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Serves to expedite dx and tx of actual and potential health problems

16. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Edema
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

17. An infant is in which Paiget stage?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Communicate using hands and eyes.
Sensory motor

18. A potential adverse rx of chemically restraining a confused patient would be
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Viral infection
Paradoxical reaction
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

19. At patient that state their shoes are tighter at the end of the day may be experiencing
Trend assessment (shift report)
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Communicate using hands and eyes.
Edema

20. Examples of personal information
Loss of taste
Pain in legs assoc w walking
Hygeine - DOB - work hx
Fluid volume deficit related to poor intake

21. Intermittent claudication is caused by?
Nursing dx
Fluid volume deficit related to poor intake
Decreased arterial perfusion
Knowing What to do/how to make a decision based upon available data.

22. What is a chochlear implant?
# of packs per day x # of years smoked
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pain
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

23. One way to test a person's cognitive ability and abstract thinking ability would be to
Pt's underlying feelings
Confusion Assessment Method
Have them do simple math problems
Data collection - data validation - data organization - data analysis - and data reporting/recording.

24. What does CAM stand for
Confusion Assessment Method
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Sensory motor

25. Where can you hear bronchovesicular breath sounds?
Edema
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Fluid volume deficit related to poor intake

26. What scale is used to determine eating and feeding issues in adults with confusion
Ongoing assessment
EdFED- Q
Paradoxical reaction
Immature immune system - structures close together lends to easy spreading from on area to another.

27. What is cognition?
The result is accurate patient dB
The process of storing - learning - retrieving - and using info.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Have them do simple math problems

28. The basis for a plan of care comes for which stage of the nursing process?
Decreased sense of taste
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nursing dx

29. Blood passes through the heart valves In what order?
To ID the problem
Symptoms
Tricuspid - mitral and the aortic
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

30. Hypogeusis is
Risk of falls increases
Interventions for which the nurse is accountable
Family - spouse - someone other than a healthcare worker - previous medical records.
Decreased sense of taste

31. What would cause changes in congitive development later in life (middle adulthood)?
Nursing dx
The process of storing - learning - retrieving - and using info.
Trauma or illness
Having to use more than one pillow when sleeping

32. An example of a secondary source is
Decreased arterial perfusion
The patient
Family - spouse - someone other than a healthcare worker - previous medical records.
Hemoglobin

33. What is the formula for cardiac output?

34. Fluid volume deficit is a __________ dx
Pain in legs assoc w walking
Nursing
# of packs per day x # of years smoked
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

35. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Defining a baseline of cognitive function - any changes or deviations from norm.
Immature immune system - structures close together lends to easy spreading from on area to another.
Trend assessment (shift report)

36. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
EdFED- Q
Family - spouse - someone other than a healthcare worker - previous medical records.
Secondary

37. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Pain on inspiration and expiration; superficial squeaking or grating
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Learning - memory and adaptation to stress

38. QUESTT is a tool for What type of an assessment?
Pain
Hemoglobin
Paradoxical reaction
Tricuspid - mitral and the aortic

39. Ongoing assessments are useful in

40. Name the 5 'W's' of assessing a change in LOC
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
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
A false - fixed belief that cannot be corrected through reasoning.

41. What is pain?
Sensory motor
A personal experience that does whatever the person in pain says it does
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

42. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Focused
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Hygeine - DOB - work hx

43. What is the purpose of the nursing process?
Initial assessment
Serves to expedite dx and tx of actual and potential health problems
Interventions for which the nurse is accountable
Trauma or illness

44. The fifth vital sign is
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
An 80 y/o patient that has emergency surgery
Pain

45. At What age do you begin to use logical thought process?
Maslow
Defining a baseline of cognitive function - any changes or deviations from norm.
The medication will not affect the patient's breathing.
School age childen

46. Data validation assures
The result is accurate patient dB
Implementation
Objective
Assess over all health status and identify the problem

47. What is the difference between a nursing dx and a med dx?
Edema
The patient
Preschool is cause and effect - school age begins to use logical thought process.
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

48. A patient that is easily fatigued may have a HgB lab value of?
Nurse
8.4
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Adolescence

49. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
A personal experience that does whatever the person in pain says it does
Abstract thinking
Pain in legs assoc w walking

50. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Decision assessment
The result is accurate patient dB
Non - opiod (ex: NSAID/acetominaphen)