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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. Where can you hear bronchovesicular breath sounds?
Symptoms
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Abstract thinking
Broncial (heard over trachea)

2. An ongoing assessment is performed
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Having to use more than one pillow when sleeping
Disorganized thinking and altered LOC
Daily

3. What factors may indicate plural rub?
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.
Irregular respirations (fast/slow) often seen at end of life
Pain on inspiration and expiration; superficial squeaking or grating

4. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
ID'ing status of exisiting problems and locating new issues

5. A patient that is easily fatigued may have a HgB lab value of?
Having to use more than one pillow when sleeping
Family - spouse - someone other than a healthcare worker - previous medical records.
Vesicular (peripheral lung areas)
8.4

6. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Disorganized thinking and altered LOC
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
The result is accurate patient dB
Level of stress - risk for violence - anxiety level - patient unmet needs

7. When a patient has increased lymphocytes - this may indicate what?
Interventions for which the nurse is accountable
Viral infection
Loss of taste
Upper airways

8. Sleep deprivation can effect
Risk of falls increases
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
ID'ing status of exisiting problems and locating new issues
Learning - memory and adaptation to stress

9. Data gathered via instrumention (pulse ox) is considered
Sensory motor
Focused
Pain on inspiration and expiration; superficial squeaking or grating
Objective

10. Factors that may reduce the efficacy of pulse oximetry include
# of packs per day x # of years smoked
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Pain
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

11. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Disorganized thinking and altered LOC
To simulate eating motions with the hands

12. What is responsible for transporting O2 in the blood
Viral infection
# of packs per day x # of years smoked
Hemoglobin
Bacterial infection

13. At What age do you begin to put thoughts into words?
Non - opiod (ex: NSAID/acetominaphen)
Toddler
A personal experience that does whatever the person in pain says it does
Nursing dx

14. Are changes in vital signs a reliable indicator of chronic pain?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Ongoing assessment
Objective
No

15. Kussamaul respirations describe

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16. What is cognition?
The process of storing - learning - retrieving - and using info.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Hearing loss
Double check equip and patient

17. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nurse
Upper airways
Hearing loss

18. All body system data is not necessary which type of assessment
Focused
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pain
Bacterial infection

19. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Loss of taste
The process of storing - learning - retrieving - and using info.
Decision assessment

20. The fifth vital sign is
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pain
Bacterial infection
Nurse

21. What do rhonchi sound like?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Decreased sense of taste
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Secondary soureces (family - friends)

22. Intermittent claudication is caused by?
Decreased arterial perfusion
An 80 y/o patient that has emergency surgery
Trend assessment (shift report)
Preschool is cause and effect - school age begins to use logical thought process.

23. Which patient would be most likely to experience sensory overload?
The medication will not affect the patient's breathing.
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
An 80 y/o patient that has emergency surgery

24. At What age do you begin to use decision making?
Symptoms
8.4
Adolescence
A false - fixed belief that cannot be corrected through reasoning.

25. The purpose of an intitial assement serves to?
Communicate using hands and eyes.
Assess over all health status and identify the problem
Upper airways
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

26. Name the 5 'W's' of assessing a change in LOC
Vesicular (peripheral lung areas)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
8.4
An 80 y/o patient that has emergency surgery

27. An example of a primary source is
Defining a baseline of cognitive function - any changes or deviations from norm.
Hearing loss
Tricuspid - mitral and the aortic
The patient

28. What is intermittent claudication?
Preschool is cause and effect - school age begins to use logical thought process.
Nursing dx
Pain in legs assoc w walking
Pt's underlying feelings

29. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Capillaries
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Nurse

30. The path of blood from the heart to the lungs is
Adolescence
Ask - Believe - Choose - Deliver - Empower
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Fast and deep respirations seen in patient's with acidosis

31. The purpose of an initial assessment is
Confusion Assessment Method
To ID the problem
Maslow
Non - opiod (ex: NSAID/acetominaphen)

32. At What age do you begin to use logical thought process?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decision assessment
The medication will not affect the patient's breathing.
School age childen

33. What is pain?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
To simulate eating motions with the hands
Stroke volume x's heart rate
A personal experience that does whatever the person in pain says it does

34. The assessment that includes the patient's overhall health status
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Wandering
Initial assessment
No

35. The basis for a plan of care comes for which stage of the nursing process?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Toddler
Sensory motor
Nursing dx

36. When a patient has increased neutrophils - this may indicate what?
Tricuspid - mitral and the aortic
Bacterial infection
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Symptoms

37. When speaking with a patient with moderate hearing loss the RN should
Symptoms
Irregular respirations (fast/slow) often seen at end of life
Non - opiod (ex: NSAID/acetominaphen)
Communicate using hands and eyes.

38. Other factors that may indicate confusion using the CAM tool could be
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Disorganized thinking and altered LOC
Toddler
Adolescence

39. Another term for a focused assessment is
Ongoing assessment
Viral infection
Daily
Capillaries

40. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Stroke volume x's heart rate
Pain

41. Diabetes is a _________ dx
The process of storing - learning - retrieving - and using info.
Medical
Loss of taste
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

42. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Secondary soureces (family - friends)
The patient
ID'ing status of exisiting problems and locating new issues
Non - opiod (ex: NSAID/acetominaphen)

43. When using restraints in a confused patient
Fast and deep respirations seen in patient's with acidosis
Disorganized thinking and altered LOC
A false - fixed belief that cannot be corrected through reasoning.
Risk of falls increases

44. Acceptable sources of assessment data when evaluating a confused patient would be
Capillaries
Secondary soureces (family - friends)
Nurse
Have them do simple math problems

45. Subjective data could include
Symptoms
Daily
Disorganized thinking and altered LOC
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

46. Examples of personal information
Non - opiod (ex: NSAID/acetominaphen)
Hygeine - DOB - work hx
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Implementation

47. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
The result is accurate patient dB
8.4
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

48. What is the difference between a nursing dx and a med dx?
Tricuspid - mitral and the aortic
Secondary soureces (family - friends)
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

49. What is the nursing process?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Hemoglobin
Symptoms

50. At patient that state their shoes are tighter at the end of the day may be experiencing
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain in legs assoc w walking
Edema
Confusion Assessment Method