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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. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Preschool is cause and effect - school age begins to use logical thought process.
Broncial (heard over trachea)
Pt's underlying feelings

2. A potential adverse rx of chemically restraining a confused patient would be
Broncial (heard over trachea)
Paradoxical reaction
Focused
ID'ing status of exisiting problems and locating new issues

3. What do rhonchi sound like?
Knowing What to do/how to make a decision based upon available data.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pt's with oxygenation and perfusion problems

4. 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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5. Sleep deprivation can effect
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Learning - memory and adaptation to stress
To ID the problem
Decision assessment

6. The assessment that includes the patient's overhall health status
Initial assessment
No
Fluid volume deficit related to poor intake
Disorganized thinking and altered LOC

7. Kussamaul respirations describe

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8. When speaking with a patient with moderate hearing loss the RN should
Irregular respirations (fast/slow) often seen at end of life
Disorganized thinking and altered LOC
Nursing
Communicate using hands and eyes.

9. Fluid volume deficit is a __________ dx
Having to use more than one pillow when sleeping
Maslow
Nursing
Secondary

10. Side effects of putting confused pts in restraints include
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Secondary soureces (family - friends)
Serves to expedite dx and tx of actual and potential health problems

11. Types of hearing loss include
Bacterial infection
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Tricuspid - mitral and the aortic

12. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Nursing dx
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain in legs assoc w walking

13. Ongoing assessments are useful in

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14. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Upper airways
The patient
The medication will not affect the patient's breathing.

15. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Bacterial infection
Hearing loss
To ID the problem

16. Nursing dx provides basis of
Interventions for which the nurse is accountable
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pt's with oxygenation and perfusion problems
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

17. Data that is recorded for an immediate need (code blue or fall) would be included in
Capillaries
Decision assessment
Broncial (heard over trachea)
Risk of falls increases

18. What would cause changes in congitive development later in life (middle adulthood)?
Secondary soureces (family - friends)
Trauma or illness
Irregular respirations (fast/slow) often seen at end of life
8.4

19. What does CAM stand for
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Confusion Assessment Method
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

20. Data from the last 24/48 hours that included patterns would be a part of
Pain in legs assoc w walking
Daily
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Trend assessment (shift report)

21. Data gathered via instrumention (pulse ox) is considered
Knowing What to do/how to make a decision based upon available data.
Objective
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Interventions for which the nurse is accountable

22. What do rales sound like?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Snap - crackle - pops; velcro - bubble wrap
Decision assessment

23. The purpose of an intitial assement serves to?
Hearing loss
Assess over all health status and identify the problem
Pt's with oxygenation and perfusion problems
Stroke volume x's heart rate

24. In Which part of the nursing process will you find delegation?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Disorganized thinking and altered LOC
To ID the problem
Implementation

25. What is the cognitive difference between a preschooler and schoolage child?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Medical
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Preschool is cause and effect - school age begins to use logical thought process.

26. What is the formula for cardiac output?

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27. What is a chochlear implant?
8.4
Risk of falls increases
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Serves to expedite dx and tx of actual and potential health problems

28. What is a component of the cognitive part of critical thinking skills?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
No
Symptoms
Knowing What to do/how to make a decision based upon available data.

29. What are Piaget's stages of cognitive development
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Daily
To simulate eating motions with the hands
Objective

30. Examples of personal information
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Hygeine - DOB - work hx
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Irregular respirations (fast/slow) often seen at end of life

31. The fifth vital sign is
Decreased sense of taste
Viral infection
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain

32. An ongoing assessment is performed
The medication will not affect the patient's breathing.
Interventions for which the nurse is accountable
Daily
Disorganized thinking and altered LOC

33. What are the ABCDE's of pain management?
An 80 y/o patient that has emergency surgery
School age childen
Ask - Believe - Choose - Deliver - Empower
Hearing loss

34. 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.
Level of stress - risk for violence - anxiety level - patient unmet needs
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Focused

35. Factors that may reduce the efficacy of pulse oximetry include
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Inattention and acute increase/decrease in cognitive function
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

36. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Hygeine - DOB - work hx

37. What is the purpose of the nursing process?
Disorganized thinking and altered LOC
Pt's with oxygenation and perfusion problems
Symptoms
Serves to expedite dx and tx of actual and potential health problems

38. What are Cheyne Stokes?
Abstract thinking
Irregular respirations (fast/slow) often seen at end of life
Level of stress - risk for violence - anxiety level - patient unmet needs
Medical

39. Two indicators that are REQUIRED for classification via the CAM tool include
Medical
Tricuspid - mitral and the aortic
Inattention and acute increase/decrease in cognitive function
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

40. Hypogeusis is
Objective
Adolescence
Decreased sense of taste
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

41. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Pt's underlying feelings
Maslow
Daily

42. A patient that is easily fatigued may have a HgB lab value of?
8.4
Secondary
Level of stress - risk for violence - anxiety level - patient unmet needs
Trend assessment (shift report)

43. Would a nursing dx be part of the primary or secondary dx?
To simulate eating motions with the hands
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Secondary
Tricuspid - mitral and the aortic

44. Expiration sounds are heard longer than inspiration In What area?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Maslow
Broncial (heard over trachea)
Implementation

45. What is intermittent claudication?
Ongoing assessment
Pain in legs assoc w walking
Inattention and acute increase/decrease in cognitive function
A personal experience that does whatever the person in pain says it does

46. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Having to use more than one pillow when sleeping
Abstract thinking
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

47. Subjective data could include
Symptoms
Decision assessment
Serves to expedite dx and tx of actual and potential health problems
Having to use more than one pillow when sleeping

48. What is pain?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
No
A personal experience that does whatever the person in pain says it does
Daily

49. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Tricuspid - mitral and the aortic
Edema
ID'ing status of exisiting problems and locating new issues

50. Orthopnea is described as?
Double check equip and patient
Symptoms
Hearing loss
Having to use more than one pillow when sleeping