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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 site where gas exchange occurs is
An 80 y/o patient that has emergency surgery
To simulate eating motions with the hands
Capillaries
Trauma or illness

2. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Decreased sense of taste
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Pain on inspiration and expiration; superficial squeaking or grating

3. What are the components of a mental status exam that are not part of a regular assessment?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Fast and deep respirations seen in patient's with acidosis
Vesicular (peripheral lung areas)
Ask - Believe - Choose - Deliver - Empower

4. What factors may indicate plural rub?
Decision assessment
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Daily
Pain on inspiration and expiration; superficial squeaking or grating

5. An example of a primary source is
The patient
Family - spouse - someone other than a healthcare worker - previous medical records.
The medication will not affect the patient's breathing.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

6. The order of air flow into the lungs is
Learning - memory and adaptation to stress
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Objective
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

7. Kussamaul respirations describe

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8. Side effects of putting confused pts in restraints include
Loss of taste
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The result is accurate patient dB
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

9. In Which part of the nursing process will you find delegation?
A personal experience that does whatever the person in pain says it does
Loss of taste
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Implementation

10. What is cognition?
Having to use more than one pillow when sleeping
The process of storing - learning - retrieving - and using info.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain

11. What is a definition of a delusion?
Pain
A false - fixed belief that cannot be corrected through reasoning.
Risk of falls increases
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

12. What is intermittent claudication?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Family - spouse - someone other than a healthcare worker - previous medical records.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Pain in legs assoc w walking

13. Why are young children at greater risk for respiratory infection?
Trauma or illness
Confusion Assessment Method
An 80 y/o patient that has emergency surgery
Immature immune system - structures close together lends to easy spreading from on area to another.

14. Acceptable sources of assessment data when evaluating a confused patient would be
Medical
Secondary soureces (family - friends)
Confusion Assessment Method
To ID the problem

15. The purpose of an intitial assement serves to?
Nursing
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Assess over all health status and identify the problem
Communicate using hands and eyes.

16. The path of blood from the lungs to the heart is
A personal experience that does whatever the person in pain says it does
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Vesicular (peripheral lung areas)

17. Data validation assures
The result is accurate patient dB
Nursing dx
Pain on inspiration and expiration; superficial squeaking or grating
Have them do simple math problems

18. Subjective data could include
Viral infection
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Having to use more than one pillow when sleeping
Symptoms

19. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Learning - memory and adaptation to stress
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

20. What do rhonchi sound like?
Pt's with oxygenation and perfusion problems
Disorganized thinking and altered LOC
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Decision assessment

21. The basis for a plan of care comes for which stage of the nursing process?
Wandering
# of packs per day x # of years smoked
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nursing dx

22. What are the steps of the nursing process?
Preschool is cause and effect - school age begins to use logical thought process.
Snap - crackle - pops; velcro - bubble wrap
Irregular respirations (fast/slow) often seen at end of life
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

23. What are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Have them do simple math problems
Assess over all health status and identify the problem
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

24. Where can you hear bronchovesicular breath sounds?
Immature immune system - structures close together lends to easy spreading from on area to another.
Hearing loss
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Bacterial infection

25. Examples of personal information
A false - fixed belief that cannot be corrected through reasoning.
Symptoms
Serves to expedite dx and tx of actual and potential health problems
Hygeine - DOB - work hx

26. Ageusia is
Pain on inspiration and expiration; superficial squeaking or grating
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Loss of taste

27. Expiration sounds are heard longer than inspiration In What area?
Abstract thinking
Bacterial infection
Broncial (heard over trachea)
Non - opiod (ex: NSAID/acetominaphen)

28. What scale is used to determine eating and feeding issues in adults with confusion
Edema
EdFED- Q
Tricuspid - mitral and the aortic
Snap - crackle - pops; velcro - bubble wrap

29. Blood passes through the heart valves In what order?
Tricuspid - mitral and the aortic
Vesicular (peripheral lung areas)
Pt's underlying feelings
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

30. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Sensory motor
Risk of falls increases
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

31. What do rales sound like?
Knowing What to do/how to make a decision based upon available data.
Fast and deep respirations seen in patient's with acidosis
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Snap - crackle - pops; velcro - bubble wrap

32. An ongoing assessment is performed
Preschool is cause and effect - school age begins to use logical thought process.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Daily
Symptoms

33. At What age do you begin to use decision making?
Non - opiod (ex: NSAID/acetominaphen)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Adolescence
Objective

34. Types of hearing loss include
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Edema
Risk of falls increases
Irregular respirations (fast/slow) often seen at end of life

35. What is a component of the cognitive part of critical thinking skills?
Hemoglobin
Secondary soureces (family - friends)
Knowing What to do/how to make a decision based upon available data.
The result is accurate patient dB

36. QUESTT is a tool for What type of an assessment?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pain
Nursing dx
Nurse

37. Another term for a focused assessment is
Inattention and acute increase/decrease in cognitive function
Ongoing assessment
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
To ID the problem

38. A nursing dx is best described as
Secondary soureces (family - friends)
A personal experience that does whatever the person in pain says it does
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Decreased sense of taste

39. When a patient has increased neutrophils - this may indicate what?
Risk of falls increases
Bacterial infection
Loss of taste
The process of storing - learning - retrieving - and using info.

40. The fifth vital sign is
Pain
Tricuspid - mitral and the aortic
Symptoms
Initial assessment

41. What is the cognitive difference between a preschooler and schoolage child?
Abstract thinking
Snap - crackle - pops; velcro - bubble wrap
Symptoms
Preschool is cause and effect - school age begins to use logical thought process.

42. 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)
Trauma or illness
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Edema

43. What is the correct approach when dealing with older adults?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
An 80 y/o patient that has emergency surgery
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

44. When noticing a patient with dementia has stopped eating - the RN's first response is?
Sensory motor
To simulate eating motions with the hands
Symptoms
Trauma or illness

45. Intermittent claudication is caused by?
Decreased arterial perfusion
Symptoms
Fast and deep respirations seen in patient's with acidosis
The process of storing - learning - retrieving - and using info.

46. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Interventions for which the nurse is accountable
Non - opiod (ex: NSAID/acetominaphen)
Decision assessment
Symptoms

47. What are Cheyne Stokes?
Paradoxical reaction
Irregular respirations (fast/slow) often seen at end of life
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pt's underlying feelings

48. The assessment that includes the patient's overhall health status
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Initial assessment
The result is accurate patient dB
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

49. What is pain?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
A personal experience that does whatever the person in pain says it does
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Tricuspid - mitral and the aortic

50. Two indicators that are REQUIRED for classification via the CAM tool include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Focused
Irregular respirations (fast/slow) often seen at end of life
Inattention and acute increase/decrease in cognitive function