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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. If an abnormal finding is revealed during assessment - the nurse should
Implementation
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Double check equip and patient
8.4

2. The assessment that includes the patient's overhall health status
Maslow
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Initial assessment
Capillaries

3. An example of a nursing dx would be
Family - spouse - someone other than a healthcare worker - previous medical records.
Initial assessment
Fluid volume deficit related to poor intake
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

4. An infant is in which Paiget stage?
Double check equip and patient
Sensory motor
Preschool is cause and effect - school age begins to use logical thought process.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

5. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Inattention and acute increase/decrease in cognitive function
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Adolescence

6. What do rales sound like?
Hearing loss
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Snap - crackle - pops; velcro - bubble wrap

7. Other factors that may indicate confusion using the CAM tool could be
Initial assessment
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Disorganized thinking and altered LOC
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

8. Side effects of putting confused pts in restraints include
Learning - memory and adaptation to stress
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Secondary
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

9. When speaking with a patient with moderate hearing loss the RN should
Toddler
Fast and deep respirations seen in patient's with acidosis
Communicate using hands and eyes.
The patient

10. At patient that state their shoes are tighter at the end of the day may be experiencing
Daily
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Edema
Symptoms

11. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Adolescence
Decreased sense of taste
The medication will not affect the patient's breathing.

12. Examples of personal information
Risk of falls increases
Assess over all health status and identify the problem
Hygeine - DOB - work hx
Pt's with oxygenation and perfusion problems

13. Nursing interventions should be based on who's theory?
Abstract thinking
EdFED- Q
Maslow
Hygeine - DOB - work hx

14. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Learning - memory and adaptation to stress

15. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
To ID the problem
Nursing
Stroke volume x's heart rate

16. Hypogeusis is
ID'ing status of exisiting problems and locating new issues
Viral infection
Decreased sense of taste
Stroke volume x's heart rate

17. At What age do you begin to put thoughts into words?
Toddler
Hemoglobin
Upper airways
Irregular respirations (fast/slow) often seen at end of life

18. When a patient has increased neutrophils - this may indicate what?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Bacterial infection
Initial assessment
Hygeine - DOB - work hx

19. What is the formula for determining pack years?
Wandering
# of packs per day x # of years smoked
EdFED- Q
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

20. Expiration sounds are heard longer than inspiration In What area?
Edema
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Immature immune system - structures close together lends to easy spreading from on area to another.
Broncial (heard over trachea)

21. A nursing dx is best described as
Knowing What to do/how to make a decision based upon available data.
EdFED- Q
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Loss of taste

22. All body system data is not necessary which type of assessment
Wandering
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain on inspiration and expiration; superficial squeaking or grating
Focused

23. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Decreased sense of taste
Hearing loss

24. Data validation assures
The result is accurate patient dB
Viral infection
Broncial (heard over trachea)
Having to use more than one pillow when sleeping

25. An example of a secondary source is
Double check equip and patient
School age childen
Family - spouse - someone other than a healthcare worker - previous medical records.
Disorganized thinking and altered LOC

26. 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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27. Data from the last 24/48 hours that included patterns would be a part of
Communicate using hands and eyes.
Risk of falls increases
Trend assessment (shift report)
Immature immune system - structures close together lends to easy spreading from on area to another.

28. An ongoing assessment is performed
Double check equip and patient
Family - spouse - someone other than a healthcare worker - previous medical records.
The process of storing - learning - retrieving - and using info.
Daily

29. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Abstract thinking
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Paradoxical reaction
To simulate eating motions with the hands

30. Types of hearing loss include
To simulate eating motions with the hands
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Decision assessment
Decreased arterial perfusion

31. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Edema
Hearing loss
A false - fixed belief that cannot be corrected through reasoning.

32. 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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33. Where can you hear bronchovesicular breath sounds?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Broncial (heard over trachea)
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

34. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Risk of falls increases
# of packs per day x # of years smoked
To ID the problem

35. Kussamaul respirations describe

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36. What is a definition of a delusion?
Ongoing assessment
8.4
A false - fixed belief that cannot be corrected through reasoning.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

37. At What age do you begin to use decision making?
Confusion Assessment Method
Immature immune system - structures close together lends to easy spreading from on area to another.
Trend assessment (shift report)
Adolescence

38. An example of a primary source is
Toddler
The patient
Nurse
Initial assessment

39. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Level of stress - risk for violence - anxiety level - patient unmet needs
Hemoglobin
Secondary soureces (family - friends)

40. A patient that is easily fatigued may have a HgB lab value of?
Broncial (heard over trachea)
Family - spouse - someone other than a healthcare worker - previous medical records.
8.4
Level of stress - risk for violence - anxiety level - patient unmet needs

41. QUESTT is a tool for What type of an assessment?
# of packs per day x # of years smoked
Nurse
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pain

42. The purpose of an initial assessment is
The patient
Edema
Sensory motor
To ID the problem

43. What are Piaget's stages of cognitive development
Knowing What to do/how to make a decision based upon available data.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Fluid volume deficit related to poor intake
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

44. One way to test a person's cognitive ability and abstract thinking ability would be to
Having to use more than one pillow when sleeping
Implementation
Nursing
Have them do simple math problems

45. Factors that may reduce the efficacy of pulse oximetry include
Maslow
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Defining a baseline of cognitive function - any changes or deviations from norm.

46. Orthopnea is described as?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Level of stress - risk for violence - anxiety level - patient unmet needs
Having to use more than one pillow when sleeping
Pt's underlying feelings

47. What is intermittent claudication?
Learning - memory and adaptation to stress
Hygeine - DOB - work hx
Pain in legs assoc w walking
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

48. Nursing dx provides basis of
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Interventions for which the nurse is accountable
Adolescence
Loss of taste

49. Would a nursing dx be part of the primary or secondary dx?
Interventions for which the nurse is accountable
Secondary
Family - spouse - someone other than a healthcare worker - previous medical records.
8.4

50. Are changes in vital signs a reliable indicator of chronic pain?
Sensory motor
Family - spouse - someone other than a healthcare worker - previous medical records.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
No