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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 factors may indicate plural rub?
School age childen
Ongoing assessment
Tricuspid - mitral and the aortic
Pain on inspiration and expiration; superficial squeaking or grating

2. When a patient has increased neutrophils - this may indicate what?
Initial assessment
Bacterial infection
Decreased sense of taste
Focused

3. Examples of personal information
A personal experience that does whatever the person in pain says it does
Focused
Communicate using hands and eyes.
Hygeine - DOB - work hx

4. What is pain?
Capillaries
School age childen
Pt's with oxygenation and perfusion problems
A personal experience that does whatever the person in pain says it does

5. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Irregular respirations (fast/slow) often seen at end of life
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain
Nurse

6. What are the steps of the nursing process?
Level of stress - risk for violence - anxiety level - patient unmet needs
Having to use more than one pillow when sleeping
To ID the problem
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

7. Data validation assures
A false - fixed belief that cannot be corrected through reasoning.
Loss of taste
Interventions for which the nurse is accountable
The result is accurate patient dB

8. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
Decreased sense of taste
Pt's underlying feelings
EdFED- Q

9. Nursing dx provides basis of
Interventions for which the nurse is accountable
Pt's with oxygenation and perfusion problems
Preschool is cause and effect - school age begins to use logical thought process.
Inattention and acute increase/decrease in cognitive function

10. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Viral infection
Pain on inspiration and expiration; superficial squeaking or grating
Paradoxical reaction

11. What is responsible for transporting O2 in the blood
Knowing What to do/how to make a decision based upon available data.
Hemoglobin
Initial assessment
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

12. What are Piaget's stages of cognitive development
The medication will not affect the patient's breathing.
Decision assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Trauma or illness

13. If an abnormal finding is revealed during assessment - the nurse should
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Initial assessment
Loss of taste
Double check equip and patient

14. An example of a primary source is
Pain
Communicate using hands and eyes.
Fluid volume deficit related to poor intake
The patient

15. In Which part of the nursing process will you find delegation?
Implementation
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sensory motor
Pain in legs assoc w walking

16. What is the correct approach when dealing with older adults?
Upper airways
To simulate eating motions with the hands
Fluid volume deficit related to poor intake
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

17. The site where gas exchange occurs is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Inattention and acute increase/decrease in cognitive function
Vesicular (peripheral lung areas)
Capillaries

18. What do rhonchi sound like?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Symptoms
Trauma or illness

19. ABG's would be an important lab value for What types of patient's?

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20. Describe the purpose of a mental status exam
No
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Defining a baseline of cognitive function - any changes or deviations from norm.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

21. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Decision assessment
Daily
Confusion Assessment Method

22. At What age do you begin to use logical thought process?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
School age childen
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
The process of storing - learning - retrieving - and using info.

23. What is the formula for cardiac output?

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24. What is a component of the cognitive part of critical thinking skills?
Pain in legs assoc w walking
Knowing What to do/how to make a decision based upon available data.
Wandering
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

25. Subjective data could include
Pain on inspiration and expiration; superficial squeaking or grating
Symptoms
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Family - spouse - someone other than a healthcare worker - previous medical records.

26. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Preschool is cause and effect - school age begins to use logical thought process.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Data collection - data validation - data organization - data analysis - and data reporting/recording.

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

28. At What age do you begin to use decision making?
Pt's with oxygenation and perfusion problems
Adolescence
Vesicular (peripheral lung areas)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

29. What does CAM stand for
Broncial (heard over trachea)
Capillaries
Confusion Assessment Method
Family - spouse - someone other than a healthcare worker - previous medical records.

30. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
School age childen
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Adolescence

31. Where can you hear bronchovesicular breath sounds?
Serves to expedite dx and tx of actual and potential health problems
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nursing dx
No

32. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Family - spouse - someone other than a healthcare worker - previous medical records.
Wandering
ID'ing status of exisiting problems and locating new issues
Implementation

33. What is cognition?
Inattention and acute increase/decrease in cognitive function
The process of storing - learning - retrieving - and using info.
Irregular respirations (fast/slow) often seen at end of life
Hygeine - DOB - work hx

34. A potential adverse rx of chemically restraining a confused patient would be
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Paradoxical reaction
Confusion Assessment Method
Knowing What to do/how to make a decision based upon available data.

35. Acceptable sources of assessment data when evaluating a confused patient would be
EdFED- Q
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
To ID the problem
Secondary soureces (family - friends)

36. Another term for a focused assessment is
Ongoing assessment
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Daily
Preschool is cause and effect - school age begins to use logical thought process.

37. Hypogeusis is
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Implementation
Tricuspid - mitral and the aortic
Decreased sense of taste

38. An example of a nursing dx would be
Snap - crackle - pops; velcro - bubble wrap
Fluid volume deficit related to poor intake
Edema
Preschool is cause and effect - school age begins to use logical thought process.

39. Blood passes through the heart valves In what order?
Objective
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Tricuspid - mitral and the aortic
Decision assessment

40. One way to test a person's cognitive ability and abstract thinking ability would be to
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Have them do simple math problems
Fluid volume deficit related to poor intake
Double check equip and patient

41. What do rales sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Family - spouse - someone other than a healthcare worker - previous medical records.
Snap - crackle - pops; velcro - bubble wrap
Edema

42. Factors that may reduce the efficacy of pulse oximetry include
Double check equip and patient
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Capillaries
Edema

43. What is the cognitive difference between a preschooler and schoolage child?
Objective
Symptoms
Viral infection
Preschool is cause and effect - school age begins to use logical thought process.

44. Side effects of putting confused pts in restraints include
Toddler
Pt's underlying feelings
Risk of falls increases
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

45. 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.
Vesicular (peripheral lung areas)
Paradoxical reaction
Preschool is cause and effect - school age begins to use logical thought process.

46. What is the nursing process?
Risk of falls increases
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Decision assessment

47. Orthopnea is described as?
Having to use more than one pillow when sleeping
Serves to expedite dx and tx of actual and potential health problems
Pt's with oxygenation and perfusion problems
Sensory motor

48. A patient that is easily fatigued may have a HgB lab value of?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
8.4
Fast and deep respirations seen in patient's with acidosis
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

49. When using restraints in a confused patient
Hemoglobin
Risk of falls increases
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Family - spouse - someone other than a healthcare worker - previous medical records.

50. Diabetes is a _________ dx
Medical
Snap - crackle - pops; velcro - bubble wrap
Interventions for which the nurse is accountable
Nurse