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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. 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
Pt's with oxygenation and perfusion problems
Focused
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

2. Acceptable sources of assessment data when evaluating a confused patient would be
To simulate eating motions with the hands
Secondary soureces (family - friends)
Pt's underlying feelings
Objective

3. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Loss of taste
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

4. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Confusion Assessment Method
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Have them do simple math problems

5. What is intermittent claudication?
Capillaries
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Learning - memory and adaptation to stress
Pain in legs assoc w walking

6. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
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
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

7. Blood passes through the heart valves In what order?
Having to use more than one pillow when sleeping
Paradoxical reaction
Tricuspid - mitral and the aortic
Ongoing assessment

8. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Pain in legs assoc w walking
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Paradoxical reaction

9. What is the formula for cardiac output?

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10. What are Piaget's stages of cognitive development
Adolescence
A personal experience that does whatever the person in pain says it does
Interventions for which the nurse is accountable
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

11. What is a definition of a delusion?
To ID the problem
No
A false - fixed belief that cannot be corrected through reasoning.
Viral infection

12. An example of a secondary source is
Nursing
To simulate eating motions with the hands
Family - spouse - someone other than a healthcare worker - previous medical records.
Serves to expedite dx and tx of actual and potential health problems

13. What is the formula for determining pack years?
A false - fixed belief that cannot be corrected through reasoning.
The patient
Decreased sense of taste
# of packs per day x # of years smoked

14. Would a nursing dx be part of the primary or secondary dx?
Family - spouse - someone other than a healthcare worker - previous medical records.
Secondary
Pain in legs assoc w walking
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

15. The purpose of an initial assessment is
To ID the problem
Immature immune system - structures close together lends to easy spreading from on area to another.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
8.4

16. What is the difference between a nursing dx and a med dx?
ID'ing status of exisiting problems and locating new issues
The result is accurate patient dB
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

17. A patient that is easily fatigued may have a HgB lab value of?
An 80 y/o patient that has emergency surgery
Pain
8.4
Implementation

18. What do rales sound like?
Defining a baseline of cognitive function - any changes or deviations from norm.
Immature immune system - structures close together lends to easy spreading from on area to another.
Snap - crackle - pops; velcro - bubble wrap
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

19. At What age do you begin to use logical thought process?
Knowing What to do/how to make a decision based upon available data.
School age childen
Edema
Interventions for which the nurse is accountable

20. What factors may indicate plural rub?
Nursing
Pain on inspiration and expiration; superficial squeaking or grating
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
To simulate eating motions with the hands

21. Fluid volume deficit is a __________ dx
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Loss of taste
Nurse
Nursing

22. If an abnormal finding is revealed during assessment - the nurse should
# of packs per day x # of years smoked
Bacterial infection
EdFED- Q
Double check equip and patient

23. When using restraints in a confused patient
Sensory motor
Loss of taste
Risk of falls increases
Bacterial infection

24. The site where gas exchange occurs is
Capillaries
Implementation
Ask - Believe - Choose - Deliver - Empower
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

25. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ask - Believe - Choose - Deliver - Empower
Pt's underlying feelings
The patient

26. An example of a primary source is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Nursing dx
The patient
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

27. Examples of personal information
Trend assessment (shift report)
Fluid volume deficit related to poor intake
Hygeine - DOB - work hx
Viral infection

28. Two indicators that are REQUIRED for classification via the CAM tool include
EdFED- Q
Double check equip and patient
Pain on inspiration and expiration; superficial squeaking or grating
Inattention and acute increase/decrease in cognitive function

29. Where can you hear bronchovesicular breath sounds?
Immature immune system - structures close together lends to easy spreading from on area to another.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
No
Toddler

30. QUESTT is a tool for What type of an assessment?
Inattention and acute increase/decrease in cognitive function
Wandering
Daily
Pain

31. Nursing interventions should be based on who's theory?
Bacterial infection
Maslow
Interventions for which the nurse is accountable
Data collection - data validation - data organization - data analysis - and data reporting/recording.

32. What is a chochlear implant?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Initial assessment
Viral infection
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

33. Data that is recorded for an immediate need (code blue or fall) would be included in
Nursing dx
Irregular respirations (fast/slow) often seen at end of life
Decision assessment
Serves to expedite dx and tx of actual and potential health problems

34. Diabetes is a _________ dx
Medical
Pain in legs assoc w walking
Snap - crackle - pops; velcro - bubble wrap
Secondary soureces (family - friends)

35. What is the nursing process?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Confusion Assessment Method
Having to use more than one pillow when sleeping

36. What do rhonchi sound like?
Symptoms
Stroke volume x's heart rate
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Upper airways

37. What is pain?
Hemoglobin
A personal experience that does whatever the person in pain says it does
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Secondary

38. 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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39. Data from the last 24/48 hours that included patterns would be a part of
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Implementation
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Trend assessment (shift report)

40. The path of blood from the lungs to the heart is
# of packs per day x # of years smoked
Knowing What to do/how to make a decision based upon available data.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Family - spouse - someone other than a healthcare worker - previous medical records.

41. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Hemoglobin
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
A false - fixed belief that cannot be corrected through reasoning.

42. What scale is used to determine eating and feeding issues in adults with confusion
Trend assessment (shift report)
EdFED- Q
Irregular respirations (fast/slow) often seen at end of life
Nursing

43. What are the components of an assessment?
Pain in legs assoc w walking
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Nurse

44. A potential adverse rx of chemically restraining a confused patient would 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)
Communicate using hands and eyes.
Interventions for which the nurse is accountable
Paradoxical reaction

45. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
The result is accurate patient dB
To simulate eating motions with the hands
Symptoms
Non - opiod (ex: NSAID/acetominaphen)

46. An ongoing assessment is performed
Daily
Secondary
Snap - crackle - pops; velcro - bubble wrap
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

47. Sleep deprivation can effect
ID'ing status of exisiting problems and locating new issues
8.4
Nursing dx
Learning - memory and adaptation to stress

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

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49. Other factors that may indicate confusion using the CAM tool could be
Fast and deep respirations seen in patient's with acidosis
Disorganized thinking and altered LOC
Learning - memory and adaptation to stress
Edema

50. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Defining a baseline of cognitive function - any changes or deviations from norm.
Pain on inspiration and expiration; superficial squeaking or grating
Adolescence