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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 are the components of an assessment?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Maslow
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

2. What are the ABCDE's of pain management?
Decreased arterial perfusion
Fluid volume deficit related to poor intake
Ask - Believe - Choose - Deliver - Empower
Nursing

3. 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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4. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
EdFED- Q
Wandering
Secondary soureces (family - friends)
Hemoglobin

5. Orthopnea is described as?
Having to use more than one pillow when sleeping
A personal experience that does whatever the person in pain says it does
Vesicular (peripheral lung areas)
Pain in legs assoc w walking

6. What are the steps of the nursing process?
The medication will not affect the patient's breathing.
Confusion Assessment Method
Communicate using hands and eyes.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

7. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to 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)
Medical
Having to use more than one pillow when sleeping
Level of stress - risk for violence - anxiety level - patient unmet needs

8. At What age do you begin to put thoughts into words?
Toddler
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Communicate using hands and eyes.
Stroke volume x's heart rate

9. What is the formula for determining pack years?
# of packs per day x # of years smoked
Have them do simple math problems
Hearing loss
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

10. What is a component of the cognitive part of critical thinking skills?
Learning - memory and adaptation to stress
Hearing loss
Knowing What to do/how to make a decision based upon available data.
Loss of taste

11. Factors that may reduce the efficacy of pulse oximetry include
Having to use more than one pillow when sleeping
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Daily

12. What is the correct approach when dealing with older adults?
Knowing What to do/how to make a decision based upon available data.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

13. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
The medication will not affect the patient's breathing.
No
Fluid volume deficit related to poor intake

14. 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
An 80 y/o patient that has emergency surgery
Toddler
Viral infection

15. What is the difference between a nursing dx and a med dx?
Inattention and acute increase/decrease in cognitive function
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

16. Acceptable sources of assessment data when evaluating a confused patient would be
Pain
ID'ing status of exisiting problems and locating new issues
Secondary soureces (family - friends)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

17. What does CAM stand for
No
Serves to expedite dx and tx of actual and potential health problems
Symptoms
Confusion Assessment Method

18. 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
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Stroke volume x's heart rate

19. Fluid volume deficit is a __________ dx
Non - opiod (ex: NSAID/acetominaphen)
Stroke volume x's heart rate
Viral infection
Nursing

20. When a patient has increased neutrophils - this may indicate what?
Nursing dx
Bacterial infection
Irregular respirations (fast/slow) often seen at end of life
Risk of falls increases

21. Nursing interventions should be based on who's theory?
Maslow
Daily
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Irregular respirations (fast/slow) often seen at end of life

22. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Nursing dx
Hygeine - DOB - work hx
Non - opiod (ex: NSAID/acetominaphen)
Sensory motor

23. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Stroke volume x's heart rate
Adolescence
Focused
Nurse

24. Are changes in vital signs a reliable indicator of chronic pain?
Having to use more than one pillow when sleeping
No
Hemoglobin
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

25. What is the formula for cardiac output?

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26. An example of a nursing dx would be
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Ongoing assessment
Fluid volume deficit related to poor intake

27. Data gathered via instrumention (pulse ox) is considered
Defining a baseline of cognitive function - any changes or deviations from norm.
A personal experience that does whatever the person in pain says it does
Fast and deep respirations seen in patient's with acidosis
Objective

28. The path of blood from the heart to the lungs is
Confusion Assessment Method
Toddler
Loss of taste
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

29. Data from the last 24/48 hours that included patterns would be a part of
Secondary soureces (family - friends)
Trend assessment (shift report)
Abstract thinking
Maslow

30. What do rales sound like?
Capillaries
Symptoms
Risk of falls increases
Snap - crackle - pops; velcro - bubble wrap

31. Data that is recorded for an immediate need (code blue or fall) would be included in
Defining a baseline of cognitive function - any changes or deviations from norm.
Nurse
# of packs per day x # of years smoked
Decision assessment

32. Expiration sounds are heard longer than inspiration In What area?
Broncial (heard over trachea)
Learning - memory and adaptation to stress
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Assess over all health status and identify the problem

33. Other factors that may indicate confusion using the CAM tool could be
Knowing What to do/how to make a decision based upon available data.
Disorganized thinking and altered LOC
School age childen
Ongoing assessment

34. 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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35. What are Cheyne Stokes?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Irregular respirations (fast/slow) often seen at end of life
Nursing dx
Risk of falls increases

36. Intermittent claudication is caused by?
A personal experience that does whatever the person in pain says it does
Fluid volume deficit related to poor intake
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Decreased arterial perfusion

37. The site where gas exchange occurs is
Capillaries
The patient
The result is accurate patient dB
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

38. In Which part of the nursing process will you find delegation?
Implementation
Nursing dx
Edema
Symptoms

39. Two indicators that are REQUIRED for classification via the CAM tool include
Inattention and acute increase/decrease in cognitive function
A personal experience that does whatever the person in pain says it does
Fast and deep respirations seen in patient's with acidosis
Family - spouse - someone other than a healthcare worker - previous medical records.

40. An infant is in which Paiget stage?
Objective
Nurse
Sensory motor
A false - fixed belief that cannot be corrected through reasoning.

41. Blood passes through the heart valves In what order?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Tricuspid - mitral and the aortic
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Upper airways

42. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Communicate using hands and eyes.
Objective
Pain

43. Another term for a focused assessment is
Having to use more than one pillow when sleeping
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Level of stress - risk for violence - anxiety level - patient unmet needs
Ongoing assessment

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

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45. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
The medication will not affect the patient's breathing.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Data collection - data validation - data organization - data analysis - and data reporting/recording.

46. Data validation assures
Implementation
The result is accurate patient dB
Secondary
Stroke volume x's heart rate

47. 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)
Sensory motor
Pt's with oxygenation and perfusion problems
Ongoing assessment

48. What is responsible for transporting O2 in the blood
Hemoglobin
Double check equip and patient
Focused
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

49. A patient that is easily fatigued may have a HgB lab value of?
Focused
8.4
Pain
The patient

50. When speaking with a patient with moderate hearing loss the RN should
Double check equip and patient
Pt's with oxygenation and perfusion problems
Communicate using hands and eyes.
Adolescence