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Nursing Fundamentals 3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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 is the formula for determining pack years?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
# of packs per day x # of years smoked
Abstract thinking
Learning - memory and adaptation to stress

2. Two indicators that are REQUIRED for classification via the CAM tool include
Implementation
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Upper airways
Inattention and acute increase/decrease in cognitive function

3. Subjective data could include
To ID the problem
A false - fixed belief that cannot be corrected through reasoning.
Symptoms
Pain on inspiration and expiration; superficial squeaking or grating

4. Data validation assures
Pt's underlying feelings
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
The result is accurate patient dB
Edema

5. Nursing interventions should be based on who's theory?
Inattention and acute increase/decrease in cognitive function
Maslow
Upper airways
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

6. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Nursing dx
Abstract thinking
Trauma or illness

7. Orthopnea is described as?
Family - spouse - someone other than a healthcare worker - previous medical records.
Having to use more than one pillow when sleeping
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Initial assessment

8. Intermittent claudication is caused by?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Decreased arterial perfusion
To ID the problem
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

9. Why are young children at greater risk for respiratory infection?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
To ID the problem
Ask - Believe - Choose - Deliver - Empower
Immature immune system - structures close together lends to easy spreading from on area to another.

10. Sleep deprivation can effect
Learning - memory and adaptation to stress
Assess over all health status and identify the problem
Trend assessment (shift report)
Viral infection

11. The assessment that includes the patient's overhall health status
Initial assessment
Decreased arterial perfusion
Focused
Family - spouse - someone other than a healthcare worker - previous medical records.

12. What is responsible for transporting O2 in the blood
Focused
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
To ID the problem
Hemoglobin

13. An ongoing assessment is performed
Fast and deep respirations seen in patient's with acidosis
Interventions for which the nurse is accountable
Daily
Maslow

14. The fifth vital sign is
Stroke volume x's heart rate
Risk of falls increases
Pain
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

15. A patient that is easily fatigued may have a HgB lab value of?
Tricuspid - mitral and the aortic
8.4
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

16. What factors may indicate plural rub?
Double check equip and patient
Nursing dx
The result is accurate patient dB
Pain on inspiration and expiration; superficial squeaking or grating

17. If an abnormal finding is revealed during assessment - the nurse should
Trauma or illness
Sensory motor
Double check equip and patient
Hygeine - DOB - work hx

18. An example of a primary source is
The process of storing - learning - retrieving - and using info.
The patient
Hygeine - DOB - work hx
Double check equip and patient

19. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Fast and deep respirations seen in patient's with acidosis
Fluid volume deficit related to poor intake
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

20. Data gathered via instrumention (pulse ox) is considered
Objective
Fluid volume deficit related to poor intake
Nurse
Focused

21. The order of air flow into the lungs is
Pain in legs assoc w walking
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Bacterial infection

22. What is the purpose of the nursing process?
Adolescence
The result is accurate patient dB
Serves to expedite dx and tx of actual and potential health problems
Objective

23. The purpose of an intitial assement serves to?
Daily
Snap - crackle - pops; velcro - bubble wrap
Assess over all health status and identify the problem
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

24. 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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25. Types of hearing loss include
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
An 80 y/o patient that has emergency surgery
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Snap - crackle - pops; velcro - bubble wrap

26. In Which part of the nursing process will you find delegation?
Ask - Believe - Choose - Deliver - Empower
Defining a baseline of cognitive function - any changes or deviations from norm.
Snap - crackle - pops; velcro - bubble wrap
Implementation

27. All body system data is not necessary which type of assessment
The medication will not affect the patient's breathing.
Focused
Abstract thinking
No

28. What is the difference between a nursing dx and a med dx?
Vesicular (peripheral lung areas)
Double check equip and patient
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
To ID the problem

29. Ongoing assessments are useful in

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30. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Risk of falls increases
Abstract thinking
Ask - Believe - Choose - Deliver - Empower

31. What is intermittent claudication?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hygeine - DOB - work hx
Pain in legs assoc w walking
Pain on inspiration and expiration; superficial squeaking or grating

32. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Preschool is cause and effect - school age begins to use logical thought process.
Sensory motor
Toddler

33. 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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34. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Decreased sense of taste
Pain
Implementation

35. What is the cognitive difference between a preschooler and schoolage child?
Stroke volume x's heart rate
Decision assessment
Preschool is cause and effect - school age begins to use logical thought process.
The patient

36. What would cause changes in congitive development later in life (middle adulthood)?
# of packs per day x # of years smoked
Sensory motor
Preschool is cause and effect - school age begins to use logical thought process.
Trauma or illness

37. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Decreased arterial perfusion
Daily
Data collection - data validation - data organization - data analysis - and data reporting/recording.

38. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Disorganized thinking and altered LOC
Hearing loss
Decision assessment

39. An example of a nursing dx would be
Initial assessment
Learning - memory and adaptation to stress
Hygeine - DOB - work hx
Fluid volume deficit related to poor intake

40. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Viral infection
Adolescence
Maslow

41. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Have them do simple math problems
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

42. What are the components of a mental status exam that are not part of a regular assessment?
Daily
To ID the problem
Non - opiod (ex: NSAID/acetominaphen)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

43. What is the difference between hallucination and delirium?
The result is accurate patient dB
Capillaries
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

44. Data that is recorded for an immediate need (code blue or fall) would be included in
Irregular respirations (fast/slow) often seen at end of life
Decision assessment
A false - fixed belief that cannot be corrected through reasoning.
Paradoxical reaction

45. What is a chochlear implant?
Pt's underlying feelings
Secondary soureces (family - friends)
Ask - Believe - Choose - Deliver - Empower
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

46. When using restraints in a confused patient
Learning - memory and adaptation to stress
ID'ing status of exisiting problems and locating new issues
Trend assessment (shift report)
Risk of falls increases

47. What is the nursing process?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Inattention and acute increase/decrease in cognitive function
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

48. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Medical
Pain
Hygeine - DOB - work hx

49. Factors that may reduce the efficacy of pulse oximetry include
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Tricuspid - mitral and the aortic
Assess over all health status and identify the problem

50. Fluid volume deficit is a __________ dx
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
EdFED- Q
Ask - Believe - Choose - Deliver - Empower
Nursing

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Nursing Fundamentals 3

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