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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. Where can wheezes best be heard?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Secondary
Upper airways

2. At What age do you begin to use decision making?
Decreased arterial perfusion
Interventions for which the nurse is accountable
Adolescence
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

3. What is pain?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
A false - fixed belief that cannot be corrected through reasoning.
A personal experience that does whatever the person in pain says it does
Hygeine - DOB - work hx

4. Acceptable sources of assessment data when evaluating a confused patient would be
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Secondary soureces (family - friends)
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

5. What are the components of a mental status exam that are not part of a regular assessment?
Nursing
Trend assessment (shift report)
Medical
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

6. An example of a nursing dx would be
Nursing
Fluid volume deficit related to poor intake
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Trauma or illness

7. The fifth vital sign is
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Learning - memory and adaptation to stress
Pain
Wandering

8. What does CAM stand for
Confusion Assessment Method
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Broncial (heard over trachea)
Toddler

9. At What age do you begin to put thoughts into words?
Irregular respirations (fast/slow) often seen at end of life
Secondary soureces (family - friends)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Toddler

10. Examples of personal information
Hygeine - DOB - work hx
A personal experience that does whatever the person in pain says it does
To ID the problem
Fluid volume deficit related to poor intake

11. Subjective data could include
Symptoms
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Focused
Risk of falls increases

12. Kussamaul respirations describe

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13. At patient that state their shoes are tighter at the end of the day may be experiencing
The medication will not affect the patient's breathing.
Hearing loss
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Edema

14. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Broncial (heard over trachea)
A false - fixed belief that cannot be corrected through reasoning.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

15. 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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16. Would a nursing dx be part of the primary or secondary dx?
Vesicular (peripheral lung areas)
Decision assessment
Irregular respirations (fast/slow) often seen at end of life
Secondary

17. What is the formula for cardiac output?

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18. When speaking with a patient with moderate hearing loss the RN should
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Communicate using hands and eyes.
Pain on inspiration and expiration; superficial squeaking or grating

19. What is the cognitive difference between a preschooler and schoolage child?
Pt's underlying feelings
Nursing dx
Decreased sense of taste
Preschool is cause and effect - school age begins to use logical thought process.

20. Why are young children at greater risk for respiratory infection?
Trauma or illness
Immature immune system - structures close together lends to easy spreading from on area to another.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
School age childen

21. What is the correct approach when dealing with older adults?
Double check equip and patient
Fluid volume deficit related to poor intake
Nurse
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

22. What factors may indicate plural rub?
Level of stress - risk for violence - anxiety level - patient unmet needs
The medication will not affect the patient's breathing.
Pain on inspiration and expiration; superficial squeaking or grating
Implementation

23. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Wandering
Symptoms
A false - fixed belief that cannot be corrected through reasoning.

24. What is the difference between a nursing dx and a med dx?
Nurse
Initial assessment
Secondary
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

25. All body system data is not necessary which type of assessment
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Focused
Irregular respirations (fast/slow) often seen at end of life
Wandering

26. What is the purpose of the nursing process?
No
Serves to expedite dx and tx of actual and potential health problems
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The patient

27. What would cause changes in congitive development later in life (middle adulthood)?
Pain in legs assoc w walking
Preschool is cause and effect - school age begins to use logical thought process.
Trauma or illness
Serves to expedite dx and tx of actual and potential health problems

28. An infant is in which Paiget stage?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pt's with oxygenation and perfusion problems
Sensory motor
The medication will not affect the patient's breathing.

29. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Learning - memory and adaptation to stress
A personal experience that does whatever the person in pain says it does
Decreased sense of taste

30. QUESTT is a tool for What type of an assessment?
Fluid volume deficit related to poor intake
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Pain
Defining a baseline of cognitive function - any changes or deviations from norm.

31. Side effects of putting confused pts in restraints include
Immature immune system - structures close together lends to easy spreading from on area to another.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Have them do simple math problems
Non - opiod (ex: NSAID/acetominaphen)

32. What is a chochlear implant?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Capillaries
Secondary
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

33. The basis for a plan of care comes for which stage of the nursing process?
Vesicular (peripheral lung areas)
Risk of falls increases
Double check equip and patient
Nursing dx

34. 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
The patient
Edema
Maslow

35. When using restraints in a confused patient
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Having to use more than one pillow when sleeping
Risk of falls increases
Objective

36. The path of blood from the heart to the lungs is
# of packs per day x # of years smoked
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Risk of falls increases
Decreased arterial perfusion

37. The site where gas exchange occurs is
Vesicular (peripheral lung areas)
Capillaries
Nurse
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

38. What are the ABCDE's of pain management?
Inattention and acute increase/decrease in cognitive function
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Ask - Believe - Choose - Deliver - Empower

39. A patient that is easily fatigued may have a HgB lab value of?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Ongoing assessment
8.4
Serves to expedite dx and tx of actual and potential health problems

40. 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)
Double check equip and patient
An 80 y/o patient that has emergency surgery
Family - spouse - someone other than a healthcare worker - previous medical records.

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

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42. What is the difference between hallucination and delirium?
Decision assessment
Immature immune system - structures close together lends to easy spreading from on area to another.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

43. What is the formula for determining pack years?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Ongoing assessment
Learning - memory and adaptation to stress
# of packs per day x # of years smoked

44. What are Cheyne Stokes?
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Pain
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Irregular respirations (fast/slow) often seen at end of life

45. What are Piaget's stages of cognitive development
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Upper airways
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Hearing loss

46. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Broncial (heard over trachea)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Level of stress - risk for violence - anxiety level - patient unmet needs

47. When a patient has increased neutrophils - this may indicate what?
Initial assessment
Bacterial infection
Medical
8.4

48. Which patient would be most likely to experience sensory overload?
Confusion Assessment Method
A personal experience that does whatever the person in pain says it does
An 80 y/o patient that has emergency surgery
Toddler

49. What is the nursing process?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
A false - fixed belief that cannot be corrected through reasoning.
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

50. Diabetes is a _________ dx
Ongoing assessment
Have them do simple math problems
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Medical