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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. Ongoing assessments are useful in

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2. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Vesicular (peripheral lung areas)
Pain on inspiration and expiration; superficial squeaking or grating
Abstract thinking
Implementation

3. What are Cheyne Stokes?
Communicate using hands and eyes.
Preschool is cause and effect - school age begins to use logical thought process.
Irregular respirations (fast/slow) often seen at end of life
The patient

4. If an abnormal finding is revealed during assessment - the nurse should
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Defining a baseline of cognitive function - any changes or deviations from norm.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Double check equip and patient

5. What do rhonchi sound like?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Pain in legs assoc w walking
Pain
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

6. Are changes in vital signs a reliable indicator of chronic pain?
Nurse
ID'ing status of exisiting problems and locating new issues
No
Have them do simple math problems

7. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Objective
Paradoxical reaction
Secondary
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

8. What are the components of an assessment?
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.
Pain
Trauma or illness

9. What is the nursing process?
Capillaries
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Maslow
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

10. When a patient has increased lymphocytes - this may indicate what?
Communicate using hands and eyes.
The process of storing - learning - retrieving - and using info.
Paradoxical reaction
Viral infection

11. The path of blood from the heart to the lungs is
Have them do simple math problems
Paradoxical reaction
Medical
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

12. What is a chochlear implant?
Secondary
Serves to expedite dx and tx of actual and potential health problems
Nursing
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

13. What is the formula for cardiac output?

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14. Nursing dx provides basis of
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Viral infection
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Interventions for which the nurse is accountable

15. Where can you hear bronchovesicular breath sounds?
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Secondary
Fast and deep respirations seen in patient's with acidosis

16. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Vesicular (peripheral lung areas)
Hemoglobin
Wandering
Secondary soureces (family - friends)

17. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Stroke volume x's heart rate
Nursing dx
Confusion Assessment Method

18. What would cause changes in congitive development later in life (middle adulthood)?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Trauma or illness
Maslow
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

19. Factors that may reduce the efficacy of pulse oximetry include
School age childen
Tricuspid - mitral and the aortic
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Stroke volume x's heart rate

20. Where can wheezes best be heard?
Upper airways
Level of stress - risk for violence - anxiety level - patient unmet needs
No
Pain

21. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
School age childen
Toddler
Pain

22. Name the 5 'W's' of assessing a change in LOC
The patient
Double check equip and patient
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Pt's underlying feelings

23. What is a component of the cognitive part of critical thinking skills?
Bacterial infection
Knowing What to do/how to make a decision based upon available data.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

24. What is pain?
Trend assessment (shift report)
A personal experience that does whatever the person in pain says it does
Viral infection
Have them do simple math problems

25. What factors may indicate plural rub?
Decision assessment
Secondary
To ID the problem
Pain on inspiration and expiration; superficial squeaking or grating

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

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27. Data gathered via instrumention (pulse ox) is considered
Objective
Symptoms
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

28. An ongoing assessment is performed
Viral infection
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Daily
Non - opiod (ex: NSAID/acetominaphen)

29. The assessment that includes the patient's overhall health status
Initial assessment
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Sensory motor
Maslow

30. Expiration sounds are heard longer than inspiration In What area?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Broncial (heard over trachea)
Interventions for which the nurse is accountable
ID'ing status of exisiting problems and locating new issues

31. What do rales sound like?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Focused
Snap - crackle - pops; velcro - bubble wrap
Defining a baseline of cognitive function - any changes or deviations from norm.

32. Which patient would be most likely to experience sensory overload?
An 80 y/o patient that has emergency surgery
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

33. Orthopnea is described as?
Edema
Viral infection
Having to use more than one pillow when sleeping
Disorganized thinking and altered LOC

34. An example of a secondary source is
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain on inspiration and expiration; superficial squeaking or grating
Family - spouse - someone other than a healthcare worker - previous medical records.

35. A patient that is easily fatigued may have a HgB lab value of?
8.4
Non - opiod (ex: NSAID/acetominaphen)
Initial assessment
Medical

36. Diabetes is a _________ dx
Have them do simple math problems
Medical
Pt's underlying feelings
Trend assessment (shift report)

37. The fifth vital sign is
Pain
Loss of taste
Secondary
A false - fixed belief that cannot be corrected through reasoning.

38. Sleep deprivation can effect
Learning - memory and adaptation to stress
Trend assessment (shift report)
Fluid volume deficit related to poor intake
Risk of falls increases

39. Examples of personal information
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Hygeine - DOB - work hx
Disorganized thinking and altered LOC
Viral infection

40. Describe the purpose of a mental status exam
Edema
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Toddler
Defining a baseline of cognitive function - any changes or deviations from norm.

41. 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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42. An example of a primary source is
The patient
Wandering
Have them do simple math problems
Communicate using hands and eyes.

43. What does CAM stand for
The medication will not affect the patient's breathing.
Confusion Assessment Method
Hemoglobin
Nursing dx

44. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Pain
Snap - crackle - pops; velcro - bubble wrap
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

45. The order of air flow into the lungs is
Wandering
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
The patient

46. What are the ABCDE's of pain management?
Family - spouse - someone other than a healthcare worker - previous medical records.
ID'ing status of exisiting problems and locating new issues
Ask - Believe - Choose - Deliver - Empower
Decreased arterial perfusion

47. What is the difference between hallucination and delirium?
Pain
Edema
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Hemoglobin

48. What is the correct approach when dealing with older adults?
Adolescence
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
The medication will not affect the patient's breathing.
Broncial (heard over trachea)

49. What scale is used to determine eating and feeding issues in adults with confusion
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Hemoglobin
EdFED- Q
Upper airways

50. What are Piaget's stages of cognitive development
Adolescence
Level of stress - risk for violence - anxiety level - patient unmet needs
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Learning - memory and adaptation to stress