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Nursing Fundamentals 3

Instructions:

Answer 50 questions in 15 minutes.
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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. An ongoing assessment is performed
Capillaries
Secondary
Daily
Pain in legs assoc w walking

2. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Initial assessment
The medication will not affect the patient's breathing.
Paradoxical reaction

3. In Which part of the nursing process will you find delegation?
Snap - crackle - pops; velcro - bubble wrap
School age childen
Implementation
Nursing dx

4. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Initial assessment
Assess over all health status and identify the problem
To ID the problem

5. 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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6. What is the correct approach when dealing with older adults?
Objective
Trauma or illness
Level of stress - risk for violence - anxiety level - patient unmet needs
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

7. The purpose of an initial assessment is
Nurse
Snap - crackle - pops; velcro - bubble wrap
To ID the problem
Hearing loss

8. What would cause changes in congitive development later in life (middle adulthood)?
Focused
Nurse
Trauma or illness
Immature immune system - structures close together lends to easy spreading from on area to another.

9. Are changes in vital signs a reliable indicator of chronic pain?
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
No
Decision assessment
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

10. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Wandering
Toddler

11. At What age do you begin to put thoughts into words?
The medication will not affect the patient's breathing.
EdFED- Q
Broncial (heard over trachea)
Toddler

12. Data validation assures
The result is accurate patient dB
The medication will not affect the patient's breathing.
Pt's with oxygenation and perfusion problems
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

13. What is the formula for determining pack years?
Communicate using hands and eyes.
School age childen
Secondary soureces (family - friends)
# of packs per day x # of years smoked

14. Types of hearing loss 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)
Pain
Initial assessment
Defining a baseline of cognitive function - any changes or deviations from norm.

15. The basis for a plan of care comes for which stage of the nursing process?
Broncial (heard over trachea)
The medication will not affect the patient's breathing.
An 80 y/o patient that has emergency surgery
Nursing dx

16. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Sensory motor
The patient
Hygeine - DOB - work hx

17. At What age do you begin to use decision making?
Double check equip and patient
Pt's with oxygenation and perfusion problems
Loss of taste
Adolescence

18. When a patient has increased lymphocytes - this may indicate what?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Double check equip and patient
Viral infection
Serves to expedite dx and tx of actual and potential health problems

19. Orthopnea is described as?
Upper airways
Pain
Having to use more than one pillow when sleeping
ID'ing status of exisiting problems and locating new issues

20. QUESTT is a tool for What type of an assessment?
Trend assessment (shift report)
No
Pain
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

21. The path of blood from the heart to the lungs is
Knowing What to do/how to make a decision based upon available data.
Daily
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

22. What are the ABCDE's of pain management?
Tricuspid - mitral and the aortic
Ask - Believe - Choose - Deliver - Empower
Daily
Toddler

23. Nursing dx provides basis of
Upper airways
# of packs per day x # of years smoked
Assess over all health status and identify the problem
Interventions for which the nurse is accountable

24. What does CAM stand for
A personal experience that does whatever the person in pain says it does
Medical
Knowing What to do/how to make a decision based upon available data.
Confusion Assessment Method

25. What are the components of a mental status exam that are not part of a regular assessment?
School age childen
Immature immune system - structures close together lends to easy spreading from on area to another.
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

26. What do rales sound like?
Risk of falls increases
Viral infection
Snap - crackle - pops; velcro - bubble wrap
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

27. When noticing a patient with dementia has stopped eating - the RN's first response is?
Fluid volume deficit related to poor intake
To simulate eating motions with the hands
Serves to expedite dx and tx of actual and potential health problems
Pain

28. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Decision assessment
Hearing loss
Pain in legs assoc w walking
Risk of falls increases

29. The fifth vital sign is
Pain
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Preschool is cause and effect - school age begins to use logical thought process.
Nurse

30. Where can you hear bronchovesicular breath sounds?
Hearing loss
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.
Disorganized thinking and altered LOC

31. What is the difference between a nursing dx and a med dx?
Tricuspid - mitral and the aortic
Toddler
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

32. When speaking with a patient with moderate hearing loss the RN should
Hygeine - DOB - work hx
Nursing dx
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Communicate using hands and eyes.

33. Where can wheezes best be heard?
Nurse
Upper airways
Stroke volume x's heart rate
Pain

34. What are Cheyne Stokes?
Secondary soureces (family - friends)
Confusion Assessment Method
Irregular respirations (fast/slow) often seen at end of life
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

35. A patient that is easily fatigued may have a HgB lab value of?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
8.4
A personal experience that does whatever the person in pain says it does
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

36. Name the 5 'W's' of assessing a change in LOC
Non - opiod (ex: NSAID/acetominaphen)
Capillaries
Snap - crackle - pops; velcro - bubble wrap
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

37. What factors may indicate plural rub?
Double check equip and patient
Pain on inspiration and expiration; superficial squeaking or grating
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Abstract thinking

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

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39. An example of a primary source is
Focused
The patient
Inattention and acute increase/decrease in cognitive function
Hemoglobin

40. Describe the purpose of a mental status exam
Initial assessment
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Defining a baseline of cognitive function - any changes or deviations from norm.
Hearing loss

41. The site where gas exchange occurs is
Capillaries
Hygeine - DOB - work hx
An 80 y/o patient that has emergency surgery
The process of storing - learning - retrieving - and using info.

42. Factors that may reduce the efficacy of pulse oximetry include
Non - opiod (ex: NSAID/acetominaphen)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
8.4
Paradoxical reaction

43. The order of air flow into the lungs is
Loss of taste
Symptoms
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

44. What is the formula for cardiac output?

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45. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Capillaries
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Bacterial infection

46. Two indicators that are REQUIRED for classification via the CAM tool include
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Capillaries
Inattention and acute increase/decrease in cognitive function
Secondary soureces (family - friends)

47. Examples of personal information
Hygeine - DOB - work hx
School age childen
Decreased sense of taste
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

48. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Family - spouse - someone other than a healthcare worker - previous medical records.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
EdFED- Q

49. What do rhonchi sound like?
Broncial (heard over trachea)
Objective
The medication will not affect the patient's breathing.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

50. What is a component of the cognitive part of critical thinking skills?
Knowing What to do/how to make a decision based upon available data.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Level of stress - risk for violence - anxiety level - patient unmet needs
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

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Nursing Fundamentals 3

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