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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 is the formula for determining pack years?
Inattention and acute increase/decrease in cognitive function
Snap - crackle - pops; velcro - bubble wrap
# of packs per day x # of years smoked
Hearing loss

2. A patient that is easily fatigued may have a HgB lab value of?
To ID the problem
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Serves to expedite dx and tx of actual and potential health problems
8.4

3. Name the 5 'W's' of assessing a change in LOC
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
A false - fixed belief that cannot be corrected through reasoning.
Trauma or illness
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

4. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
To ID the problem
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Daily
Non - opiod (ex: NSAID/acetominaphen)

5. What is cognition?
The process of storing - learning - retrieving - and using info.
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
8.4

6. The site where gas exchange occurs is
Capillaries
Trend assessment (shift report)
Decreased sense of taste
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

7. Fluid volume deficit is a __________ dx
Pain
The process of storing - learning - retrieving - and using info.
ID'ing status of exisiting problems and locating new issues
Nursing

8. What is responsible for transporting O2 in the blood
Hemoglobin
Serves to expedite dx and tx of actual and potential health problems
Communicate using hands and eyes.
Edema

9. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Pain
Snap - crackle - pops; velcro - bubble wrap
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

10. What is a component of the cognitive part of critical thinking skills?
Pt's with oxygenation and perfusion problems
Vesicular (peripheral lung areas)
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Knowing What to do/how to make a decision based upon available data.

11. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Medical
Upper airways
A false - fixed belief that cannot be corrected through reasoning.

12. An example of a secondary source is
Secondary soureces (family - friends)
Viral infection
Stroke volume x's heart rate
Family - spouse - someone other than a healthcare worker - previous medical records.

13. Would a nursing dx be part of the primary or secondary dx?
Double check equip and patient
Stroke volume x's heart rate
Family - spouse - someone other than a healthcare worker - previous medical records.
Secondary

14. If an abnormal finding is revealed during assessment - the nurse should
Have them do simple math problems
Pain on inspiration and expiration; superficial squeaking or grating
Double check equip and patient
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

15. Hypogeusis is
# of packs per day x # of years smoked
Decreased sense of taste
Toddler
Nurse

16. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Confusion Assessment Method
Wandering
Pt's underlying feelings
School age childen

17. At What age do you begin to put thoughts into words?
EdFED- Q
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Edema
Toddler

18. What are Cheyne Stokes?
Ongoing assessment
Irregular respirations (fast/slow) often seen at end of life
ID'ing status of exisiting problems and locating new issues
Ask - Believe - Choose - Deliver - Empower

19. When noticing a patient with dementia has stopped eating - the RN's first response is?
Fluid volume deficit related to poor intake
Edema
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
To simulate eating motions with the hands

20. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Interventions for which the nurse is accountable
Hemoglobin
Secondary

21. What are the components of an assessment?
Pain
An 80 y/o patient that has emergency surgery
Data collection - data validation - data organization - data analysis - and data reporting/recording.
The process of storing - learning - retrieving - and using info.

22. All body system data is not necessary which type of assessment
Trend assessment (shift report)
Toddler
Hemoglobin
Focused

23. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Learning - memory and adaptation to stress
Fast and deep respirations seen in patient's with acidosis
Have them do simple math problems

24. An ongoing assessment is performed
Implementation
Having to use more than one pillow when sleeping
Irregular respirations (fast/slow) often seen at end of life
Daily

25. A nursing dx is best described as
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain in legs assoc w walking
School age childen

26. Data that is recorded for an immediate need (code blue or fall) would be included in
Decision assessment
Learning - memory and adaptation to stress
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Adolescence

27. Where can you hear bronchovesicular breath sounds?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The result is accurate patient dB
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Pt's with oxygenation and perfusion problems

28. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Capillaries
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

29. What factors may indicate plural rub?
Pain on inspiration and expiration; superficial squeaking or grating
Serves to expedite dx and tx of actual and potential health problems
Confusion Assessment Method
Loss of taste

30. Two indicators that are REQUIRED for classification via the CAM tool include
Objective
EdFED- Q
Inattention and acute increase/decrease in cognitive function
Decreased arterial perfusion

31. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Immature immune system - structures close together lends to easy spreading from on area to another.
Having to use more than one pillow when sleeping
Tricuspid - mitral and the aortic

32. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
A personal experience that does whatever the person in pain says it does
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain
Abstract thinking

33. At patient that state their shoes are tighter at the end of the day may be experiencing
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Objective
Edema
Secondary

34. In Which part of the nursing process will you find delegation?
A false - fixed belief that cannot be corrected through reasoning.
Pt's underlying feelings
Implementation
Trend assessment (shift report)

35. Factors that may reduce the efficacy of pulse oximetry include
Vesicular (peripheral lung areas)
Tricuspid - mitral and the aortic
Upper airways
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

36. Are changes in vital signs a reliable indicator of chronic pain?
# of packs per day x # of years smoked
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Level of stress - risk for violence - anxiety level - patient unmet needs
No

37. What is the correct approach when dealing with older adults?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Tricuspid - mitral and the aortic
Vesicular (peripheral lung areas)

38. 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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39. 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
Decision assessment
Non - opiod (ex: NSAID/acetominaphen)
Viral infection

40. Ageusia is
Abstract thinking
Loss of taste
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Nursing

41. Diabetes is a _________ dx
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Wandering
Pt's underlying feelings
Medical

42. The order of air flow into the lungs is
Knowing What to do/how to make a decision based upon available data.
Serves to expedite dx and tx of actual and potential health problems
No
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

43. What is a definition of a delusion?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Wandering
A false - fixed belief that cannot be corrected through reasoning.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

44. Another term for a focused assessment is
8.4
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Ongoing assessment
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

45. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Immature immune system - structures close together lends to easy spreading from on area to another.
A personal experience that does whatever the person in pain says it does
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

46. What do rales sound like?
Capillaries
Snap - crackle - pops; velcro - bubble wrap
EdFED- Q
8.4

47. Where can wheezes best be heard?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Wandering
Upper airways

48. What are the components of a mental status exam that are not part of a regular assessment?
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Preschool is cause and effect - school age begins to use logical thought process.
Adolescence

49. An example of a nursing dx would be
8.4
Disorganized thinking and altered LOC
Level of stress - risk for violence - anxiety level - patient unmet needs
Fluid volume deficit related to poor intake

50. Data from the last 24/48 hours that included patterns would be a part of
Broncial (heard over trachea)
Trend assessment (shift report)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Secondary