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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. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Upper airways
Daily
No

2. The site where gas exchange occurs is
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Viral infection
Capillaries
Broncial (heard over trachea)

3. What factors may indicate plural rub?
Medical
Maslow
Pain on inspiration and expiration; superficial squeaking or grating
Pain

4. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Level of stress - risk for violence - anxiety level - patient unmet needs
Snap - crackle - pops; velcro - bubble wrap
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Focused

5. What is the cognitive difference between a preschooler and schoolage child?
Hygeine - DOB - work hx
Nursing
Defining a baseline of cognitive function - any changes or deviations from norm.
Preschool is cause and effect - school age begins to use logical thought process.

6. What are the ABCDE's of pain management?
Interventions for which the nurse is accountable
The patient
Ask - Believe - Choose - Deliver - Empower
EdFED- Q

7. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
8.4
Nurse
A false - fixed belief that cannot be corrected through reasoning.
Learning - memory and adaptation to stress

8. Diabetes is a _________ dx
To simulate eating motions with the hands
The process of storing - learning - retrieving - and using info.
Objective
Medical

9. What is the difference between a nursing dx and a med dx?
Loss of taste
Daily
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Have them do simple math problems

10. Ageusia is
Loss of taste
To ID the problem
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Edema

11. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Fast and deep respirations seen in patient's with acidosis
A personal experience that does whatever the person in pain says it does
To simulate eating motions with the hands

12. When a patient has increased neutrophils - this may indicate what?
Trauma or illness
Bacterial infection
Paradoxical reaction
Data collection - data validation - data organization - data analysis - and data reporting/recording.

13. Fluid volume deficit is a __________ dx
The medication will not affect the patient's breathing.
Nursing dx
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nursing

14. The purpose of an intitial assement serves to?
Assess over all health status and identify the problem
Fast and deep respirations seen in patient's with acidosis
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
The medication will not affect the patient's breathing.

15. What is pain?
Decision assessment
Daily
A personal experience that does whatever the person in pain says it does
Upper airways

16. In Which part of the nursing process will you find delegation?
Implementation
Ask - Believe - Choose - Deliver - Empower
Decision assessment
Wandering

17. Subjective data could include
Trauma or illness
Level of stress - risk for violence - anxiety level - patient unmet needs
ID'ing status of exisiting problems and locating new issues
Symptoms

18. When a patient has increased lymphocytes - this may indicate what?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Tricuspid - mitral and the aortic
Viral infection
Capillaries

19. What is the purpose of the nursing process?
Stroke volume x's heart rate
Preschool is cause and effect - school age begins to use logical thought process.
Serves to expedite dx and tx of actual and potential health problems
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

20. What is responsible for transporting O2 in the blood
Serves to expedite dx and tx of actual and potential health problems
School age childen
Hemoglobin
A false - fixed belief that cannot be corrected through reasoning.

21. Where can you hear bronchovesicular breath sounds?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Decreased sense of taste
An 80 y/o patient that has emergency surgery
To simulate eating motions with the hands

22. A patient that is easily fatigued may have a HgB lab value of?
Implementation
Risk of falls increases
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
8.4

23. Where can wheezes best be heard?
Decreased sense of taste
Upper airways
EdFED- Q
Preschool is cause and effect - school age begins to use logical thought process.

24. QUESTT is a tool for What type of an assessment?
Pain
Viral infection
Secondary soureces (family - friends)
Snap - crackle - pops; velcro - bubble wrap

25. An ongoing assessment is performed
Implementation
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Medical
Daily

26. Which patient would be most likely to experience sensory overload?
Snap - crackle - pops; velcro - bubble wrap
Pain in legs assoc w walking
An 80 y/o patient that has emergency surgery
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy

27. Are changes in vital signs a reliable indicator of chronic pain?
Immature immune system - structures close together lends to easy spreading from on area to another.
8.4
No
School age childen

28. Nursing dx provides basis of
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Interventions for which the nurse is accountable
Communicate using hands and eyes.
Pain in legs assoc w walking

29. When using restraints in a confused patient
Risk of falls increases
Pain
Pain
Ask - Believe - Choose - Deliver - Empower

30. What do rhonchi sound like?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Inattention and acute increase/decrease in cognitive function
Level of stress - risk for violence - anxiety level - patient unmet needs

31. Would a nursing dx be part of the primary or secondary dx?
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Having to use more than one pillow when sleeping
Secondary
Vesicular (peripheral lung areas)

32. Data from the last 24/48 hours that included patterns would be a part of
Level of stress - risk for violence - anxiety level - patient unmet needs
Trend assessment (shift report)
Adolescence
Decreased sense of taste

33. What is a definition of a delusion?
Secondary soureces (family - friends)
Hygeine - DOB - work hx
Focused
A false - fixed belief that cannot be corrected through reasoning.

34. The fifth vital sign is
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pt's with oxygenation and perfusion problems
Pain
Initial assessment

35. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Nursing
Nurse
Focused

36. The order of air flow into the lungs is
A false - fixed belief that cannot be corrected through reasoning.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Abstract thinking
Non - opiod (ex: NSAID/acetominaphen)

37. An example of a secondary source is
An 80 y/o patient that has emergency surgery
Family - spouse - someone other than a healthcare worker - previous medical records.
The process of storing - learning - retrieving - and using info.
Snap - crackle - pops; velcro - bubble wrap

38. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hearing loss
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Paradoxical reaction
# of packs per day x # of years smoked

39. Name the 5 'W's' of assessing a change in LOC
Risk of falls increases
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Having to use more than one pillow when sleeping
Bacterial infection

40. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Adolescence
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

41. What is the formula for cardiac output?

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42. What is intermittent claudication?
Pain in legs assoc w walking
Daily
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

43. What is the nursing process?
Pt's underlying feelings
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Double check equip and patient
Medical

44. 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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45. Other factors that may indicate confusion using the CAM tool could be
A false - fixed belief that cannot be corrected through reasoning.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Disorganized thinking and altered LOC
Preschool is cause and effect - school age begins to use logical thought process.

46. Orthopnea is described as?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Hygeine - DOB - work hx
Having to use more than one pillow when sleeping
An 80 y/o patient that has emergency surgery

47. Hypogeusis is
Decreased arterial perfusion
Decreased sense of taste
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Paradoxical reaction

48. Intermittent claudication is caused by?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Decreased arterial perfusion
Snap - crackle - pops; velcro - bubble wrap
Family - spouse - someone other than a healthcare worker - previous medical records.

49. Sleep deprivation can effect
Ongoing assessment
8.4
Learning - memory and adaptation to stress
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

50. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Edema
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.