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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 cognition?
Assess over all health status and identify the problem
The process of storing - learning - retrieving - and using info.
Communicate using hands and eyes.
Risk of falls increases

2. QUESTT is a tool for What type of an assessment?
Pain
Broncial (heard over trachea)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Family - spouse - someone other than a healthcare worker - previous medical records.

3. 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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4. When speaking with a patient with moderate hearing loss the RN should
Snap - crackle - pops; velcro - bubble wrap
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Communicate using hands and eyes.

5. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Hygeine - DOB - work hx
8.4
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

6. The site where gas exchange occurs is
The result is accurate patient dB
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Capillaries
EdFED- Q

7. Acceptable sources of assessment data when evaluating a confused patient would be
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Nurse
Inattention and acute increase/decrease in cognitive function
Secondary soureces (family - friends)

8. An example of a primary source is
The patient
Non - opiod (ex: NSAID/acetominaphen)
Ongoing assessment
Stroke volume x's heart rate

9. What are the components of an assessment?
Trauma or illness
Pain in legs assoc w walking
Decreased sense of taste
Data collection - data validation - data organization - data analysis - and data reporting/recording.

10. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Trauma or illness
Tricuspid - mitral and the aortic
Focused

11. A patient that is easily fatigued may have a HgB lab value of?
8.4
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Decision assessment
Stroke volume x's heart rate

12. Inspiration sounds are heard longer than expiration sounds In What area?
Trend assessment (shift report)
Implementation
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Vesicular (peripheral lung areas)

13. All body system data is not necessary which type of assessment
Focused
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Ask - Believe - Choose - Deliver - Empower
Decision assessment

14. What do rales sound like?
Bacterial infection
Fast and deep respirations seen in patient's with acidosis
Confusion Assessment Method
Snap - crackle - pops; velcro - bubble wrap

15. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Secondary
Ongoing assessment
Confusion Assessment Method
Level of stress - risk for violence - anxiety level - patient unmet needs

16. What is the formula for determining pack years?
Level of stress - risk for violence - anxiety level - patient unmet needs
Disorganized thinking and altered LOC
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
# of packs per day x # of years smoked

17. Would a nursing dx be part of the primary or secondary dx?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Secondary
Paradoxical reaction
The process of storing - learning - retrieving - and using info.

18. What are the components of a mental status exam that are not part of a regular assessment?
Bacterial infection
Hearing loss
Sensory motor
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

19. Types of hearing loss include
Family - spouse - someone other than a healthcare worker - previous medical records.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
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

20. The purpose of an initial assessment is
To ID the problem
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The patient
Pt's with oxygenation and perfusion problems

21. What is the difference between a nursing dx and a med dx?
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Secondary
Objective
Vesicular (peripheral lung areas)

22. Orthopnea is described as?
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Having to use more than one pillow when sleeping
Hygeine - DOB - work hx
Vesicular (peripheral lung areas)

23. At patient that state their shoes are tighter at the end of the day may be experiencing
Interventions for which the nurse is accountable
Edema
Fluid volume deficit related to poor intake
To ID the problem

24. Nursing dx provides basis of
Serves to expedite dx and tx of actual and potential health problems
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Interventions for which the nurse is accountable
Have them do simple math problems

25. Another term for a focused assessment is
Defining a baseline of cognitive function - any changes or deviations from norm.
Ongoing assessment
The patient
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

26. Which patient would be most likely to experience sensory overload?
Initial assessment
An 80 y/o patient that has emergency surgery
Communicate using hands and eyes.
Serves to expedite dx and tx of actual and potential health problems

27. What factors may indicate plural rub?
Immature immune system - structures close together lends to easy spreading from on area to another.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Pain on inspiration and expiration; superficial squeaking or grating
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

28. When a patient has increased neutrophils - this may indicate what?
Bacterial infection
Toddler
No
Pain

29. A potential adverse rx of chemically restraining a confused patient would be
Paradoxical reaction
Fluid volume deficit related to poor intake
To ID the problem
Pt's with oxygenation and perfusion problems

30. Expiration sounds are heard longer than inspiration In What area?
Pt's underlying feelings
Data collection - data validation - data organization - data analysis - and data reporting/recording.
No
Broncial (heard over trachea)

31. What do rhonchi sound like?
Sensory motor
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
The patient

32. What is the nursing process?
ID'ing status of exisiting problems and locating new issues
Medical
Implementation
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

33. What does CAM stand for
Bacterial infection
Defining a baseline of cognitive function - any changes or deviations from norm.
Confusion Assessment Method
Hearing loss

34. Factors that may reduce the efficacy of pulse oximetry include
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Focused
Trauma or illness
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

35. What is a chochlear implant?
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Ongoing assessment
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

36. Blood passes through the heart valves In what order?
Pt's underlying feelings
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Tricuspid - mitral and the aortic
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

37. Where can wheezes best be heard?
# of packs per day x # of years smoked
Upper airways
Pt's underlying feelings
Medical

38. The fifth vital sign is
Serves to expedite dx and tx of actual and potential health problems
Pain on inspiration and expiration; superficial squeaking or grating
ID'ing status of exisiting problems and locating new issues
Pain

39. Examples of personal information
To simulate eating motions with the hands
Pain on inspiration and expiration; superficial squeaking or grating
An 80 y/o patient that has emergency surgery
Hygeine - DOB - work hx

40. Describe the purpose of a mental status exam
Defining a baseline of cognitive function - any changes or deviations from norm.
Tricuspid - mitral and the aortic
Edema
Implementation

41. Data gathered via instrumention (pulse ox) is considered
Trauma or illness
Pain on inspiration and expiration; superficial squeaking or grating
Objective
The result is accurate patient dB

42. Where can you hear bronchovesicular breath sounds?
Secondary
Inattention and acute increase/decrease in cognitive function
Assess over all health status and identify the problem
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

43. What are the steps of the nursing process?
EdFED- Q
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Immature immune system - structures close together lends to easy spreading from on area to another.
Sensory motor

44. The basis for a plan of care comes for which stage of the nursing process?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Defining a baseline of cognitive function - any changes or deviations from norm.
Nursing dx
Irregular respirations (fast/slow) often seen at end of life

45. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
To ID the problem
Toddler
Bacterial infection
Non - opiod (ex: NSAID/acetominaphen)

46. The order of air flow into the lungs is
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Decreased arterial perfusion
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Ask - Believe - Choose - Deliver - Empower

47. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Loss of taste
8.4

48. What is the formula for cardiac output?

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49. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
ID'ing status of exisiting problems and locating new issues
Broncial (heard over trachea)
Ongoing assessment

50. When a patient has increased lymphocytes - this may indicate what?
Secondary
Viral infection
Bacterial infection
Nurse