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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. 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
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

2. At What age do you begin to use logical thought process?
Hearing loss
No
School age childen
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

3. An infant is in which Paiget stage?
8.4
Sensory motor
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Learning - memory and adaptation to stress

4. When a patient has increased lymphocytes - this may indicate what?
Stroke volume x's heart rate
School age childen
Family - spouse - someone other than a healthcare worker - previous medical records.
Viral infection

5. What is a chochlear implant?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
To ID the problem
Pain
Sensory motor

6. What is the purpose of the nursing process?
Capillaries
School age childen
Serves to expedite dx and tx of actual and potential health problems
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

7. A patient that is easily fatigued may have a HgB lab value of?
Loss of taste
Level of stress - risk for violence - anxiety level - patient unmet needs
The medication will not affect the patient's breathing.
8.4

8. Types of hearing loss include
Hygeine - DOB - work hx
Toddler
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Data collection - data validation - data organization - data analysis - and data reporting/recording.

9. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Objective
Symptoms
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

10. What does CAM stand for
Secondary soureces (family - friends)
The patient
Confusion Assessment Method
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

11. At What age do you begin to put thoughts into words?
Viral infection
Toddler
Learning - memory and adaptation to stress
8.4

12. What is the cognitive difference between a preschooler and schoolage child?
Preschool is cause and effect - school age begins to use logical thought process.
Initial assessment
Abstract thinking
Paradoxical reaction

13. What is pain?
Focused
EdFED- Q
A personal experience that does whatever the person in pain says it does
Daily

14. Which patient would be most likely to experience sensory overload?
The patient
The medication will not affect the patient's breathing.
An 80 y/o patient that has emergency surgery
Paradoxical reaction

15. Where can you hear bronchovesicular breath sounds?
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
An 80 y/o patient that has emergency surgery
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

16. What are the components of an assessment?
To simulate eating motions with the hands
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Upper airways
Ongoing assessment

17. When a patient has increased neutrophils - this may indicate what?
Learning - memory and adaptation to stress
Symptoms
Bacterial infection
Secondary soureces (family - friends)

18. A nursing dx is best described as
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Assess over all health status and identify the problem
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

19. What is the nursing process?
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Initial assessment
Decision assessment

20. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Capillaries
The medication will not affect the patient's breathing.
Irregular respirations (fast/slow) often seen at end of life

21. Another term for a focused assessment is
Daily
Ongoing assessment
The medication will not affect the patient's breathing.
No

22. 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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23. Kussamaul respirations describe

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24. In Which part of the nursing process will you find delegation?
Stroke volume x's heart rate
Bacterial infection
Implementation
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

25. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Interventions for which the nurse is accountable
Stroke volume x's heart rate
Risk of falls increases

26. Side effects of putting confused pts in restraints include
Vesicular (peripheral lung areas)
A false - fixed belief that cannot be corrected through reasoning.
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Daily

27. Why are young children at greater risk for respiratory infection?
Immature immune system - structures close together lends to easy spreading from on area to another.
The result is accurate patient dB
The process of storing - learning - retrieving - and using info.
Family - spouse - someone other than a healthcare worker - previous medical records.

28. Ongoing assessments are useful in

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29. The site where gas exchange occurs is
Capillaries
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
# of packs per day x # of years smoked
Defining a baseline of cognitive function - any changes or deviations from norm.

30. Two indicators that are REQUIRED for classification via the CAM tool include
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Pain
Inattention and acute increase/decrease in cognitive function
Viral infection

31. What do rhonchi sound like?
Implementation
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Capillaries
Abstract thinking

32. Are changes in vital signs a reliable indicator of chronic pain?
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Decision assessment
No

33. What is responsible for transporting O2 in the blood
Hemoglobin
Medical
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Nursing

34. Data gathered via instrumention (pulse ox) is considered
Objective
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Upper airways
Implementation

35. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Pt's with oxygenation and perfusion problems
Family - spouse - someone other than a healthcare worker - previous medical records.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

36. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
No
Nurse

37. What is the difference between hallucination and delirium?
Pain
Secondary soureces (family - friends)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Disorganized thinking and altered LOC

38. Expiration sounds are heard longer than inspiration In What area?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Broncial (heard over trachea)
Pain
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital

39. What are the ABCDE's of pain management?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Decision assessment
Have them do simple math problems
Ask - Believe - Choose - Deliver - Empower

40. Data that is recorded for an immediate need (code blue or fall) would be included in
Immature immune system - structures close together lends to easy spreading from on area to another.
No
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Decision assessment

41. Would a nursing dx be part of the primary or secondary dx?
Toddler
Focused
Secondary
To ID the problem

42. What is the correct approach when dealing with older adults?
Decision assessment
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Secondary soureces (family - friends)
Capillaries

43. What scale is used to determine eating and feeding issues in adults with confusion
Edema
EdFED- Q
Adolescence
Having to use more than one pillow when sleeping

44. A patient failing to answer questions or displaying a reluctance to participate in group or family activities 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)
The medication will not affect the patient's breathing.
Initial assessment
Hearing loss

45. Nursing interventions should be based on who's theory?
To simulate eating motions with the hands
Tricuspid - mitral and the aortic
Maslow
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

46. 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
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Stroke volume x's heart rate
Adolescence

47. Acceptable sources of assessment data when evaluating a confused patient would be
Fast and deep respirations seen in patient's with acidosis
Secondary soureces (family - friends)
Decision assessment
The patient

48. The purpose of an initial assessment is
8.4
Learning - memory and adaptation to stress
ID'ing status of exisiting problems and locating new issues
To ID the problem

49. Examples of personal information
Upper airways
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Hygeine - DOB - work hx
Pt's with oxygenation and perfusion problems

50. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Bacterial infection
Trauma or illness
Tricuspid - mitral and the aortic