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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 purpose of the nursing process?
Objective
The patient
Serves to expedite dx and tx of actual and potential health problems
No

2. Examples of personal information
Paradoxical reaction
Hygeine - DOB - work hx
Wandering
School age childen

3. 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
Adolescence
Trauma or illness
Upper airways

4. What is the cognitive difference between a preschooler and schoolage child?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Preschool is cause and effect - school age begins to use logical thought process.
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

5. The order of air flow into the lungs is
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Capillaries
An 80 y/o patient that has emergency surgery
Hygeine - DOB - work hx

6. What is responsible for transporting O2 in the blood
To simulate eating motions with the hands
Data collection - data validation - data organization - data analysis - and data reporting/recording.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Hemoglobin

7. Hypogeusis is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Confusion Assessment Method
Decreased sense of taste
Paradoxical reaction

8. An example of a secondary source is
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Inattention and acute increase/decrease in cognitive function
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Family - spouse - someone other than a healthcare worker - previous medical records.

9. At What age do you begin to put thoughts into words?
Objective
Toddler
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Nursing

10. Orthopnea is described as?
Nurse
Having to use more than one pillow when sleeping
Trauma or illness
Communicate using hands and eyes.

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

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12. What is the nursing process?
Snap - crackle - pops; velcro - bubble wrap
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Having to use more than one pillow when sleeping

13. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Pain in legs assoc w walking
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Have them do simple math problems
The result is accurate patient dB

14. When using restraints in a confused patient
Confusion Assessment Method
Risk of falls increases
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Serves to expedite dx and tx of actual and potential health problems

15. Fluid volume deficit is a __________ dx
Nursing
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Trend assessment (shift report)

16. An infant is in which Paiget stage?
Ask - Believe - Choose - Deliver - Empower
Confusion Assessment Method
Sensory motor
Decision assessment

17. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Fluid volume deficit related to poor intake
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

18. What does CAM stand for
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Confusion Assessment Method
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Tricuspid - mitral and the aortic

19. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Wandering
Upper airways
A personal experience that does whatever the person in pain says it does
Viral infection

20. What is pain?
A personal experience that does whatever the person in pain says it does
Having to use more than one pillow when sleeping
Symptoms
An 80 y/o patient that has emergency surgery

21. Sleep deprivation can effect
Capillaries
Trend assessment (shift report)
Learning - memory and adaptation to stress
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

22. The path of blood from the lungs to the heart is
An 80 y/o patient that has emergency surgery
Pt's with oxygenation and perfusion problems
A personal experience that does whatever the person in pain says it does
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

23. Name the 5 'W's' of assessing a change in LOC
Nursing dx
Disorganized thinking and altered LOC
Upper airways
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

24. What is a component of the cognitive part of critical thinking skills?
Pt's underlying feelings
Upper airways
Symptoms
Knowing What to do/how to make a decision based upon available data.

25. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Wandering
Maslow
Decreased arterial perfusion

26. The purpose of an initial assessment is
Edema
Defining a baseline of cognitive function - any changes or deviations from norm.
To ID the problem
Level of stress - risk for violence - anxiety level - patient unmet needs

27. The site where gas exchange occurs is
Immature immune system - structures close together lends to easy spreading from on area to another.
Capillaries
Preschool is cause and effect - school age begins to use logical thought process.
Broncial (heard over trachea)

28. Ageusia is
Adolescence
Interventions for which the nurse is accountable
The medication will not affect the patient's breathing.
Loss of taste

29. When a patient has increased lymphocytes - this may indicate what?
Viral infection
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Maslow
The medication will not affect the patient's breathing.

30. Are changes in vital signs a reliable indicator of chronic pain?
No
Bacterial infection
Viral infection
Non - opiod (ex: NSAID/acetominaphen)

31. Acceptable sources of assessment data when evaluating a confused patient would be
Nursing dx
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Maslow
Secondary soureces (family - friends)

32. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Family - spouse - someone other than a healthcare worker - previous medical records.
Ongoing assessment
Non - opiod (ex: NSAID/acetominaphen)

33. Two indicators that are REQUIRED for classification via the CAM tool include
Fluid volume deficit related to poor intake
Inattention and acute increase/decrease in cognitive function
Fast and deep respirations seen in patient's with acidosis
Viral infection

34. Would a nursing dx be part of the primary or secondary dx?
Secondary soureces (family - friends)
Secondary
Decision assessment
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)

35. When speaking with a patient with moderate hearing loss the RN should
Irregular respirations (fast/slow) often seen at end of life
ID'ing status of exisiting problems and locating new issues
Communicate using hands and eyes.
The patient

36. Subjective data could include
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Serves to expedite dx and tx of actual and potential health problems
Symptoms
Nursing dx

37. What is the formula for determining pack years?
Decision assessment
Nursing dx
# of packs per day x # of years smoked
Vesicular (peripheral lung areas)

38. An example of a primary source is
Wandering
The process of storing - learning - retrieving - and using info.
The patient
The medication will not affect the patient's breathing.

39. At What age do you begin to use logical thought process?
Irregular respirations (fast/slow) often seen at end of life
School age childen
Hygeine - DOB - work hx
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

40. What factors may indicate plural rub?
The result is accurate patient dB
Focused
Pt's underlying feelings
Pain on inspiration and expiration; superficial squeaking or grating

41. Kussamaul respirations describe

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42. What is a definition of a delusion?
Communicate using hands and eyes.
Stroke volume x's heart rate
A false - fixed belief that cannot be corrected through reasoning.
Tricuspid - mitral and the aortic

43. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Fast and deep respirations seen in patient's with acidosis
Non - opiod (ex: NSAID/acetominaphen)
Symptoms
A false - fixed belief that cannot be corrected through reasoning.

44. What is cognition?
Maslow
To ID the problem
The process of storing - learning - retrieving - and using info.
Trend assessment (shift report)

45. The fifth vital sign is
Double check equip and patient
Pain
Have them do simple math problems
Symptoms

46. QUESTT is a tool for What type of an assessment?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Secondary
Pain
Vesicular (peripheral lung areas)

47. What is a chochlear implant?
Loss of taste
Pain
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Decision assessment

48. What do rales sound like?
Pain
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Snap - crackle - pops; velcro - bubble wrap
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

49. Ongoing assessments are useful in

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50. Data that is recorded for an immediate need (code blue or fall) would be included in
Double check equip and patient
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.
Decision assessment