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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 scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Learning - memory and adaptation to stress
Broncial (heard over trachea)
Medical

2. At What age do you begin to put thoughts into words?
Ask - Believe - Choose - Deliver - Empower
Hemoglobin
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Toddler

3. Kussamaul respirations describe

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4. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Hygeine - DOB - work hx
Level of stress - risk for violence - anxiety level - patient unmet needs
Stroke volume x's heart rate
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

5. 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.
Disorganized thinking and altered LOC
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.

6. What is cognition?
The process of storing - learning - retrieving - and using info.
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
ID'ing status of exisiting problems and locating new issues
Medical

7. What are the ABCDE's of pain management?
Decreased sense of taste
A false - fixed belief that cannot be corrected through reasoning.
Ask - Believe - Choose - Deliver - Empower
Learning - memory and adaptation to stress

8. When a patient has increased neutrophils - this may indicate what?
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Bacterial infection
Hemoglobin
Pain in legs assoc w walking

9. A potential adverse rx of chemically restraining a confused patient would be
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Hygeine - DOB - work hx
Paradoxical reaction
Knowing What to do/how to make a decision based upon available data.

10. What is pain?
Have them do simple math problems
The process of storing - learning - retrieving - and using info.
A personal experience that does whatever the person in pain says it does
Risk of falls increases

11. The site where gas exchange occurs is
Immature immune system - structures close together lends to easy spreading from on area to another.
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Pain in legs assoc w walking
Capillaries

12. At What age do you begin to use decision making?
Nursing dx
Serves to expedite dx and tx of actual and potential health problems
Adolescence
Family - spouse - someone other than a healthcare worker - previous medical records.

13. When a patient has increased lymphocytes - this may indicate what?
Viral infection
Secondary soureces (family - friends)
Double check equip and patient
Data collection - data validation - data organization - data analysis - and data reporting/recording.

14. An example of a nursing dx would be
Decreased arterial perfusion
School age childen
Fluid volume deficit related to poor intake
Pain

15. At patient that state their shoes are tighter at the end of the day may be experiencing
Fast and deep respirations seen in patient's with acidosis
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Edema
Sensory motor

16. When using restraints in a confused patient
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Risk of falls increases
A personal experience that does whatever the person in pain says it does
Decreased sense of taste

17. Factors that may reduce the efficacy of pulse oximetry include
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Pain on inspiration and expiration; superficial squeaking or grating
Medical
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

18. 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 soureces (family - friends)
Bacterial infection
Trauma or illness

19. What is the nursing process?
Have them do simple math problems
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.
Hygeine - DOB - work hx

20. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Hemoglobin
Nurse
Trend assessment (shift report)
Risk of falls increases

21. The purpose of an initial assessment is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Immature immune system - structures close together lends to easy spreading from on area to another.
To ID the problem
Viral infection

22. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
An 80 y/o patient that has emergency surgery
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nurse
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

23. All body system data is not necessary which type of assessment
Defining a baseline of cognitive function - any changes or deviations from norm.
Secondary
Focused
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

24. Data gathered via instrumention (pulse ox) is considered
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Snap - crackle - pops; velcro - bubble wrap
Objective

25. What is the formula for cardiac output?

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26. Where can you hear bronchovesicular breath sounds?
Irregular respirations (fast/slow) often seen at end of life
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Hygeine - DOB - work hx
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

27. What are the components of a mental status exam that are not part of a regular assessment?
Pain
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Vesicular (peripheral lung areas)
Decision assessment

28. Data validation assures
The result is accurate patient dB
Vesicular (peripheral lung areas)
Ask - Believe - Choose - Deliver - Empower
Serves to expedite dx and tx of actual and potential health problems

29. Expiration sounds are heard longer than inspiration In What area?
To ID the problem
Learning - memory and adaptation to stress
Broncial (heard over trachea)
Loss of taste

30. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Ongoing assessment
8.4
Interventions for which the nurse is accountable

31. In Which part of the nursing process will you find delegation?
Maslow
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Pt's underlying feelings
Implementation

32. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Nursing
Assess over all health status and identify the problem
Family - spouse - someone other than a healthcare worker - previous medical records.
Hearing loss

33. The path of blood from the lungs to the heart is
Upper airways
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Secondary soureces (family - friends)
Eye hygeine - accomodating factors - what was the level of decline - how long has it been

34. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Nursing dx
Snap - crackle - pops; velcro - bubble wrap
Non - opiod (ex: NSAID/acetominaphen)
Loss of taste

35. When speaking with a patient with moderate hearing loss the RN should
Communicate using hands and eyes.
Pt's underlying feelings
Paradoxical reaction
Tricuspid - mitral and the aortic

36. The path of blood from the heart to the lungs is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The process of storing - learning - retrieving - and using info.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Trauma or illness

37. What are the steps of the nursing process?
A personal experience that does whatever the person in pain says it does
Nursing dx
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
A false - fixed belief that cannot be corrected through reasoning.

38. What is a definition of a delusion?
Communicate using hands and eyes.
Bacterial infection
A false - fixed belief that cannot be corrected through reasoning.
Pain on inspiration and expiration; superficial squeaking or grating

39. What does CAM stand for
Confusion Assessment Method
Decreased arterial perfusion
Risk of falls increases
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

40. What is intermittent claudication?
Pain in legs assoc w walking
Toddler
Decision assessment
The medication will not affect the patient's breathing.

41. 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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42. Where can wheezes best be heard?
An 80 y/o patient that has emergency surgery
Upper airways
Having to use more than one pillow when sleeping
Immature immune system - structures close together lends to easy spreading from on area to another.

43. Would a nursing dx be part of the primary or secondary dx?
Pain
Secondary
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

44. The fifth vital sign is
School age childen
Pain
Stroke volume x's heart rate
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

45. Other factors that may indicate confusion using the CAM tool could be
Hearing loss
Implementation
Sensory motor (birth - 2 years) - Preoperational (2-7) - Concrete operational (7-11) - Formal operational (11- adult)
Disorganized thinking and altered LOC

46. 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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47. Data from the last 24/48 hours that included patterns would be a part of
The result is accurate patient dB
Snap - crackle - pops; velcro - bubble wrap
Hemoglobin
Trend assessment (shift report)

48. Are changes in vital signs a reliable indicator of chronic pain?
No
Ask - Believe - Choose - Deliver - Empower
Toddler
Decreased arterial perfusion

49. Orthopnea is described as?
Capillaries
An 80 y/o patient that has emergency surgery
Having to use more than one pillow when sleeping
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

50. Inspiration sounds are heard longer than expiration sounds In What area?
Vesicular (peripheral lung areas)
Initial assessment
ID'ing status of exisiting problems and locating new issues
Have them do simple math problems