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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. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
8.4

2. What do rales sound like?
Nurse
Defining a baseline of cognitive function - any changes or deviations from norm.
Snap - crackle - pops; velcro - bubble wrap
Maslow

3. 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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4. When a patient has increased neutrophils - this may indicate what?
Tricuspid - mitral and the aortic
Bacterial infection
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Toddler

5. A potential adverse rx of chemically restraining a confused patient would be
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Paradoxical reaction
8.4
Assess over all health status and identify the problem

6. Factors that may reduce the efficacy of pulse oximetry include
Initial assessment
Secondary soureces (family - friends)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Disorganized thinking and altered LOC

7. What factors may indicate plural rub?
An 80 y/o patient that has emergency surgery
Decision assessment
Pain on inspiration and expiration; superficial squeaking or grating
Non - opiod (ex: NSAID/acetominaphen)

8. What scale is used to determine eating and feeding issues in adults with confusion
EdFED- Q
Decision assessment
Pain in legs assoc w walking
Sensory motor

9. Side effects of putting confused pts in restraints include
To ID the problem
The patient
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Knowing What to do/how to make a decision based upon available data.

10. Would a nursing dx be part of the primary or secondary dx?
Trauma or illness
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Secondary
Toddler

11. What would cause changes in congitive development later in life (middle adulthood)?
Knowing What to do/how to make a decision based upon available data.
Nurse
Trauma or illness
Pt's underlying feelings

12. Other factors that may indicate confusion using the CAM tool could be
Immature immune system - structures close together lends to easy spreading from on area to another.
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Knowing What to do/how to make a decision based upon available data.
Disorganized thinking and altered LOC

13. What is responsible for transporting O2 in the blood
Immature immune system - structures close together lends to easy spreading from on area to another.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Hemoglobin
A systematic method for organizing and delivering effective and efficient goal centric nursing care based on problem solving principles.

14. The purpose of an intitial assement serves to?
An 80 y/o patient that has emergency surgery
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Pain
Assess over all health status and identify the problem

15. Examples of personal information
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Defining a baseline of cognitive function - any changes or deviations from norm.
Hygeine - DOB - work hx
Level of stress - risk for violence - anxiety level - patient unmet needs

16. What does CAM stand for
Stroke volume x's heart rate
Confusion Assessment Method
Learning - memory and adaptation to stress
Upper airways

17. What are the steps of the nursing process?
Sensory motor
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Secondary

18. Hypogeusis is
Toddler
Hearing loss
The process of storing - learning - retrieving - and using info.
Decreased sense of taste

19. The order of air flow into the lungs is
School age childen
Abstract thinking
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli
Secondary soureces (family - friends)

20. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Edema
Hemoglobin
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nurse

21. Types of hearing loss include
EdFED- Q
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Symptoms

22. Another term for a focused assessment is
Stroke volume x's heart rate
Disorganized thinking and altered LOC
Immature immune system - structures close together lends to easy spreading from on area to another.
Ongoing assessment

23. Which patient would be most likely to experience sensory overload?
Risk of falls increases
An 80 y/o patient that has emergency surgery
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Broncial (heard over trachea)

24. When performing an ongoing assessment for a patient with disturbed thinking the nurse should be sure to include
Hygeine - DOB - work hx
Edema
Level of stress - risk for violence - anxiety level - patient unmet needs
# of packs per day x # of years smoked

25. What is the cognitive difference between a preschooler and schoolage child?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Preschool is cause and effect - school age begins to use logical thought process.
Paradoxical reaction
Pt's underlying feelings

26. Name the 5 'W's' of assessing a change in LOC
Learning - memory and adaptation to stress
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Trauma or illness
Nursing

27. At What age do you begin to use decision making?
An 80 y/o patient that has emergency surgery
Viral infection
Adolescence
Fluid volume deficit related to poor intake

28. The path of blood from the lungs to the heart is
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Inattention and acute increase/decrease in cognitive function
Non - opiod (ex: NSAID/acetominaphen)
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)

29. Data from the last 24/48 hours that included patterns would be a part of
Trend assessment (shift report)
Nursing
Data collection - data validation - data organization - data analysis - and data reporting/recording.
EdFED- Q

30. What is the formula for determining pack years?
Hygeine - DOB - work hx
Medical
Risk of falls increases
# of packs per day x # of years smoked

31. Data validation assures
The result is accurate patient dB
Adolescence
Level of stress - risk for violence - anxiety level - patient unmet needs
Medical

32. At What age do you begin to put thoughts into words?
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances
Communicate using hands and eyes.
Toddler
Stroke volume x's heart rate

33. Where can you hear bronchovesicular breath sounds?
Pain in legs assoc w walking
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Hemoglobin
School age childen

34. An example of a nursing dx would be
Fluid volume deficit related to poor intake
Nursing dx
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
An 80 y/o patient that has emergency surgery

35. When using restraints in a confused patient
Risk of falls increases
Implementation
Serves to expedite dx and tx of actual and potential health problems
Family - spouse - someone other than a healthcare worker - previous medical records.

36. What is a component of the cognitive part of critical thinking skills?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
An 80 y/o patient that has emergency surgery
Knowing What to do/how to make a decision based upon available data.

37. Acceptable sources of assessment data when evaluating a confused patient would be
Have them do simple math problems
Ongoing assessment
Pain
Secondary soureces (family - friends)

38. What are Cheyne Stokes?
Irregular respirations (fast/slow) often seen at end of life
Ongoing assessment
Decision assessment
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

39. What is the correct approach when dealing with older adults?
Ask - Believe - Choose - Deliver - Empower
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Upper airways
Hemoglobin

40. Asking a patient what would you do if there is a fire in the wastebasket - is a way to assess their
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
To simulate eating motions with the hands
Fluid volume deficit related to poor intake
Abstract thinking

41. The path of blood from the heart to the lungs is
Non - opiod (ex: NSAID/acetominaphen)
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Serves to expedite dx and tx of actual and potential health problems
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins

42. When noticing a patient with dementia has stopped eating - the RN's first response is?
To simulate eating motions with the hands
Confusion Assessment Method
Level of stress - risk for violence - anxiety level - patient unmet needs
The result is accurate patient dB

43. In Which part of the nursing process will you find delegation?
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Implementation
Focused
Decreased arterial perfusion

44. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Pain
Pt's underlying feelings
The patient
Hearing loss

45. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
EdFED- Q
Non - opiod (ex: NSAID/acetominaphen)
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Wandering

46. What do rhonchi sound like?
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Maslow
Immature immune system - structures close together lends to easy spreading from on area to another.
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

47. Two indicators that are REQUIRED for classification via the CAM tool include
Inattention and acute increase/decrease in cognitive function
Adolescence
The medication will not affect the patient's breathing.
Fast and deep respirations seen in patient's with acidosis

48. The basis for a plan of care comes for which stage of the nursing process?
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.
The medication will not affect the patient's breathing.
Nursing dx

49. An example of a secondary source is
Family - spouse - someone other than a healthcare worker - previous medical records.
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Implementation
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

50. If an abnormal finding is revealed during assessment - the nurse should
Double check equip and patient
Family - spouse - someone other than a healthcare worker - previous medical records.
Fluid volume deficit related to poor intake
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins