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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. QUESTT is a tool for What type of an assessment?
Pain
Capillaries
Paradoxical reaction
School age childen

2. Are changes in vital signs a reliable indicator of chronic pain?
No
Implementation
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Confusion Assessment Method

3. What is a definition of a delusion?
Secondary soureces (family - friends)
Ongoing assessment
A false - fixed belief that cannot be corrected through reasoning.
Having to use more than one pillow when sleeping

4. What factors may indicate plural rub?
# of packs per day x # of years smoked
Immature immune system - structures close together lends to easy spreading from on area to another.
Pain on inspiration and expiration; superficial squeaking or grating
EdFED- Q

5. An ongoing assessment is performed
Hygeine - DOB - work hx
Initial assessment
The process of storing - learning - retrieving - and using info.
Daily

6. Where can you hear bronchovesicular breath sounds?
Preschool is cause and effect - school age begins to use logical thought process.
Pain
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
A false - fixed belief that cannot be corrected through reasoning.

7. What is the formula for cardiac output?

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8. Data validation assures
Decision assessment
Disorganized thinking and altered LOC
The result is accurate patient dB
Capillaries

9. When performing an interview with a patient with vision loss - select the correct questions for obtaining an accurate vision history
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Tricuspid - mitral and the aortic
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve

10. The basis for a plan of care comes for which stage of the nursing process?
Nursing dx
Sensory motor
Trauma or illness
Snap - crackle - pops; velcro - bubble wrap

11. Types of hearing loss include
Fast and deep respirations seen in patient's with acidosis
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 result is accurate patient dB
Double check equip and patient

12. The purpose of an initial assessment is
Nursing dx
To simulate eating motions with the hands
To ID the problem
Tricuspid - mitral and the aortic

13. What do rales sound like?
Stroke volume x's heart rate
Sensory motor
Snap - crackle - pops; velcro - bubble wrap
Hearing loss

14. An example of a primary source is
Initial assessment
The patient
Wandering
Nursing

15. Data gathered via instrumention (pulse ox) is considered
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Abstract thinking
Objective

16. Two indicators that are REQUIRED for classification via the CAM tool include
Risk of falls increases
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Sensory motor
Inattention and acute increase/decrease in cognitive function

17. What is the difference between a nursing dx and a med dx?
Daily
Med dx often involves problems with organ systems or disease and is the reason for admission to the hospital
Symptoms
Viral infection

18. Other factors that may indicate confusion using the CAM tool could be
Disorganized thinking and altered LOC
Vesicular (peripheral lung areas)
Sensory motor
# of packs per day x # of years smoked

19. Acceptable sources of assessment data when evaluating a confused patient would be
Secondary soureces (family - friends)
Paradoxical reaction
Preschool is cause and effect - school age begins to use logical thought process.
Communicate using hands and eyes.

20. Nursing interventions should be based on who's theory?
Paradoxical reaction
Inattention and acute increase/decrease in cognitive function
Bacterial infection
Maslow

21. Examples of personal information
Hygeine - DOB - work hx
Level of stress - risk for violence - anxiety level - patient unmet needs
Inattention and acute increase/decrease in cognitive function
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)

22. A patient failing to answer questions or displaying a reluctance to participate in group or family activities may be experiencing
Hemoglobin
Pain
Hearing loss
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts

23. 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.
Sensory motor
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Bacterial infection

24. When speaking with a patient with moderate hearing loss the RN should
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Communicate using hands and eyes.
Ongoing assessment
Pt's with oxygenation and perfusion problems

25. What is intermittent claudication?
Pain in legs assoc w walking
The patient
Disorganized thinking and altered LOC
Communicate using hands and eyes.

26. An example of a secondary source is
Capillaries
Medical
Family - spouse - someone other than a healthcare worker - previous medical records.
A false - fixed belief that cannot be corrected through reasoning.

27. What would cause changes in congitive development later in life (middle adulthood)?
Snap - crackle - pops; velcro - bubble wrap
Defining a baseline of cognitive function - any changes or deviations from norm.
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Trauma or illness

28. Sleep deprivation can effect
Have them do simple math problems
No
Learning - memory and adaptation to stress
Fluid volume deficit related to poor intake

29. If an abnormal finding is revealed during assessment - the nurse should
# of packs per day x # of years smoked
Double check equip and patient
Medical
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

30. What are the ABCDE's of pain management?
Defining a baseline of cognitive function - any changes or deviations from norm.
Have them do simple math problems
Ask - Believe - Choose - Deliver - Empower
Fast and deep respirations seen in patient's with acidosis

31. One way to test a person's cognitive ability and abstract thinking ability would be to
Have them do simple math problems
Sensorineural (auditory or cortical nerve - or brain stem malfunction) - conductive (bones in middle ear) - mixed (damage to inner/middle/outer ear or auditory nerve)
Adolescence
Fluid volume deficit related to poor intake

32. An infant is in which Paiget stage?
Sensory motor
Ongoing assessment
Implementation
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation

33. Name the 5 'W's' of assessing a change in LOC
Pain in legs assoc w walking
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Preschool is cause and effect - school age begins to use logical thought process.
Have them do simple math problems

34. Where can wheezes best be heard?
Upper airways
Stroke volume x's heart rate
Tricuspid - mitral and the aortic
Objective

35. What is the difference between hallucination and delirium?
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Nursing
Assess over all health status and identify the problem
Serves to expedite dx and tx of actual and potential health problems

36. Once a medical dx has been made - who is accountable for the reporting s/s of complications?
Nurse
Hearing loss
Decision assessment
Abstract thinking

37. Fluid volume deficit is a __________ dx
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Abstract thinking
Nursing
Secondary soureces (family - friends)

38. Orthopnea is described as?
Fluid volume deficit related to poor intake
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.
Having to use more than one pillow when sleeping
# of packs per day x # of years smoked

39. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
Non - opiod (ex: NSAID/acetominaphen)
Inattention and acute increase/decrease in cognitive function
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Viral infection

40. What is a component of the cognitive part of critical thinking skills?
Knowing What to do/how to make a decision based upon available data.
Confusion Assessment Method
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

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. Keeping patient's belongings - shoes - suitcases and street clothes - etc. out of view are helpful for preventing: wandering?
Risk of falls increases
Wandering
Implementation
No

43. At What age do you begin to use decision making?
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Adolescence
Secondary
Ongoing assessment

44. What scale is used to determine eating and feeding issues in adults with confusion
The patient
EdFED- Q
Ask - Believe - Choose - Deliver - Empower
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response

45. At patient that state their shoes are tighter at the end of the day may be experiencing
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
To ID the problem
Toddler
Edema

46. What is the formula for determining pack years?
Fast and deep respirations seen in patient's with acidosis
A personal experience that does whatever the person in pain says it does
Sensory motor
# of packs per day x # of years smoked

47. In Which part of the nursing process will you find delegation?
Implementation
The result is accurate patient dB
Loss of taste
Hemoglobin

48. Nursing dx provides basis of
Pain on inspiration and expiration; superficial squeaking or grating
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Interventions for which the nurse is accountable
Assess over all health status and identify the problem

49. All body system data is not necessary which type of assessment
Focused
Immature immune system - structures close together lends to easy spreading from on area to another.
Ask - Believe - Choose - Deliver - Empower
Having to use more than one pillow when sleeping

50. Data that is recorded for an immediate need (code blue or fall) would be included in
Serves to expedite dx and tx of actual and potential health problems
Hearing loss
Decision assessment
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli