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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. The order of air flow into the lungs is
# of packs per day x # of years smoked
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.
Hemoglobin
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

2. When a patient has increased lymphocytes - this may indicate what?
Viral infection
The result is accurate patient dB
Paradoxical reaction
Pt's with oxygenation and perfusion problems

3. When a patient has increased neutrophils - this may indicate what?
Edema
Double check equip and patient
Objective
Bacterial infection

4. At patient that state their shoes are tighter at the end of the day may be experiencing
Implementation
Loss of taste
Viral infection
Edema

5. The fifth vital sign is
Pain
Implementation
School age childen
Non - opiod (ex: NSAID/acetominaphen)

6. What is the cognitive difference between a preschooler and schoolage child?
Confusion Assessment Method
School age childen
Decision assessment
Preschool is cause and effect - school age begins to use logical thought process.

7. At What age do you begin to put thoughts into words?
Decreased sense of taste
Toddler
Nurse
EdFED- Q

8. The path of blood from the heart to the lungs is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Objective
Wandering
Pain

9. Two indicators that are REQUIRED for classification via the CAM tool include
Wandering
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Inattention and acute increase/decrease in cognitive function
Adolescence

10. Would a nursing dx be part of the primary or secondary dx?
Double check equip and patient
Secondary
Nursing
Surgically implanted device for deaf or hard or hearing - also called bionic ear.

11. Inspiration sounds are heard longer than expiration sounds In What area?
Focused
Vesicular (peripheral lung areas)
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Pt's underlying feelings

12. The purpose of an intitial assement serves to?
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Broncial (heard over trachea)
Assess over all health status and identify the problem
EdFED- Q

13. What is a definition of a delusion?
A false - fixed belief that cannot be corrected through reasoning.
Adolescence
Objective
Secondary

14. What are the ABCDE's of pain management?
Ask - Believe - Choose - Deliver - Empower
Pt's with oxygenation and perfusion problems
Fluid volume deficit related to poor intake
Tricuspid - mitral and the aortic

15. Another term for a focused assessment is
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Risk of falls increases
Pain in legs assoc w walking
Ongoing assessment

16. One way to test a person's cognitive ability and abstract thinking ability would be to
Trauma or illness
An 80 y/o patient that has emergency surgery
Fluid volume deficit related to poor intake
Have them do simple math problems

17. If an abnormal finding is revealed during assessment - the nurse should
Upper airways
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Double check equip and patient
Anteriorly @ intercostal spaces 1 and 2. Posteriorly between the scapulae.

18. The site where gas exchange occurs is
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
The result is accurate patient dB
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
Capillaries

19. What does CAM stand for
Symptoms
ID'ing status of exisiting problems and locating new issues
Confusion Assessment Method
# of packs per day x # of years smoked

20. An example of a primary source is
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
The result is accurate patient dB
Decreased arterial perfusion
The patient

21. What would cause changes in congitive development later in life (middle adulthood)?
Trauma or illness
Immature immune system - structures close together lends to easy spreading from on area to another.
Viral infection
Learning - memory and adaptation to stress

22. The purpose of an initial assessment is
Serves to expedite dx and tx of actual and potential health problems
Adolescence
Confusion Assessment Method
To ID the problem

23. If patient reports pain of 3 on scale of 0-10 - What is the appropriate class of pain reliever?
The medication will not affect the patient's breathing.
Communicate using hands and eyes.
A personal experience that does whatever the person in pain says it does
Non - opiod (ex: NSAID/acetominaphen)

24. What are the steps of the nursing process?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
8.4
Initial assessment
The patient

25. A patient that is dying is on morphine. The family is concerned the prs breathing will stop. What is the correct RN response?

26. What is the purpose of the nursing process?
Serves to expedite dx and tx of actual and potential health problems
No
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
The result is accurate patient dB

27. Describe the purpose of a mental status exam
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.
Secondary
Defining a baseline of cognitive function - any changes or deviations from norm.
Decision assessment

28. What are Cheyne Stokes?
8.4
Trauma or illness
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Irregular respirations (fast/slow) often seen at end of life

29. In Which part of the nursing process will you find delegation?
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.
Implementation
ID'ing status of exisiting problems and locating new issues

30. Ageusia is
Pain in legs assoc w walking
Eye hygeine - accomodating factors - what was the level of decline - how long has it been
A false - fixed belief that cannot be corrected through reasoning.
Loss of taste

31. Data validation assures
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
The result is accurate patient dB
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
To ID the problem

32. What is the formula for determining pack years?
Pain
# of packs per day x # of years smoked
Edema
Clinical judement about a patient - family or community response to actual or potential health problems and life processes.

33. What are the components of a mental status exam that are not part of a regular assessment?
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Learning - memory and adaptation to stress
Edema
Long and s/t memory - attention - ability to calculate problems/abstract thinking - delusions/perceptual disturbances

34. When dealing with a confused patient - should the nurse acknowledge the patient's underlying feelings or the content of the delusion?

35. Name the 5 'W's' of assessing a change in LOC
Wind (hypoxia/pneumonia) - water (UTI/dehydration) - wound (infection/sepsis) - walk (DVT - showering clots) and weird (new drugs)
Sensory motor
Adolescence
Confusion Assessment Method

36. What scale is used to determine eating and feeding issues in adults with confusion
Ongoing assessment
Nurse
EdFED- Q
School age childen

37. An ongoing assessment is performed
Daily
Upper airways
Immature immune system - structures close together lends to easy spreading from on area to another.
Toddler

38. A patient that is easily fatigued may have a HgB lab value of?
Focused
8.4
Sup/inferior vena cava - into the r/atrium - tricuspid - rt ventricle - pulmonary veins
Fluid volume deficit related to poor intake

39. Data gathered via instrumention (pulse ox) is considered
Sensory motor
Ask - Believe - Choose - Deliver - Empower
Toddler
Objective

40. Fluid volume deficit is a __________ dx
Risk of falls increases
Nursing
Defining a baseline of cognitive function - any changes or deviations from norm.
Snap - crackle - pops; velcro - bubble wrap

41. What is a component of the cognitive part of critical thinking skills?
Pt's with oxygenation and perfusion problems
Knowing What to do/how to make a decision based upon available data.
Level of stress - risk for violence - anxiety level - patient unmet needs
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

42. What is a chochlear implant?
Loss of taste
Sensory motor
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Nares - nasopharynx - trachea - bronchi - broncioles - alveoli

43. An infant is in which Paiget stage?
ADPIE - Assessment - Dx - Planning - Implentation and Evaluation
Upper airways
Confusion Assessment Method
Sensory motor

44. All body system data is not necessary which type of assessment
Pt's with oxygenation and perfusion problems
Focused
Communicate using hands and eyes.
Maslow

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

46. An example of a nursing dx would be
Pain
Fluid volume deficit related to poor intake
Surgically implanted device for deaf or hard or hearing - also called bionic ear.
Family - spouse - someone other than a healthcare worker - previous medical records.

47. Side effects of putting confused pts in restraints include
Functional decline - cardiovascular distress - incontinence - pressure ulcers - aggitation - muscle atrohpy
Approach from front - walk slow - stand to side - crouch low - offer hand - call by name - wait for response
Ongoing assessment
Delerium has stimulus that is misinterpreted - whereas a halluciantion has no stimulus.

48. Nursing interventions should be based on who's theory?
Maslow
Tricuspid - mitral and the aortic
Fast and deep respirations seen in patient's with acidosis
EdFED- Q

49. What are the components of an assessment?
Risk of falls increases
Pulmonary artery - left atrium - mitral valve - left ventricle - aortic valve
Data collection - data validation - data organization - data analysis - and data reporting/recording.
Nailpolish - skin color - too bright light - poor peripheral blood flow - patient is too cold - low HgB levels -

50. QUESTT is a tool for What type of an assessment?
Trend assessment (shift report)
Best heard over large airways due to secretions in lungs - sounds like gurgles - snorts
Pain
Focused