Fundamentals Test 1

Question 1

What is the nursing process?

Answer 1

ADPIE: Assessment, Diagnosis, plan, implementation, evaluation

Question 2

Medical-surgical nursing

Answer 2

Adult health nursing: To promote health and prevent illness or injury in patients from 18 to >100.

Question 3

Physical restraints

Answer 3

Check every 30-60 min. Remove every 2 hours.

Question 4

Physiological changes when aging

Answer 4

• Medications aren’t absorbed
• Everything Slows down
• Higher risk for toxicity

Question 5

Delirium

Answer 5

An ACUTE state of confusion. Short-term and reversible.

Question 6

Dementia

Answer 6

A slow progressive cognitive decline. CHRONIC confusion.

Question 7

Depression

Answer 7

A mood disorder that can have cognitive, affective, and physical manifestations.

Question 8

Young old
Middle old
Old old
Elite old

Answer 8

65-74
75-84
85-99
100+

Question 9

Neglect

Answer 9

Failure to provide basic needs.

Question 10

Physical Abuse

Answer 10

Use of physical that results in bodily injury.

Question 11

Financial Abuse

Answer 11

Mismanagement or misuse of property or resources.

Question 12

Emotional Abuse

Answer 12

Intentional use of threats, humiliation, intimidation, and isolation.

Question 13

Autosomal Dominant

Answer 13

• Gene alleles controlling trait
• A dominant gene allele is expressed only when one allele of the pair is dominant.
• Appears in every generation with no skipping.
• Risk 50%
• Equal in males and females

Question 14

Autosomal Recessive

Answer 14

• Required to be an autosomal chromosome
• Only expressed when both alleles are present
• May not appear in all generations
• only 25% of a family will be affected

Question 15

Genetic Testing

Answer 15

• Sickle cell disease
• Hemophilia
• Hereditary hemochromatosis
• Cystic Fibrosis
• Beta thalassemia
• Tay-Sachs disease
• Huntington disease

Question 16

Purpose of rehab

Answer 16

• The continuous process of learning to live with chronic and disabling conditions, often those resulting from trauma.
• Aims to help patient return to best possible physical, mental, social, vocational, and economic capacity.

Question 17

Cultural competence

Answer 17

Respecting all differences and not letting one’s own biases influence others.

Question 18

Nursing intervention anxiety and post-op care

Answer 18

Physical signs of anxiety include; restlessness, increased pulse, BP, respiratory rate, and crying.

Question 19

Pre-op intervention

Answer 19

• remove most clothes & wear hospital gown
• valuable w/ family or locked up
• tape rings in place if cannot be removed
• patient wears identification band
• dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be removed.

Question 20

Prevent DVTs

Answer 20

• antiembolism stockings (TED hose)
• pneumatic compression device
• leg exercises
• mobility

Question 21

General anesthesia

Answer 21

Patient is unconscious

Question 22

Local anesthesia

Answer 22

Applied to skin or mucous membrane, affects nerve impulse.

Question 23

Regional anesthesia

Answer 23

Blocks multiple peripheral nerves, used when general can’t be used.

Question 24

Epidural

Answer 24

Waist down

Question 25

Conscious

Answer 25

Patient is not awake, in a sleepy state.

Question 26

Allergy that gives increased risk to allergy to iodine

Answer 26

Shellfish

Question 27

Incentive spirometer

Answer 27

Encourages patient to take deep breaths. Seal lips around mouthpiece, inhale spontaneously, & hold breath for 3-5 sec. for effective lung expansion. Atelectasis: collapse of alveolar

Question 28

Discharge planning

Answer 28

Begins in pre-op phase.

Question 29

Urine output

Answer 29

30 mL/hr

Question 30

Sickle cell

Answer 30

Recessive

Question 31

Huntington's

Answer 31

Dominant

Question 32

How many chromosomes?

Answer 32

23

Question 33

Creatine level

Answer 33

0.5-1.2

Question 34

Peristalsis

Answer 34

A series of muscle contractions that occur in your digestive tract. Up to 24 hours after surgery.

Question 35

Respiratory system assessment

Answer 35

- patient airway and adequate gas exchange - note artificial airway, when applicable - rate, pattern, and depth of breathing - breath sounds - snoring and stridor - respiratory depression or hypoxemia

Question 36

Cardio assessment

Answer 36

- vital signs - heart sounds - cardiac monitoring - peripheral vascular assessment

Question 37

Neurologic system assessment

Answer 37

motor function- simple commands; patient to move extremities.

Question 38

Renal/ urinary system

Answer 38

- check for urine retention - consider other sources of output like sweat, vomitus, or diarrhea stools - report urine output of <30 mL/hr

Question 39

Gastrointestinal system

Answer 39

- 30% experience n/v after general anesthesia - peristalsis may be delayed up to 24hrs - monitor bowel sounds

Question 40

Skin assessment

Answer 40

- normal wound healing | - ineffective wound healing can be seen most often between the 5th and 10th days after surgery

Question 41

Dehiscence

Answer 41

A partial or complete separation of the outer wound layers.

Question 42

Evisceration

Answer 42

A total separation of all wound layers and protrusion of internal organs through the open wound. `

Question 43

Rapid response

Answer 43

Save lives and decrease risk for harm by providing care to patients before a respiratory or cardiac arrest occurs.