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Fundamentals of Nursing > Fundamentals Test #1 > Flashcards

Fundamentals Test #1 Flashcards

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1
Q

What is the Nursing Process?

A

A dynamic, continuous, client-centered, problem-solving, and decision-making framework

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2
Q

What is the first step in the Nursing Process?

A

Assessment/Data Collection

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3
Q

What are the types of assessments?

A

Initial Assessment, Focused Assessment, and a Ongoing Assessment

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4
Q

What is Subjective Data

A

Data that the client tells the nurse

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5
Q

What is Objective Data?

A

Data that can be quantified and is observed

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6
Q

What is Secondary Subjective Data?

A

Data collected from other sources based on what the client has told them

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7
Q

What is Secondary Objective Data?

A

Data that is collected from items such as pt chart, doctor, etc.

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8
Q

What is the second step in the Nursing Process?

A

Analysis/Data Collection

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9
Q

What is Analysis/Data Collection?

A

Using critical thinking skills to identify clients’ health status or problems

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10
Q

What is the third step in the Nursing Process?

A

Planning

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11
Q

When does discharge planning begin?

A

Immediately!!!

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12
Q

What is Maslow’s Hierarchy of Basic Needs?

A

Physiological -> Safety & Security -> Love and Belonging -> Self-Esteem -> Self-Actualization

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13
Q

What is involved in the planning stage?

A

A nurse determines the plan of care for a client and sets goals that the client can reach

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14
Q

Difference in goals and outcomes?

A

Goals identify optimal status whereas outcomes identify the observable criterion that will determine success or failure of the goal

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15
Q

Requirements for a goal?

A

Client-Centered, Singular, Observable, Measurable, Time-Limited, Mutually Agreeable, and Reasonable

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16
Q

What is the end product of planning?

A

Nursing Care Plan

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17
Q

The fourth step in the Nursing Process?

A

Implementation

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18
Q

How do nurses select what procedures they perform?

A

Evidence-Based Rationale

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19
Q

What is implementation?

A

Nurses provide the care they have planned for through interventions

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20
Q

What is the last step in the Nursing Process?

A

Evaluation

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21
Q

What is evaluation?

A

Evaluating how the client responded to treatment and examining if the goals are met

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22
Q

What happens with goals?

A

Expected Outcome and Actual Outcome are compared

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23
Q

If a client has not achieved satisfactory goal outcomes, what is the next step?

A

To reassess the client to determine the next set of actions

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24
Q

What are the five nursing process steps?

A

Assessment -> Diagnose/Analyze -> Plan -> Implement -> Evaluate

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25
Q

What are vital signs?

A

Measurements of the body’s most basic functions and are: Temp, Pulse, Respiration, and BP

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26
Q

Oral Temperature Ranges?

A

96.8 (36C) - 100.4 (38C)

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27
Q

Differences in Rectal, Oral, Axillary, and Temporal ranges?

A

Rectal: 0.5C/0.9F Higher; Axillary: 0.5C/0.9F Lower; Temporal 0.5C/1.0F Higher

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28
Q

Newborn Temperature Range?

A

97.7 - 99.5 (36.5-37.5)

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29
Q

Normal pulse range?

A

60-100 BPM

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30
Q

Normal respirations range?

A

12-20 Breaths per min

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31
Q

Normal Blood Pressure?

A

Below 120 / Below 80

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32
Q

Prehypertension Range?

A

120 to 139 / 80 to 89

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33
Q

Stage 1 Hypertension Range?

A

140 to 159 / 90 to 99

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34
Q

Stage 2 Hypertension Range?

A

Greater than 160 / Greater than 100

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35
Q

What are the ABC’s of Nursing?

A

Airway, Breathing, Circulation

36
Q

What is the A in ABC’s of nursing mean?

A

A clear patient airway so oxygen will have a pathway into the lungs for gas exchange and carbon dioxide can be expelled from the body

37
Q

What does the B in ABC’s of nursing mean?

A

An effective breathing pattern and respiratory effort to take in enough oxygen to meet cellular demands for oxygen throughout the body

38
Q

What does the C in ABC’s of nursing mean?

A

An effective circulatory system to deliver oxygen throughout the body and allow carbon dioxide removal through the pulmonary circulatory network

39
Q

What are the priorities levels?

A

Low, Medium, and High

40
Q

What is a low priority problem?

A

Problems that can be resolved with minimal interventions and do not cause significants dysfunction; Ex. Client request for afternoon snack

41
Q

What is a medium priority problem?

A

Problems that may result in unhealthy physical or emotional consequences but which are not life threatening; Ex. Spiritual Distress

42
Q

What is a high priority problem?

A

Problems of life-threatening problems of airway, breathing, and circulation or conditions that have a potential to become life threatening within a short amount of time; Ex. Chest Tube Insertion (need to monitor)

43
Q

Assessment Steps:

A

Collect Data -> Organize Data -> Validate Data

44
Q

Diagnosis Steps:

A

Analyze Data -> Identify Health Problems, Risks, and Strengths -> Formulate Diagnostic Statements

45
Q

Planning Steps:

A

Prioritize Problems/Dx -> Formulate Goals/Desired Outcomes -> Select Nursing Interventions -> Write Nursing Int.

46
Q

Implementation Steps:

A

Reassess Client -> Determine Nurse’s need for Assistance -> Implement the Nursing Int. -> Supervise Delegated Care -> Document Nursing Activities

47
Q

Evaluation Steps:

A

Collect Data Related to Outcomes -> Compare Data with Outcomes -> Relate Nursing Actions to Client Goals/Outcomes -> Draw Conclusions -> Continue, Modify, or Terminate the client’s care plan

48
Q

What is the three step process to write a nursing diagnosis?

A

Problem -> Etiology -> Signs & Symptons

49
Q

What is an independent intervention?

A

Activities that nurses are licensed to do within their scope; Ex. Physical Care, Assessment, Emotional Support, etc.

50
Q

What is a collaborative intervention?

A

A combination of professionals performing one intervention

51
Q

What are the five rights of delegation?

A

Task, Circumstance, Person, Direction & Communication, and Supervision & Evaluation

52
Q

What procedures for the most part can be delegated?

A

Non-Invasive Procedures

53
Q

What are Values?

A

Personal beliefs about idea that determine standards the shape behavior

54
Q

What are Morals?

A

Personal Values and beliefs about behavior and decision/making

55
Q

What are the basic principles of ethics?

A

Advocacy, Responsibility, Accountability, and Confidentiality

56
Q

Advocacy is?

A

Support of clients’ health, wellness, safety, and personal rights, including privacy

57
Q

Responsibility is?

A

Willingness to respect obligations and follow through on promises

58
Q

Accountability is?

A

Ability to answer for one’s own actions

59
Q

Confidentiality is?

A

Protection of privacy without diminishing access to high-quality care

60
Q

What are the ethical principles for client care?

A

Autonomy, Beneficence, Fidelity, Justice, Nonmaleficence, and Veracity

61
Q

Autonomy is?

A

Right to make one’s own personal decisions

62
Q

Beneficence is?

A

Action that promotes good for others without self interest

63
Q

Fidelity is?

A

Fulfillment of promises

64
Q

Justice is?

A

Fairness in care delivery and use of resources

65
Q

Nonmaleficence is?

A

Commitment to do no harm

66
Q

Veracity is?

A

Commitment to tell the truth

67
Q

What are unintentional torts?

A

Negligence and Malpractice

68
Q

What are Quasi-Intentional Torts?

A

Breach of Confidentiality and Defamation of Character

69
Q

What are intentional torts?

A

Assault, Battery, and False Imprisonment

70
Q

What is negligence?

A

Conduct that deviates from what a reasonable person would do in a circumstance

71
Q

What is professional negligence?

A

Conduct deviating from the standard of practice dictated by the profession

72
Q

Elements of malpractice?

A

Duty, Breach of Duty, Foreseeability, Causation, and form of injury/harm

73
Q

What is Assault?

A

Action of creating an apprehension of offensive, insulting, or physically injurious touching

74
Q

What is Battery?

A

Willful touching of another individual that is unwanted, embarrassing, or unwarranted

75
Q

What is informed consent?

A

When a provider explains and the client understands

76
Q

Nurse’s role in informed consent?

A

Nurse can witness signature and can ensure that the provider has obtained informed consent responsibly

77
Q

What must a client provide written informed consent for?

A

Invasive procedures

78
Q

What is a living will?

A

A legal document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitated is facing end of life issues

79
Q

What is a durable power of attorney?

A

A health care proxy designation to make decisions for their health if they are unable to do so

80
Q

Nurse responsibility regarding abuse?

A

Must report abuse and communicable diseases

81
Q

What are Clarifying Techniques?

A

Restating, Reflecting, Paraphrasing, and Exploring

82
Q

What is “restating”

A

Using the client’s exact words

83
Q

What is “reflecting”

A

Directs the focus back to the client for him to examine his feelings

84
Q

What is “paraphrasing”

A

Restate the client’s feelings and thoughts for him to confirm what he has communicated

85
Q

What is “exploring”

A

Allows the nurse to gather more information about important topics the client mentioned

Fundamentals of Nursing (4 decks)

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