Week 1 Exam 1 Nursing Process

Question 1

What is Bloom’s Taxonomy? (Think triangle, 6 levels. List in order)
Lecture 1, slide 15

Answer 1

1. create-produce new or original work
2. evaluate- justify a stand or decision
3. analyze- draw connections among ideas
4. apply- use info n new situations
5. understand-explain ideas or concepts
6. remember- recall facts and basic concepts

Question 2

Definition of Nursing

Answer 2

The American Nurses Association (ANA) states nursing is theprotection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (ANA, 2023).

Question 3

Explain importance of QSEN (Quality and Safety Education for Nurses) to current nursing education.

Answer 3

QSEN (patient-centered care, teamwork, collaboration,evidence-based practice, safety and informatics)

Why important? regulate care.
how do nurses benefit? Regulate care and prevent harm
How do patients benefit? improve patient care, right training

Question 4

What is the responsibility of an RN?

Answer 4

perform physical exams, health history. Provide health promotion, counseling, and education. prevent harm.

Question 5

When do nurses provide education?

Answer 5

When administer meds, or other personalized information.

Question 6

What does KBN do?

Answer 6

provide license for nurses

Question 7

What does ACEN do?

Answer 7

accreditation for education

Question 8

QSEN- what are the six core competencies?

Answer 8

The six core competencies are: 1.Evidence Based Practice
2.Quality Improvement
3.Safety
4.Informatics
5.Patient Centered Care
6.Teamwork and Collaboration

Question 9

Nursing mostly came about because of…

Answer 9

war and solider care

Question 10

Florence Nightingale

Answer 10

is known as the founder of modern day nursing

Question 11

JCAHO is what?

Answer 11

Joint Commission on Accreditation of Healthcare Organizations
Hospital “grade” based on how they perform on set of standards. One measurement is looking at how hospitals perform on JCAHO’s National Patient Safety Goals. They grade the hospital: A,B,C

Centers for Medicare/Medicaid Services (CMS)- Pays bills based on hospital grade

Private Insurances will also require certain standards to be met prior to paying a facility or practitioner for services.

Question 12

National patient Safety Goals
ask if on exam

Answer 12

slide 41

Question 13

Why does Joint Commission come in to hospitals?

Answer 13

For reimbursement from medicaid.

Question 14

Are hospital acquired infections reimbursed?

Answer 14

No.
- pressure ulcers, MRSA, C-DIFF,post op problems, hospital fall or fracture and some others are not paid by medicare.

Question 15

Issues in healthcare

Answer 15

• aging population
  -alternative therapies
  -consumerism (who has the best hospital)
  -Rural vs Virtual

Question 16

The nurse is infuriated by an inappropriate comment the client makes regarding religion. What is the nurse’s best response?

Answer 16

A. Ask for another patient assignment.
B. Care for the client as if they would anyone else.
C. Tell the client you don’t agree with them. But, will agree to disagree.
D. Educate the client on different religions.

Answer B.

Question 17

3 Key Concepts to Evidence Based Practice

Answer 17

1.Practice: stimulates ideas to improve quality of care
2. Research: the nurse investigates to the idea or question
3. Theory: the nurse develops a practice theory based on findings

Question 18

Nursing theory by: Dr. Jean Watson developed the Science of Human Caring theory in 1988.

Answer 18

Nurses cam provide something “more”. For example: empathy, compassion

Question 19

Nursing theory help nurses by:

Answer 19

Nursing theories serve as a guide for assessment, problem identification, and interventions. They help nurses communicate what is important.

Question 20

Clinical practice theories guide what?

Answer 20

Clinical Practice.

Question 21

Patricia Benner: Had what kind of nurse theory?

Answer 21

Novice to Expert – match nursing skill with patient acuity

Question 22

The purpose of nursing research is to..

Answer 22

develop knowledge about issues important to nursing. Goal to improve patient care.

Evidence Base Practice Examples:

Heparin vs Saline Locked IV’s Discontinuing Catheters 2 Days Post Op
Briefs vs Pure Wicks

Question 23

Phases of the research process

Answer 23

Select and define the problem.
Select a research design.
Collect data.
Analyze data.
Use research findings.
Share findings.

Question 24

Informed Consent is what?

Answer 24

Patient provided the most up to date accurate information. Patient has right to refuse. Nurse can only educate.

Question 25

What is the Nursing Process?

Answer 25

ADPIE
Assessment
Diagnosis/Problem
Planning
Implementation
Evaluation

Question 26

What is assessment?

Answer 26

Systematic gathering of information r/t the physiological, psychological, sociocultural, developmental, and spiritual status of an individual, group, or community.
Purpose: obtain data to allow the nurse to help
Subjective Data is data the nurse receives from the patient or family.
Objective Data can be measured or observed by the nurse or other HCP.

Question 27

What is included in the assessment stage?

Answer 27

Health history – biographical data, chief complaint, family history, complementary medicine, social history
Organizing data
Validating data
Documenting data

Question 28

What is included when Documenting data stage?

Answer 28

Document as soon as possible.
Use proper spelling and grammar.
Use acronyms sparingly.
Write patients own words, when possible.
Record only the most important patient words.
Use concrete, specific information.
Record cues, not inferences. For example, incision is red and smelly versus the incision is infected.

Question 29

What is included in the Diagnosis stage?

Answer 29

Diagnosis involves analyzing the data you collected. Using critical thinking, the nurse identifies trends and draws conclusions about the client’s health status, strengths, and problems.

Question 30

Is a Nursing Diagnosis different from a Doctor diagnosis?

Answer 30

Yes.
Nurse- impaired pathway
Doctor- Pneumonia (Nurse can’t use this term).

Question 31

Prioritize Problems – What will the nurse do FIRST? What is the nurse’s priority?

Answer 31

Assessment, Breathing.

Nurses typically assess first.
Maslow’s theory
What can the nurse do without leaving the room?
What will kill the patient first?
Least invasive with greatest benefit.

Question 32

What is Maslow’s hierarchy of needs? Week 1 second pp, slide 27

Answer 32

1. self-actualization
2. Esteem
3. Love and Belonging
4. Safety Needs
5. Physiological needs

Question 33

Suppose that on Todd’s transfer from the ED (Meet Your Patient), you made the following nursing diagnoses for him. Using problem urgency as your criterion, assign each of these diagnoses a low, medium, or high priority.

Answer 33

Shortness of air related to kidney failure 1. HIGH

Risk for Falls related to decreased sensation and mobility in legs 2. LOW

Lack of Knowledge (renal disease process) r/t new diagnosis of renal involvement secondary to type 2 DM
3. MEDIUM

Question 34

What is the Planning stage?

Answer 34

Initial planning begins with the first client contact.
Ongoing planning refers to changes made in the plan as you evaluate the clients response to care. Day to day decisions may change.
Discharge planning refers to planning for self-care and continuity of care after the client leaves the facility. The purpose of discharge planning is to promote the client’s progress toward health or disease management and to reduce chances of readmission.

Question 35

Discharge Planning begins when?

Answer 35

Initial Assessment

Question 36

Nursing Care Plans:

Answer 36

Standardized Plans: Preprinted plans for specialized patients

For example, a client who has a coronary artery bypass graft (CABG) is admitted to a CVICU. The client will have a standardized plan preset for them.
Extubated within 6 hours.
Up to the chair within 8 hours.
Ambulating the next morning.
Urinary Catheter discontinued day 2 post op.

Question 37

Patient GOALS should be written how?

Answer 37

Goals should be written SMART – specific, measurable, attainable, relevant, and timed

Question 38

What is the Evaluation Stage?

Answer 38

All interventions should be evaluated. Did your receive the response you expected from the intervention. For example:

Goal: Patient will maintain O2 sat greater than 88% throughout my shift.

Evaluation: Goal met. Patient maintained O2 sat greater than 88%.

Question 39

Client X is readmitted to the hospital 2 days after discharge. Client X states they had verbalized several times that they didn’t feel comfortable going home. Now they are back after a fall at home trying to go to the bathroom. Client X lives with their spousein a ranch style home in downtown Lexington.

VS: 145/95 HR 110 RR 20 O2 Sat 88 Pain 6
Assessment: Alert and oriented, speech is appropriate, gait is unsteady per baseline, lung sounds are diminished in LLL, bowel sounds normal, small abrasion to left knee, DP pulses present.
What should the nurse do first?
Ask about quality of pain
Ask the client his normal HR and BP
Ask the patient if they are short of air
Give 500 mg of Tylenol stat

Answer 39

What should the nurse do first?
1. Ask about quality of pain
2. Ask the client his normal HR and BP
3. Ask the patient if they are short of air
4. Give 500 mg of Tylenol stat

Number 3.

Question 40

The nurse enters the room of a newly admitted client. The client is tearful and states they want to go home. VS: 140/90, o2sat 94%, RR 14, T 99. The client verbalizes a pain score of 7 out of 10. The client tells the nurse they are worried about leakage in the car and in public. What is the nurses first intervention?

Answer 40

A. Assure the client things will get better.
B. Ask more about pain.
C. Give the client a damp cloth to wash face.
D. Ask the patient why they are upset.

B.

Question 41

The nurse received report on 4 patients. Which patient will the nurse see first?

Answer 41

1.
An 80 year old receiving narcotics and up ad lib.
2. A 45 year old admitted with a leg fracture requesting pain medication.
3. A surgery patient who arrived to the floor 30 minutes ago and needs their antibiotic.
4. A 50 year old requesting a breathing treatment.

answer 4.

Question 42

What is objective vs subjective data?

Question 43

Know the difference in physical assessments- focus vs wellness