Critical Thinking
Basic thinking, recognizing cues.
What are the 5 steps to the nursing process?
ADPIE - Assessment, Diagnosis, Planning, Implementation, Evaluation
Define Electronic Health Record (EHR)
Comprehensive digital version of patient medical history.
What is the most effective method to prevent infection?
Hand hygiene
Name types of infections.
Localized, systemic and Healthcare-associated infections (HAI).
What is inductive reasoning?
Uses specific observations to make generalizations.
What are the two types of data?
Subjective (What the patient tells you)
Objective (What you observe, data (labs, reports)
What does SOAP note stand for?
S-Subjective, O-Objective, A-Assessment, P-Plan
Progress Note Documentation
Define standard precaution.
Precautions are applied to all patients.
How does malnutrition affect infection risk?
Increase infection risk.
What is clinical judgment?
It is the observable outcome of critical thinking and decision-making.
Name sources of patient data.
Patients, families, records, team members, diagnostics.
Protecting patient information from unauthorized access.
List components of PPE.
Gloves, gowns, masks, eye protection
What is critical thinking in Assessment?
Validating and interpreting data to identify health problems.
List attitudes essential for critical thinking.
confidence, independence, fairness, responsibility, risk-taking discipline, perserverance, creativity, curosity, integrity, and humility.
How do nurses validate assessment findings?
Compare data with norms, and verify with the patient.
List general guidelines for documentation.
Accuracy, timeliness, completeness, confidentiality.
Explain the chain of infection.
Agent, reservoir, portal of exit, transmission, portal of entry.
How do you properly remove PPE to avoid contamination?
Remove, gloves, gown, eye protection, then mask.
Describe the role of reflection in nursing practice.
Reflection helps evaluate and improve clinical decisions.
What is the purpose of a concept map?
To identify cues and patterns, to apply interventions.
Describe narrative documentation.
Traditional story-like format, chronological account of patient care.
List 3 signs of systemic infection.
Fatigue, chills, sweats
Hypotension (Low BP)
Tachycardia (↑ HR)
Confusion or Altered mental status
State principles of sterile technique.
Perform hand hygiene, keep a sterile field, sterile gloves must be worn, and avoid contamination.