Ethics & Legal Responsibilities
The Nursing Process
Infection Control
Head-to-Toe
Fluid & Electrolyte Imbalances
100

The right to make one's own personal decisions, even when those decisions might not be in that person's own best interest.

Autonomy

100
Systematic collection of information about clients' present health statuses to identify needs and additional data to collect based on findings.

Assessment

100

PPE minimally necessitating surgical mask

Droplet Isolation Precautions

100

Normal findings of auscultating an abdomen.

Bowel sounds are active in all 4 quadrants

100

Sodium Level of 160 mEq/L

Hypernatremia

200

A commitment to tell the truth

Veracity

200

In this step, the nurse determines the effectiveness of the nursing care plan. The nurse collects data based on the outcome criteria then compare what actually happened with the planned outcomes.

Evaluation

200

On the chain of infection, this includes bacteria, virus, fungus, prions, and parasites.

Causative Agent

200

Irregular respirations characterized by a cyclical pattern of shallow breaths that progress to a normal pattern, slows down, ends with an apneic period and cycles again.

Cheyne-Stokes Respirations

200

Symptoms include tetany, and positive Chvostek's Sign & Trousseau's Sign

Hypocalcemia

300

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of this ethical principle.

Nonmaleficence

300

A newly licensed nurse assesses a client who reports 4 out 10 pain. The nurse notes in the client's MAR an analgesic that may be given every 4 hr PRN for pain. The nurse administering the medication is an example of this part of the nursing process.

Implementation

300

Immunity developed by infants through ingestion of maternal breastmilk

Naturally Acquired Passive Immunity

300

Integument finding where there is loss of color that may be indicative of anemia, shock, or lack of blood flow.

Pallor

300

Imbalance causing EKG changes, showing peaked T waves, widened PR and QRS.

Hyperkalemia

400

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. The nurse understands the AP's action is an example of this tort.

Assault

400
Ineffective airway clearance related to fatigue as evidenced by dyspnea

Diagnosis

400

A client experiencing an onset of specific symptoms such as fever, malaise, cough, congestion, and rhinorrhea is on this stage of an infection.

Illness Stage

400

The degree of edema, characterized by a depth of severe pitting, 8mm deep, with a prolonged skin response

4+ Pitting Edema

400

Excessive sodium intake from IV fluids, diet, or medications and age-related changes in cardiovascular and kidney function are risk factors for this imbalance.

Fluid volume excess / Overhydration / Hypervolemia

500

A document in which clients designate a health care proxy to make health care decisions for them if they are unable to do so. The proxy can be any competent adult the client chooses.

Power of Attorney for Health Care

500

The assessment of vital signs and data collected through observation and examination such as grimacing, guarding, frowning.

Objective Data

500

Initiated when providing care for a client with active Varicella infection.

Airborne Isolation Precautions

500

Assessment finding of a "normal" functioning CN II and CN III

PERRLA

500

Increased hemoconcentration, increased BUN and an increased specific gravity are indicative of this imbalance

Hypovolemia / Fluid Volume Deficit / Dehydration