Nursing Process
Describe Each step of the Nursing Process?
Assessment: Collection of data, analysis and verification of information
Diagnosis: Analyze information
Planning: Nurse and Patient mutually decide on a plan of care (POC)
Implementation: Taking agreed on action to alter patients status/symptoms
Evaluation: Nurse and patient mutually evaluate attainment of expected outcomes and survey each step of the nursing process
After collecting data you should....?
Validate it!
A nurse is caring for a client who has a terminal illness. The client is restless and reports sever pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?
A. Ask why the client is refusing the pain medication.
B. Administer a PRN antianxiety medication
C. Assist the client in changing positions
D. Offer the client a heat or cold pack to place on painful areas.
A. Aske why the client is refusing the pain medication.
If patient has (2) of anything, always....?
Assess for symmetry~
Edema is a sign of....?
A "cue" is information that is obtained through______?
Use of your SENSES
What is the difference between subjective and objective data?
*Subjective date is information that the patient gives you
*Objective data is measurable, information that is observed, felt, heard, smelled etc.
A nurse is collecting data from a client who has asthma and reports several food allergies. Which of the following actions should the nurse perform first:
A. Document the clients food allergies in the medical record
B. Ask the client to identify the specific food allergies
C. Monitor the client for indications of anaphylaxis
D. Have epinephrine available for administration
B. Ask the client to identify the specific food allergies.
The physical exam will reveal mostly_______ data?
Objective
If a pulse cannot be palpated a ________ may also be used to confirm.
Doppler
What does PES stand for in nursing diagnosis?
PES = Problem related to the Etiology (cause) as evidenced/manifested by the Signs and Symptoms (defining characteristics).
When you initiate a care plan, list the diagnoses in order from_________?
Highest to lowest!
*ABC priority is first followed by Maslow's Hierarchy
A nurse is assisting with the admission of a client who will undergo a craniotomy. During the planning phase of the nursing process, to which of the following areas should the nurse contribute?
A. Establishing client outcomes
B. Collecting information about past health problems
C. Determining whether the client has met goals
D. Identifying the clients specific health problems.
A. Establishing client outcomes
Cyanosis may be a symptom of....?
Poor oxygen, circulation
What is the term for abnormal lung sounds?
Adventitious lung sounds
Who is the only source of "Subjective" data?
The patient
Patient "goals and outcomes" should be SMART, what does that stand for?
Specific
Measurable
Attainable
Realistic
Timely
A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first?
A. Instruct the client to cough
B. Administer oxygen via face mask
C. Evaluate the client for stridor
D. Keep the client in semi-to high-Fowler's position
C. Evaluate the client for stridor.
*The first action the nurse should take using the nursing process is to collect data from the client.
A. Thin, shiny skin
B. Coolness to touch
C. Marked Edema
D. Dusky red coloration
C. Marked Edema
A patient with asthma has gone to an urgent care center for treatment. ON auscultation of the lungs, a nurse hears rhonchi. These sounds are described as:
A. Dry and grating
B. Loud, low-pitched and course
C. High-pitched, fine and short
D. High-pitched and musical
B. Loud, low-pitched, rumbling course sound heard during either inspiration or expiration.
What nursing interventions can the nurse implement without an order?
(name at least 3)
-Turning the patient
-Education
-Assisting with feeding
-Assisting with bathing
-Performing assessments
-Monitoring patient
What are examples of Objective Data?
Vitals
Labs
Diagnostic Tests
SOunds
All "at risk for" diagnosis will NEVER have.....?
Proof or evidence.
What are causes of phlebitis?
-Insertion technique
-Condition of thevein
-Duration of the cannulation
-Type of fluid/medication
A nurse has checked the the medical record and found that a patient has anemia. The presence of anemia is accompanied by the nurse's finding of:
A. Pallor
B. Erythema
C. Jaundice
D. Cyanosis
A. Pallor