Adult Nursing I: Exam 1 Questions With Complete
Solutions
Guidelines of Documentation
- consistent with professional and agency standards
- complete
- accurate
- concise
- factual
- organized and timely
- legally prudent
- confidential
- non-judgemental
- content
-format
- accountability
- confidentiality
Important Components of Telephone/Verbal Orders
- record
- ALWAYS read back to confirm correctness
- date/time
- write "verbal order"
- your name and prescriber's name
- prescriber will review and sign at a later date/time
Components of Hand-Off Reports
,- basic identifying information
- current health status & vitals
- orders
- anything abnormal that happened during your shift
- anything that needs to be continued onto the next shift
- client/family questions or concerns
- reports on transfers/discharges
Incident Reports
A tool used by healthcare facilities to document unexpected
events that result in, or have the potential to result in, harm to a
patient or person or damaged property.
The Nursing Process
A systematic method that directs the nurse, with the patient's
participation, to accomplish a number of steps:
- assessing
- diagnosing
- planning
- implementation
- evaluation
Assessing (Nursing Process)
Collection, validation, and communication of patient data.
- make a judgement about a patient's health status, ability to
manage their own care, and need for nursing.
- plan individual holistic care that draws on patient strengths and
is responsive to changes in the patient's conditions
Diagnosis (Nursing Process)
, Analysis of patient data to identify patient strengths and health
problems.
- develop a prioritized list of problems/needs
Planning (Nursing Process)
Specification of patient outcomes to prevent, reduce, or resolve
the problems identified; and related nursing interventions.
- develop an individualized plan of nursing care
- identify patient strengths that can be tapped to facilitate
achievement of desired outcomes.
Implementation (Nursing Process)
Carrying out the plan of care.
- assist patients to achieve desired outcomes - promote wellness,
prevent disease and illness, restore health, and facilitate coping
with altered functioning.
Evaluation (Nursing Process)
Measuring the extent to which the patient has achieved the
outcomes specified in the plan of care; identifying factors that
positively or negatively influenced outcome achievement;
revising the plan of care if necessary.
- continue, modify, or terminate nursing care
Stages of Assessment
1. collection of information
- primary sources
- secondary sources
2. validate the data
3. interpret data
Solutions
Guidelines of Documentation
- consistent with professional and agency standards
- complete
- accurate
- concise
- factual
- organized and timely
- legally prudent
- confidential
- non-judgemental
- content
-format
- accountability
- confidentiality
Important Components of Telephone/Verbal Orders
- record
- ALWAYS read back to confirm correctness
- date/time
- write "verbal order"
- your name and prescriber's name
- prescriber will review and sign at a later date/time
Components of Hand-Off Reports
,- basic identifying information
- current health status & vitals
- orders
- anything abnormal that happened during your shift
- anything that needs to be continued onto the next shift
- client/family questions or concerns
- reports on transfers/discharges
Incident Reports
A tool used by healthcare facilities to document unexpected
events that result in, or have the potential to result in, harm to a
patient or person or damaged property.
The Nursing Process
A systematic method that directs the nurse, with the patient's
participation, to accomplish a number of steps:
- assessing
- diagnosing
- planning
- implementation
- evaluation
Assessing (Nursing Process)
Collection, validation, and communication of patient data.
- make a judgement about a patient's health status, ability to
manage their own care, and need for nursing.
- plan individual holistic care that draws on patient strengths and
is responsive to changes in the patient's conditions
Diagnosis (Nursing Process)
, Analysis of patient data to identify patient strengths and health
problems.
- develop a prioritized list of problems/needs
Planning (Nursing Process)
Specification of patient outcomes to prevent, reduce, or resolve
the problems identified; and related nursing interventions.
- develop an individualized plan of nursing care
- identify patient strengths that can be tapped to facilitate
achievement of desired outcomes.
Implementation (Nursing Process)
Carrying out the plan of care.
- assist patients to achieve desired outcomes - promote wellness,
prevent disease and illness, restore health, and facilitate coping
with altered functioning.
Evaluation (Nursing Process)
Measuring the extent to which the patient has achieved the
outcomes specified in the plan of care; identifying factors that
positively or negatively influenced outcome achievement;
revising the plan of care if necessary.
- continue, modify, or terminate nursing care
Stages of Assessment
1. collection of information
- primary sources
- secondary sources
2. validate the data
3. interpret data
