NURS 226 MIDTERM UPDATED ACTUAL Questions and
CORRECT Answers
five steps of the nursing process (ADPIE) 1) assessment 2) diagnosis 3) planning 4) implementation 5) evaluation
types of assessment initial assessment, focused assessment, quick priority assessment, emergency
assessment, time lapsed assessment
cues what you observe ("patient doesn't respond when I speak to him on the left side"
Is a cue that something is wrong)
inferences the judgement you reach about the cue (patient's hearing may be impaired on his
left side)
nursing process involves 1) problem statement/diagnostic label, 2) etiology/related factors (what's causing
the problem), 3) signs, symptoms, risk factors
goal writing includes subject ("the patient will"), verb ("demonstrate an understanding"), conditions
(signs and symptoms), performance criteria ("ambulate without experiencing
pain"), target time ("within 24 hours")
Maslow's Hierarchy of Needs physiological needs (TOP PRIORITY), safety needs, love and belonging needs,
self esteem needs, self actualization needs
SMART goals specific, measurable, attainable, realistic, timed,
nurse initiated intervention anything the nurse can do independently without an order
physician initiated intervention anything that nurses need an order for (only nurse and doctor involved)
collaborative intervention involves a physician, a nurse, and another member on the care team
patient adherence the patient follows through with the care plan
care plan outlines nursing diagnoses, goals, interventions, and evaluations for a patient;
helps nurse prioritize problems
documenting vs reporting documenting: written or electronic recording; reporting: telling someone else
(verbal or electronic communication of info. e.g., shift hand off, or calling the
provider)
SOAP note subjective data, objective data, assessment (caregivers judgement about the
situation, plan
, materials used to give a bath basin, washcloths, towels, soap, lotion, clean gown and linens, gloves (supplies
should be gathered before beginning hygiene care)
recommended sequence when giving a complete bath to 1) eyes
a patient 2) face, ears, neck
3) arms and hands
4) chest and abdomen
5) legs and feet
6) back and buttocks
7) perineal
(always wash cleanest to dirtiest area)
peri care for females front to back, use separate section of washcloth for each stroke
peri care for men tip of the penis (center outwards), top of the penis, down the shaft
steps in performing eye care use clean water, wipe inner to outer canthus with separate corners of cloth
fowlers 45-60 degrees
semi fowlers 30 degrees
high fowlers 90 degrees
trendelenberg head below feet by 15 degrees
reverse trendelenberg head above feet by 15 degrees
pharmacokinetics what the body does to the drug; absorption, distribution, metabolism, excretion
absorption how long it takes for the med to get into the bloodstream
factors that affect absorption route of admin (oral meds take longer than IV meds, pulmonary is fast), lipid
solubility, pH (acidic meds absorb in stomach, alkaline meds absorb in small
intestines, absorb more slowly), blood flow, conditions at site of admin, drug
dosage (higher dosage = more absorption)
out of all the parenteral routes, which has the slowest intradermal injections
absorption
distribution how long it takes to go where it needs to work
distribution depends on adequacy of blood circulation (subQ takes longer because there's not as many
blood vessels in that area), protein binding (better protein binding = better
distribution), selectively permeable blood barrier that protects CNS
metabolism AKA biotransmission, drug taken from active form and broken down into inactive
form
primary site of drug metabolism liver (also occurs in GI tract, lungs, and kidneys)
CORRECT Answers
five steps of the nursing process (ADPIE) 1) assessment 2) diagnosis 3) planning 4) implementation 5) evaluation
types of assessment initial assessment, focused assessment, quick priority assessment, emergency
assessment, time lapsed assessment
cues what you observe ("patient doesn't respond when I speak to him on the left side"
Is a cue that something is wrong)
inferences the judgement you reach about the cue (patient's hearing may be impaired on his
left side)
nursing process involves 1) problem statement/diagnostic label, 2) etiology/related factors (what's causing
the problem), 3) signs, symptoms, risk factors
goal writing includes subject ("the patient will"), verb ("demonstrate an understanding"), conditions
(signs and symptoms), performance criteria ("ambulate without experiencing
pain"), target time ("within 24 hours")
Maslow's Hierarchy of Needs physiological needs (TOP PRIORITY), safety needs, love and belonging needs,
self esteem needs, self actualization needs
SMART goals specific, measurable, attainable, realistic, timed,
nurse initiated intervention anything the nurse can do independently without an order
physician initiated intervention anything that nurses need an order for (only nurse and doctor involved)
collaborative intervention involves a physician, a nurse, and another member on the care team
patient adherence the patient follows through with the care plan
care plan outlines nursing diagnoses, goals, interventions, and evaluations for a patient;
helps nurse prioritize problems
documenting vs reporting documenting: written or electronic recording; reporting: telling someone else
(verbal or electronic communication of info. e.g., shift hand off, or calling the
provider)
SOAP note subjective data, objective data, assessment (caregivers judgement about the
situation, plan
, materials used to give a bath basin, washcloths, towels, soap, lotion, clean gown and linens, gloves (supplies
should be gathered before beginning hygiene care)
recommended sequence when giving a complete bath to 1) eyes
a patient 2) face, ears, neck
3) arms and hands
4) chest and abdomen
5) legs and feet
6) back and buttocks
7) perineal
(always wash cleanest to dirtiest area)
peri care for females front to back, use separate section of washcloth for each stroke
peri care for men tip of the penis (center outwards), top of the penis, down the shaft
steps in performing eye care use clean water, wipe inner to outer canthus with separate corners of cloth
fowlers 45-60 degrees
semi fowlers 30 degrees
high fowlers 90 degrees
trendelenberg head below feet by 15 degrees
reverse trendelenberg head above feet by 15 degrees
pharmacokinetics what the body does to the drug; absorption, distribution, metabolism, excretion
absorption how long it takes for the med to get into the bloodstream
factors that affect absorption route of admin (oral meds take longer than IV meds, pulmonary is fast), lipid
solubility, pH (acidic meds absorb in stomach, alkaline meds absorb in small
intestines, absorb more slowly), blood flow, conditions at site of admin, drug
dosage (higher dosage = more absorption)
out of all the parenteral routes, which has the slowest intradermal injections
absorption
distribution how long it takes to go where it needs to work
distribution depends on adequacy of blood circulation (subQ takes longer because there's not as many
blood vessels in that area), protein binding (better protein binding = better
distribution), selectively permeable blood barrier that protects CNS
metabolism AKA biotransmission, drug taken from active form and broken down into inactive
form
primary site of drug metabolism liver (also occurs in GI tract, lungs, and kidneys)
