ASU MEPN NUR 514 FINAL EXAM UPDATED ACTUAL
Questions and CORRECT Answers
ADPIE - Nursing Process Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment (nursing process)- Subjective information given from the viewpoint of the patient or someone in the patient's
life; it is a symptom. WHAT IS SAID
Assessment (nursing process)- Objective information directly observed by the healthcare worker; it is a sign. WHAT IS
OBSERVED
Planning (nursing process) -establish priorities
-develop outcomes
-set timelines for outcomes
-identify interventions
-integrate evidence-based trends and research
-document plan of care
Nursing Diagnosis used to evaluate the response of the whole person to actual or potential health
problems
Implementation nursing process - Implement in a safe and timely manner
- Use evidence-based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- Document implementation and any modification
Nursing ABC's airway, breathing, circulation
, Maslow's Hierarchy of Needs (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships,
Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization
nursing delegation *E-A-T (do not delegate what nurse can: evaluate, assess, teach)*
responsibility and authority of tasks are transferred from 1 to another who accepts
responsibility
o Responsibility: obligation to accomplish task, Accountability: accepting
ownership, Authority: right to act or empower
o UAP: no scope of practice, noninvasive, skin care, range-of-motion, ambulation,
grooming, and hygiene measures
o LPN: UAP and dressings, suctioning, urinary catheterization, administering meds
(PO, SQ, IM, some piggyback)
o RN: responsible for assessment, planning care, analyzing client data,
implementing and evaluating care, supervising care, initiating teaching, and
administering medications intravenously.
Nursing Priority ABC's (airway, breathing, circulation)
LEAST INVASIVE ACTION FIRST
chain of infection infectious agent, reservoir, portal of exit, mode of transmission, portal of entry,
susceptible host
nurse-client relationship 5 characteristics of RN-pt relationship: mutual definition, goal direction,
boundaries, therapeutic communication, pt goal
patient centered care providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all clinical
decisions
acute pain pain that is felt suddenly from injury, disease, trauma, or surgery
Questions and CORRECT Answers
ADPIE - Nursing Process Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment (nursing process)- Subjective information given from the viewpoint of the patient or someone in the patient's
life; it is a symptom. WHAT IS SAID
Assessment (nursing process)- Objective information directly observed by the healthcare worker; it is a sign. WHAT IS
OBSERVED
Planning (nursing process) -establish priorities
-develop outcomes
-set timelines for outcomes
-identify interventions
-integrate evidence-based trends and research
-document plan of care
Nursing Diagnosis used to evaluate the response of the whole person to actual or potential health
problems
Implementation nursing process - Implement in a safe and timely manner
- Use evidence-based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- Document implementation and any modification
Nursing ABC's airway, breathing, circulation
, Maslow's Hierarchy of Needs (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships,
Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization
nursing delegation *E-A-T (do not delegate what nurse can: evaluate, assess, teach)*
responsibility and authority of tasks are transferred from 1 to another who accepts
responsibility
o Responsibility: obligation to accomplish task, Accountability: accepting
ownership, Authority: right to act or empower
o UAP: no scope of practice, noninvasive, skin care, range-of-motion, ambulation,
grooming, and hygiene measures
o LPN: UAP and dressings, suctioning, urinary catheterization, administering meds
(PO, SQ, IM, some piggyback)
o RN: responsible for assessment, planning care, analyzing client data,
implementing and evaluating care, supervising care, initiating teaching, and
administering medications intravenously.
Nursing Priority ABC's (airway, breathing, circulation)
LEAST INVASIVE ACTION FIRST
chain of infection infectious agent, reservoir, portal of exit, mode of transmission, portal of entry,
susceptible host
nurse-client relationship 5 characteristics of RN-pt relationship: mutual definition, goal direction,
boundaries, therapeutic communication, pt goal
patient centered care providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all clinical
decisions
acute pain pain that is felt suddenly from injury, disease, trauma, or surgery
