NUR 101/ NUR101 Exam 2 Study guide
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
Who can delegate, to whom, and what?
RN may delegate to UAP (NAC, LVN, LPN):
vitals, ADL, ambulation, meals, turn/position, bathing, document
Religious beliefs of Jehovah's witness
Will refuse blood transfusions
Independent Intervention
Nurse is able to provide w/out PCP order
Ex. Provide emotional support, reposition patient, nursing diagnosis
Dependent Intervention
Require order of PCP to be implemented
Ex. Administering med or O2
, NUR 101/ NUR101 Exam 2 Study guide
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
Indicators of a patient's readiness to learn
Pt. educational and knowledge level
Pt. cultural consideration
Pt. potential communication barriers
Pt. cognition level
Pt. environment
Assessment
Is there a problem?
Data collection
Interview
Physical exam
Diagnosis
Identification/labeling of a problem
Analyzing data and clustering
, NUR 101/ NUR101 Exam 2 Study guide
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
Identifying pts. Problems
Writing specific nursing Dx
3 types
1.Actual
2.Risk
3.Health Promotion
Gives framework on which nurse can proved care in an organized and effective manner
Promotes positive pt. outcomes, quality pt. care and pt. satisfaction
Diagnosis:
Actual Dx
3 segments: diagnosis label, related factors, and defining characteristics
Describes the response of a patient to a current need, problem or life process
Three-parts:
1. patient's identified need/problem
2. etiology or underlying cause i.e. related to [r/t]
, NUR 101/ NUR101 Exam 2 Study guide
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
3. signs and symptoms i.e. AEB [as evidenced by] or AMB [as manifested by]
Example:
Nursing DX: Ineffective gas exchange
R/T excess fluid/congestion in lungs
AEB: O2 Sats 89%, RR30, productive cough
*never put a medical diagnosis! only diagnosis that a nurse can act on
ex. dont write pneumonia
Diagnosis:
Risk Dx
2 segments: A diagnosis label and risk factors
Identify specific potential problems in individuals vulnerable to developing complications due to
their current disease state or life experience.
Two-part risk nursing diagnosis
1. Dx: patients identified need/problem
2. RT: factors indicating vulnerability (i.e. risk factors)
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
Who can delegate, to whom, and what?
RN may delegate to UAP (NAC, LVN, LPN):
vitals, ADL, ambulation, meals, turn/position, bathing, document
Religious beliefs of Jehovah's witness
Will refuse blood transfusions
Independent Intervention
Nurse is able to provide w/out PCP order
Ex. Provide emotional support, reposition patient, nursing diagnosis
Dependent Intervention
Require order of PCP to be implemented
Ex. Administering med or O2
, NUR 101/ NUR101 Exam 2 Study guide
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
Indicators of a patient's readiness to learn
Pt. educational and knowledge level
Pt. cultural consideration
Pt. potential communication barriers
Pt. cognition level
Pt. environment
Assessment
Is there a problem?
Data collection
Interview
Physical exam
Diagnosis
Identification/labeling of a problem
Analyzing data and clustering
, NUR 101/ NUR101 Exam 2 Study guide
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
Identifying pts. Problems
Writing specific nursing Dx
3 types
1.Actual
2.Risk
3.Health Promotion
Gives framework on which nurse can proved care in an organized and effective manner
Promotes positive pt. outcomes, quality pt. care and pt. satisfaction
Diagnosis:
Actual Dx
3 segments: diagnosis label, related factors, and defining characteristics
Describes the response of a patient to a current need, problem or life process
Three-parts:
1. patient's identified need/problem
2. etiology or underlying cause i.e. related to [r/t]
, NUR 101/ NUR101 Exam 2 Study guide
(Latest 2026/ 2027 Update) Health
Assessment | Questions & Answers| Grade A|
100% Correct (Verified Elaborations)- Fortis
3. signs and symptoms i.e. AEB [as evidenced by] or AMB [as manifested by]
Example:
Nursing DX: Ineffective gas exchange
R/T excess fluid/congestion in lungs
AEB: O2 Sats 89%, RR30, productive cough
*never put a medical diagnosis! only diagnosis that a nurse can act on
ex. dont write pneumonia
Diagnosis:
Risk Dx
2 segments: A diagnosis label and risk factors
Identify specific potential problems in individuals vulnerable to developing complications due to
their current disease state or life experience.
Two-part risk nursing diagnosis
1. Dx: patients identified need/problem
2. RT: factors indicating vulnerability (i.e. risk factors)
