NS 125 Final Exam Review Sheet (Multiple Choice 87 questions/ 2 points)
Steps of the Nursing Process:
● Assessment
○ Data gathering
■ Best info from pt
■ If pt not available, maybe wait or ask fam, close friend
○ Objective versus Subjective
○ Methods/sources of data collection
■ Interview
■ Healthy history
● Subjective info from pt
■ Physical exam
● Objective
■ Medical records
■ Lab & diagnostics
■ Providers
■ Data interpretation/ clustering/ documentation
■ Example:
● Categorize the following data:
○ Pain 8/10- subjective (objective if used assessment/scale)
○ Skin is moist/hot- objective
○ Vital signs 144/86, 112, 22, 98.7- objective
○ ℅ nausea, no vomiting- subjective
○ ℅ increased pain w/ movement- subjective
○ Pt withdrawn- objective
● Nursing Diagnosis
○ 3 components in nursing dx:
■ P
● Problem: choose whether is an actual or potential problem
○ Ex: acute pain
■ E
● Etiology: factors that may precede, contribute to, or be associated w/ human
response
○ Ex: unknown abdominal disorder
○ Can’t include medical dx! Unless you explain it (“secondary to”)
■ S
● Signs & symptoms: look for signs & symptoms that point to nursing dx
○ Ex: pain 10/10, doubled over in pain
■ Concept
○ Examples:
■ (P)Acute pain related to (E)inflammation of the pancreas secondary to pancreatitis as
evidenced by (S) pain rating 8/10 guarding of abdomen, facial grimace
■ Impaired physical mobility related to fracture of leg as evidenced by limited range of
motion, 2 assist to get from bed to chair, walker use & pt states “I feel so weak”
○ Ex: impaired skin integrity, risk for injury, r/t prolonged pressure and moisture, r/t history of falls,
blood pressure medication, decreased awareness of environment
,● Planning
○ Identify patient goal
■ Broad goal
■ Related to nursing dx
● Positive to nursing dx
● Ex: pt will obtain pain control
■ Client will
■ Obtain, maintain, regain
○ Identify expected pt outcomes
■ State how to measure if broad goal is met
■ Needs to include time frame
● Short term vs long term
■ Realistic
■ Measureable
■ Achievable
■ Specific (avoid normal, adequate, proper, or WNL (within normal limits))
■ Ex: AEB:
● 1. Pt rate pain 3/10 by 1800 9/24/18
● 2. Pt will have no facial grimace or clenching of fists by 9/24/18
○ Examples:
■ Pt will obtain pain control by end of shift (goal)
● Pt will verbalize adequate relief of pain (5/10) by end of my shift (outcome)
● Pt will have no facial grimacing or clenching of fists by end of shift (outcome)
■ Pt will regain mobility
● Pt will demonstrate use of walker w/out verbal cues or reminders by (short term
outcome)
● Pt will walk w/ steady gait w/out use of assistive device by (long term outcome)
○ Ex:
■ Goal: the client will maintain current skin integrity
■ Goal: the client will not have any injury
● Implementation
○ Set the plan into action
○ Nursing interventions
■ 4 types of interventions
● Assess
○ Assessment of problems
○ Assessment of how intervention works
■ Pain characteristics
■ Response to analgesic given
■ Goal (go back to goals)
● Teach
○ Teaching about problem
■ Ex: what is bowel obstruction & how do we treat?
○ Teaching about intervention
■ Pain scale
■ Diet
■ New medication
● Treat
, ○ (3 types: independent- don’t need dr order (reposition, elevate),
dependent- need dr order for (meds, specific tx, dressing change,
nasogastric tube), collaborative- working w/ other specialties (ex: work
w/ social worker, hospice, PT))
○ Nursing interventions that help treat problem
■ Turn cough, deep breathe
○ Doctors orders that help treat problem
■ Administer prescribed medication
○ Collaboration between specialties
■ Dietary
■ PT/OT
■ Hospice
● Prevent (not used this semester)
○ Preventative teaching
○ Preventative measures
■ Exercise
■ Range of motion (ROM)
■ Annual screenings
○ Rationale for Interventions
● Evidence-based practice behind nursing interventions
● Explain why intervention helps problem
○ Use textbook or policy & procedure manual
○ For medications the rationale is the mechanism of action in the drug book
● Evaluation
○ Determine if the plan assisted the patient in meeting goal/outcomes
■ What interventions need to be done differently to meet goal?
○ Reassessment of patient
○ Determine extent of outcome achievement
■ Fully met
■ Partially met
■ Not met at all
○ Revise care plan as needed
○ Ex:
■ Pt will obtain pain control by end of shift
● Pt will verbalize adequate relief of pain (5/10) by end of shift (outcome)
○ Met- pt rated pain 3/10 after admin of pain meds
● Pt will have no facial grimacing or clenching of fists by end of shift (outcome)
○ Met- pt shows no signs of facial grimace or clenching of fists
■ Pt will regain mobility
● Pt will demonstrate use of walker w/out verbal cues or reminders by (short term
outcome)
○ Not met- pt able to use walker w/ constant verbal cues from staff
● Pt will walk w/ steady gait w/out use of assistive device by (long term outcome)
○ Not met- goal is long term goal, will continue to evaluate
, Accurate documentation of the Nursing Process:
● Quality documentation:
○ Factual
■ Descriptive, objective info
○ Accurate
■ Use measurement, don’t include unnecessary info
○ Complete
■ Complete w/ appropriate & essential info
■ Don’t want to miss anything
■ Use approved abbreviations for institution
○ Current
■ Real time charting
● Complete right after doing something, right as it is happening
● Helps see acuity (how many times nurse has been in room, what they’ve done,
each individual time, etc)
○ Organized
■ Writing a narrative note, use nursing process
● Subjective info only from pt & in quotes or “pt states”, etc.
● Legal guidelines:
○ Personal opinions not included
○ Correct errors
○ Record all facts
○ Document communication w/ other providers
■ Ex: document when talked to social worker, dr, etc.
○ Document only for yourself
■ don’ t take credit for what you didn’t do
○ Avoid generalized phrases
■ Ex: pt appears well rested→ what does that mean?
○ date/time/signature/credentials included
○ Security of password
■ Don’t share password
RACE:
● R-rescue
● A-alarm
● C-contain
● E-evacuate/extinguish
National Patient Safety Goals:
● Improve patient safety with a focus on current problems and how to solve them
○ Identify patients correctly
■ Use 2 pt identifiers (eg name & birthdate)
■ Try to have pt state info
○ Improve staff communication
■ Contact provider if needed for order, if you have question and have done everything you
can
■ Documentation
■ SBAR
Steps of the Nursing Process:
● Assessment
○ Data gathering
■ Best info from pt
■ If pt not available, maybe wait or ask fam, close friend
○ Objective versus Subjective
○ Methods/sources of data collection
■ Interview
■ Healthy history
● Subjective info from pt
■ Physical exam
● Objective
■ Medical records
■ Lab & diagnostics
■ Providers
■ Data interpretation/ clustering/ documentation
■ Example:
● Categorize the following data:
○ Pain 8/10- subjective (objective if used assessment/scale)
○ Skin is moist/hot- objective
○ Vital signs 144/86, 112, 22, 98.7- objective
○ ℅ nausea, no vomiting- subjective
○ ℅ increased pain w/ movement- subjective
○ Pt withdrawn- objective
● Nursing Diagnosis
○ 3 components in nursing dx:
■ P
● Problem: choose whether is an actual or potential problem
○ Ex: acute pain
■ E
● Etiology: factors that may precede, contribute to, or be associated w/ human
response
○ Ex: unknown abdominal disorder
○ Can’t include medical dx! Unless you explain it (“secondary to”)
■ S
● Signs & symptoms: look for signs & symptoms that point to nursing dx
○ Ex: pain 10/10, doubled over in pain
■ Concept
○ Examples:
■ (P)Acute pain related to (E)inflammation of the pancreas secondary to pancreatitis as
evidenced by (S) pain rating 8/10 guarding of abdomen, facial grimace
■ Impaired physical mobility related to fracture of leg as evidenced by limited range of
motion, 2 assist to get from bed to chair, walker use & pt states “I feel so weak”
○ Ex: impaired skin integrity, risk for injury, r/t prolonged pressure and moisture, r/t history of falls,
blood pressure medication, decreased awareness of environment
,● Planning
○ Identify patient goal
■ Broad goal
■ Related to nursing dx
● Positive to nursing dx
● Ex: pt will obtain pain control
■ Client will
■ Obtain, maintain, regain
○ Identify expected pt outcomes
■ State how to measure if broad goal is met
■ Needs to include time frame
● Short term vs long term
■ Realistic
■ Measureable
■ Achievable
■ Specific (avoid normal, adequate, proper, or WNL (within normal limits))
■ Ex: AEB:
● 1. Pt rate pain 3/10 by 1800 9/24/18
● 2. Pt will have no facial grimace or clenching of fists by 9/24/18
○ Examples:
■ Pt will obtain pain control by end of shift (goal)
● Pt will verbalize adequate relief of pain (5/10) by end of my shift (outcome)
● Pt will have no facial grimacing or clenching of fists by end of shift (outcome)
■ Pt will regain mobility
● Pt will demonstrate use of walker w/out verbal cues or reminders by (short term
outcome)
● Pt will walk w/ steady gait w/out use of assistive device by (long term outcome)
○ Ex:
■ Goal: the client will maintain current skin integrity
■ Goal: the client will not have any injury
● Implementation
○ Set the plan into action
○ Nursing interventions
■ 4 types of interventions
● Assess
○ Assessment of problems
○ Assessment of how intervention works
■ Pain characteristics
■ Response to analgesic given
■ Goal (go back to goals)
● Teach
○ Teaching about problem
■ Ex: what is bowel obstruction & how do we treat?
○ Teaching about intervention
■ Pain scale
■ Diet
■ New medication
● Treat
, ○ (3 types: independent- don’t need dr order (reposition, elevate),
dependent- need dr order for (meds, specific tx, dressing change,
nasogastric tube), collaborative- working w/ other specialties (ex: work
w/ social worker, hospice, PT))
○ Nursing interventions that help treat problem
■ Turn cough, deep breathe
○ Doctors orders that help treat problem
■ Administer prescribed medication
○ Collaboration between specialties
■ Dietary
■ PT/OT
■ Hospice
● Prevent (not used this semester)
○ Preventative teaching
○ Preventative measures
■ Exercise
■ Range of motion (ROM)
■ Annual screenings
○ Rationale for Interventions
● Evidence-based practice behind nursing interventions
● Explain why intervention helps problem
○ Use textbook or policy & procedure manual
○ For medications the rationale is the mechanism of action in the drug book
● Evaluation
○ Determine if the plan assisted the patient in meeting goal/outcomes
■ What interventions need to be done differently to meet goal?
○ Reassessment of patient
○ Determine extent of outcome achievement
■ Fully met
■ Partially met
■ Not met at all
○ Revise care plan as needed
○ Ex:
■ Pt will obtain pain control by end of shift
● Pt will verbalize adequate relief of pain (5/10) by end of shift (outcome)
○ Met- pt rated pain 3/10 after admin of pain meds
● Pt will have no facial grimacing or clenching of fists by end of shift (outcome)
○ Met- pt shows no signs of facial grimace or clenching of fists
■ Pt will regain mobility
● Pt will demonstrate use of walker w/out verbal cues or reminders by (short term
outcome)
○ Not met- pt able to use walker w/ constant verbal cues from staff
● Pt will walk w/ steady gait w/out use of assistive device by (long term outcome)
○ Not met- goal is long term goal, will continue to evaluate
, Accurate documentation of the Nursing Process:
● Quality documentation:
○ Factual
■ Descriptive, objective info
○ Accurate
■ Use measurement, don’t include unnecessary info
○ Complete
■ Complete w/ appropriate & essential info
■ Don’t want to miss anything
■ Use approved abbreviations for institution
○ Current
■ Real time charting
● Complete right after doing something, right as it is happening
● Helps see acuity (how many times nurse has been in room, what they’ve done,
each individual time, etc)
○ Organized
■ Writing a narrative note, use nursing process
● Subjective info only from pt & in quotes or “pt states”, etc.
● Legal guidelines:
○ Personal opinions not included
○ Correct errors
○ Record all facts
○ Document communication w/ other providers
■ Ex: document when talked to social worker, dr, etc.
○ Document only for yourself
■ don’ t take credit for what you didn’t do
○ Avoid generalized phrases
■ Ex: pt appears well rested→ what does that mean?
○ date/time/signature/credentials included
○ Security of password
■ Don’t share password
RACE:
● R-rescue
● A-alarm
● C-contain
● E-evacuate/extinguish
National Patient Safety Goals:
● Improve patient safety with a focus on current problems and how to solve them
○ Identify patients correctly
■ Use 2 pt identifiers (eg name & birthdate)
■ Try to have pt state info
○ Improve staff communication
■ Contact provider if needed for order, if you have question and have done everything you
can
■ Documentation
■ SBAR
