Fundamentals Nursing - Exam #2
Hypertonic solution - ANS-3% NaCl - causes shift of fluid from ICF to ECF - out of the
cells into the vessels. Hypertonic solutions have high osmolality - high ability to draw
water toward it and draw water out of the cells.
Hypotonic solution - ANS-0.45% NaCl - causes shift of fluid from ECF to ICF - pushes
water from the vessels into the cells. HypOtonic - cells expand with fluid - used for
dehydration.
Isotonic Solution - ANS-0.9% NaCl and Lactated Ringer's solution. Expand the vascular
volume without causing a shift in fluids
Osmosis - ANS-movement of water (solvent) across a plasma membrane from a High
concentration of water to low concentration of water to achieve equillibrium
Diffusion - ANS-movement of solutes from area of HIGH concentration to LOW
concentration
Filtration - ANS-movement of fluid/solutes through membranes by high pressure. High
pressure in arteries forces oxygen nutrients into cells. High force in tissue pushes
waste/Co2 into veins
Active Transport - ANS-movement of solutes against concentration gradient (from Low
to High). Requires ATP (energy) to force molecules against gradient. Ex -
sodium/potassium pump
What is the ANA? - ANS-ANA = American Nursing Association. They established
Nursing Code of Ethics, Scope of Nursing - Nurse practice acts. Adminstrative Law -
enforced state to adhere to Nurse practice acts
Documentation "Dos" and "don'ts" - ANS-Entries should include date, time (military),
problem, intervention used and evaluation of outcomes. Proper spelling and terminology
should be used. Errors should have strike throughs with "mistaken entry" written with
initials, date and time next to it. Documentation should be written in chronological order.
When documenting entry out of order, list current time and time that omitted data took
place as well as what happened.
, What is PIE charting? - ANS-PIE = problem, intervention and evaluation
Problem - state the issue/problem that patient is stating or dealing with
Intervention - describe how problem was addressed - what was done to fix the problem?
Evaluation - what was the outcome of the intervention
What is SOAP charting? - ANS-SOAP = subjective, objective data, assessment,
planning
What is SOAPIE charting? - ANS-SOAPIE = subjective data, objective data,
assessment, planning, intervention and evaluation
What is objective data? - ANS-objective data = data that can be seen, heard, smelled,
felt and validated by the nurse. Inlcudes vital signs and lab reports, x-rays, etc
What is subjective data? - ANS-subjective data = data this is expressed by the patient.
Ex - pain, symptoms, feelings, past illnesses (not documented), concerns
What is primary data? - ANS-Data that is obtained directly from the patient
what is secondary data? - ANS-Data that is provided by someone other than the patient.
Ex - spouse, old medical record
What is the assessment phase? - ANS-First step in ADPIE - assessment is where nurse
collects, organizes, validates and documents data. Goal is to establish complete
database of patient information
What is the diagnosis phase? - ANS-Second step of ADPIE - nurse addressess current
health problems that patient exhibits and determine issues that patient may be at risk for
developing. Help determine problems, strengths and weaknesses of the patient
Actual diagnosis - ANS-problems/issues that the patient is currently exhibiting
At-risk dignosis - ANS-identify problems that the patient may develop based on past or
current medical history
Wellness diagnosis - ANS-readiness for enhancement
What is the planning phase? - ANS-Third step in ADPIE - develop a care plan to
address nursing diagnosis. Plans should be individualized to each patient. Nurse should
Hypertonic solution - ANS-3% NaCl - causes shift of fluid from ICF to ECF - out of the
cells into the vessels. Hypertonic solutions have high osmolality - high ability to draw
water toward it and draw water out of the cells.
Hypotonic solution - ANS-0.45% NaCl - causes shift of fluid from ECF to ICF - pushes
water from the vessels into the cells. HypOtonic - cells expand with fluid - used for
dehydration.
Isotonic Solution - ANS-0.9% NaCl and Lactated Ringer's solution. Expand the vascular
volume without causing a shift in fluids
Osmosis - ANS-movement of water (solvent) across a plasma membrane from a High
concentration of water to low concentration of water to achieve equillibrium
Diffusion - ANS-movement of solutes from area of HIGH concentration to LOW
concentration
Filtration - ANS-movement of fluid/solutes through membranes by high pressure. High
pressure in arteries forces oxygen nutrients into cells. High force in tissue pushes
waste/Co2 into veins
Active Transport - ANS-movement of solutes against concentration gradient (from Low
to High). Requires ATP (energy) to force molecules against gradient. Ex -
sodium/potassium pump
What is the ANA? - ANS-ANA = American Nursing Association. They established
Nursing Code of Ethics, Scope of Nursing - Nurse practice acts. Adminstrative Law -
enforced state to adhere to Nurse practice acts
Documentation "Dos" and "don'ts" - ANS-Entries should include date, time (military),
problem, intervention used and evaluation of outcomes. Proper spelling and terminology
should be used. Errors should have strike throughs with "mistaken entry" written with
initials, date and time next to it. Documentation should be written in chronological order.
When documenting entry out of order, list current time and time that omitted data took
place as well as what happened.
, What is PIE charting? - ANS-PIE = problem, intervention and evaluation
Problem - state the issue/problem that patient is stating or dealing with
Intervention - describe how problem was addressed - what was done to fix the problem?
Evaluation - what was the outcome of the intervention
What is SOAP charting? - ANS-SOAP = subjective, objective data, assessment,
planning
What is SOAPIE charting? - ANS-SOAPIE = subjective data, objective data,
assessment, planning, intervention and evaluation
What is objective data? - ANS-objective data = data that can be seen, heard, smelled,
felt and validated by the nurse. Inlcudes vital signs and lab reports, x-rays, etc
What is subjective data? - ANS-subjective data = data this is expressed by the patient.
Ex - pain, symptoms, feelings, past illnesses (not documented), concerns
What is primary data? - ANS-Data that is obtained directly from the patient
what is secondary data? - ANS-Data that is provided by someone other than the patient.
Ex - spouse, old medical record
What is the assessment phase? - ANS-First step in ADPIE - assessment is where nurse
collects, organizes, validates and documents data. Goal is to establish complete
database of patient information
What is the diagnosis phase? - ANS-Second step of ADPIE - nurse addressess current
health problems that patient exhibits and determine issues that patient may be at risk for
developing. Help determine problems, strengths and weaknesses of the patient
Actual diagnosis - ANS-problems/issues that the patient is currently exhibiting
At-risk dignosis - ANS-identify problems that the patient may develop based on past or
current medical history
Wellness diagnosis - ANS-readiness for enhancement
What is the planning phase? - ANS-Third step in ADPIE - develop a care plan to
address nursing diagnosis. Plans should be individualized to each patient. Nurse should
