Nursing Fundamentals Study Guide Review
Summary
1.Autonomy: Patient has right to make his/her own decision, even if it is
not his/her best interest.
Beneficence: Do what is best for the patient (do good)
Fidelity: Keep your promises
Justice: Provide fairness in care and allocation of resources
Nonmaleficence: Do no harm (ex: checking/verifying meds)
Veracity: Tell the truth: Nursing Ethical Principles:
What are they? (6)
2.Torts:
Unintentional Torts
Intentional Torts: Unintentional Torts:
- Negligence (ex: forgetting to set bed alarm for a pt at risk for falls)
- Malpractice (ex: med error that
harms pt) Intentional Torts:
- Assault (ex: RN threatens pt) (A before B)
- Battery (ex: RN hits pt or administers med against pt's will)
- False imprisonment (ex: RN inappropriately restrains a pt or
administers a chemical restraint such as a sedative)
3.Informed Consent:
Provider responsibilities
RN responsibilities: Provider responsibilities:
- communicate purpose of procedure & complete description of
procedure in pt's primary language (use medical interpreter if
needed)
-Responsible to get informed consents
- explain risks vs. benefits
- describe other options to treat the
condition RN responsibilities:
- make sure provider gave pt above info
- ensure pt is competent enough to give informed consent (i.e. pt is
an adult or emancipated minor, not impaired)
- notify provider if pt has more questions or doesn't understand any info
provided
4.Mandatory Reporting for RNs: Mandatory Reporting for RNs:
- Suspicion of abuse (child, elderly, domestic violence) immediately;
don't wait or investigate
,- Communicate diseases to local/state health dept (mandated by state)
5.Advance Directives:
Living will
Durable Power of Attorney (DPOA), Provider's orders: Advance Directives:
- Living will: communicates pt's wishes regarding medical tx if pt become
incapac-
itated
- DPOA: pt designates health care proxy to make medical decisions for
them if they become incapacitated
- Provider's orders: Prescription for DNR or AND (allow natural death)
6.Nursing Documentation:
Objective data
Subjective data
Legal guidelines
Incident reports: Objective data: what you see, hear, feel, smell. Do not
include opinions or interpretations of data.
Subjective data: Document as direct quotes, or clearly identify
information as a statement by pt.
Legal guidelines: Do not leave blank spaces in documentation. Do not use
correction tape/fluid or scratch/black out words. Include your name &
title.
Incident Reports: Created when an accident or unusual event occurs (ex
med error, fall). Used for quality improvement at facility. It is NOT part o
the pt's record, and should not be referred to in the pt's medical record.
7.Delegation:
What tasks should the RN NOT delegate?
What tasks can a RN delegate to a PN (i.e. LVN)?
What tasks can a RN delegate to assistive personnel (i.e. CNA)?: RN
should not delegate: patient education, any task that requires nursing
judgment, nursing assessment, blood transfusions
OK to delegate to PN: med administration, enteral feedings, urinary
catheter inser- tion, suctioning, wound care, trach care, reinforcement of
pt teaching
OK to delegate to CNA: bathing, dressing, ambulating, toileting, feeding
pts w/o swallowing precautions, positioning, vital signs, bed making,
specimen collection, I&Os, basic CPR
8.Delegation:
What are the 5 rights of delegation?: Right task: repetitive, non-invasive,
doesn't require much supervision
Right circumstances: do not assign a pt who is unstable
,Right person: make sure delegate is competent & operating w/in their
scope of practice, check facility's job description
Right direction & communication: communicate timeline, expected
results, and follow-up communication expectations
Right supervision & evaluation: intervene if needed, provide feedback
9.Nursing Process:
What are the 5 steps in the nursing process?: Assessment/data collection:
in-
cludes subjective data (symptoms) and objective data (signs). Always
assess before taking action.
Analysis/data collection: Cluster the collected data, identify
patterns/trends, com- pare data to expected values
Planning: Prioritize interventions & identify measurable outcomes (time-
limited, specific)
Implementation: Perform nursing care, document pt's responses to
interventions Evaluation: Compare actual results w/ planned outcomes.
Determine next steps
10.Patient Admission:
Key tasks/procedures: - document pt's advance directice status
- vital signs, height/weight, allergies, head-to-toe assessment, health
history, spiri- tual/cultural considerations
- assess for swallowing issues prior to allowing pt to eat/drink; if unable,
keep pt NPO until swallow eval
- safety assessment, implement fall precautions if appropriate
- inventory pt belongings, lock valuables in facility safe
- med reconciliation: compare home meds w/ provider's prescriptions
- discharge planning starts at admission
11.Patient Transfer:
Best practice for patient handoff
Patient Discharge:
What is included in the patient's discharge instructions?: Patient transfer:
- use SBAR (situation, background, assessment,
recommendations) Included in patient discharge
instructions:
- diet & activity restrictions
- detailed instructions for procedures at home (ex: wound dressing
changes)
- list of meds, when to take, precautions regarding meds
- s/s of complications, when to seek medical attention
, - follow-up appointment information
- names, numbers of providers & community resources
12.Immunity:
Nonspecific innate vs Specific adaptive: Nonspecific innate immunity:
defense mechanisms (i.e. barriers) in the body that respond immediately
to all antigens.
Barriers include: skin, stomach acid, mucus, inflammatory response,
phagocytic cells
Specific adaptive immunity: body produces antibodies in response to a
specific antigen through action of B & T lymphocytes. Requires more
time, but the immune response against that antigen in the future is more
efficient.
13.Immunity:
Active natural
Active artificial
Passive natural
Passive artificial: Active natural immunity: body produces antibodies in
response to exposure to live pathogen
Active artificial immunity: body produces antibodies in response to
vaccine Passive natural immunity: antibodies are passed from the mom
to her baby through the placenta or breastmilk
Passive artificial immunity: immunoglobulins are administered to an
individual after they have been exposed to a pathogen
14.Infections:
Chain of infection
Risk factors
What is virulence?: Chain of infection:
causative agent (ex: toxin, bacteria) --> reservoir (ex: human, soil) -->
portal of exit (ex: blood, resp tract) --> mode of transmission (ex: contac
droplet) --> portal of entry --> susceptible host
Risk factors: compromised immunity, chronic/acute disease, poor
personal & hand hygiene, crowded living environment, IV drug use,
unprotected sex, poor sanitation Virulence: the ability of a pathogen to
produce disease
15.Infections:
Stages of infection: Incubation: time from when the pathogen enters the
body until the first symptom appears
Prodromal stage: time from onset of general symptoms (i.e. malaise,
fatigue) to specific symptoms
Illness stage: time when specific symptoms occur
Summary
1.Autonomy: Patient has right to make his/her own decision, even if it is
not his/her best interest.
Beneficence: Do what is best for the patient (do good)
Fidelity: Keep your promises
Justice: Provide fairness in care and allocation of resources
Nonmaleficence: Do no harm (ex: checking/verifying meds)
Veracity: Tell the truth: Nursing Ethical Principles:
What are they? (6)
2.Torts:
Unintentional Torts
Intentional Torts: Unintentional Torts:
- Negligence (ex: forgetting to set bed alarm for a pt at risk for falls)
- Malpractice (ex: med error that
harms pt) Intentional Torts:
- Assault (ex: RN threatens pt) (A before B)
- Battery (ex: RN hits pt or administers med against pt's will)
- False imprisonment (ex: RN inappropriately restrains a pt or
administers a chemical restraint such as a sedative)
3.Informed Consent:
Provider responsibilities
RN responsibilities: Provider responsibilities:
- communicate purpose of procedure & complete description of
procedure in pt's primary language (use medical interpreter if
needed)
-Responsible to get informed consents
- explain risks vs. benefits
- describe other options to treat the
condition RN responsibilities:
- make sure provider gave pt above info
- ensure pt is competent enough to give informed consent (i.e. pt is
an adult or emancipated minor, not impaired)
- notify provider if pt has more questions or doesn't understand any info
provided
4.Mandatory Reporting for RNs: Mandatory Reporting for RNs:
- Suspicion of abuse (child, elderly, domestic violence) immediately;
don't wait or investigate
,- Communicate diseases to local/state health dept (mandated by state)
5.Advance Directives:
Living will
Durable Power of Attorney (DPOA), Provider's orders: Advance Directives:
- Living will: communicates pt's wishes regarding medical tx if pt become
incapac-
itated
- DPOA: pt designates health care proxy to make medical decisions for
them if they become incapacitated
- Provider's orders: Prescription for DNR or AND (allow natural death)
6.Nursing Documentation:
Objective data
Subjective data
Legal guidelines
Incident reports: Objective data: what you see, hear, feel, smell. Do not
include opinions or interpretations of data.
Subjective data: Document as direct quotes, or clearly identify
information as a statement by pt.
Legal guidelines: Do not leave blank spaces in documentation. Do not use
correction tape/fluid or scratch/black out words. Include your name &
title.
Incident Reports: Created when an accident or unusual event occurs (ex
med error, fall). Used for quality improvement at facility. It is NOT part o
the pt's record, and should not be referred to in the pt's medical record.
7.Delegation:
What tasks should the RN NOT delegate?
What tasks can a RN delegate to a PN (i.e. LVN)?
What tasks can a RN delegate to assistive personnel (i.e. CNA)?: RN
should not delegate: patient education, any task that requires nursing
judgment, nursing assessment, blood transfusions
OK to delegate to PN: med administration, enteral feedings, urinary
catheter inser- tion, suctioning, wound care, trach care, reinforcement of
pt teaching
OK to delegate to CNA: bathing, dressing, ambulating, toileting, feeding
pts w/o swallowing precautions, positioning, vital signs, bed making,
specimen collection, I&Os, basic CPR
8.Delegation:
What are the 5 rights of delegation?: Right task: repetitive, non-invasive,
doesn't require much supervision
Right circumstances: do not assign a pt who is unstable
,Right person: make sure delegate is competent & operating w/in their
scope of practice, check facility's job description
Right direction & communication: communicate timeline, expected
results, and follow-up communication expectations
Right supervision & evaluation: intervene if needed, provide feedback
9.Nursing Process:
What are the 5 steps in the nursing process?: Assessment/data collection:
in-
cludes subjective data (symptoms) and objective data (signs). Always
assess before taking action.
Analysis/data collection: Cluster the collected data, identify
patterns/trends, com- pare data to expected values
Planning: Prioritize interventions & identify measurable outcomes (time-
limited, specific)
Implementation: Perform nursing care, document pt's responses to
interventions Evaluation: Compare actual results w/ planned outcomes.
Determine next steps
10.Patient Admission:
Key tasks/procedures: - document pt's advance directice status
- vital signs, height/weight, allergies, head-to-toe assessment, health
history, spiri- tual/cultural considerations
- assess for swallowing issues prior to allowing pt to eat/drink; if unable,
keep pt NPO until swallow eval
- safety assessment, implement fall precautions if appropriate
- inventory pt belongings, lock valuables in facility safe
- med reconciliation: compare home meds w/ provider's prescriptions
- discharge planning starts at admission
11.Patient Transfer:
Best practice for patient handoff
Patient Discharge:
What is included in the patient's discharge instructions?: Patient transfer:
- use SBAR (situation, background, assessment,
recommendations) Included in patient discharge
instructions:
- diet & activity restrictions
- detailed instructions for procedures at home (ex: wound dressing
changes)
- list of meds, when to take, precautions regarding meds
- s/s of complications, when to seek medical attention
, - follow-up appointment information
- names, numbers of providers & community resources
12.Immunity:
Nonspecific innate vs Specific adaptive: Nonspecific innate immunity:
defense mechanisms (i.e. barriers) in the body that respond immediately
to all antigens.
Barriers include: skin, stomach acid, mucus, inflammatory response,
phagocytic cells
Specific adaptive immunity: body produces antibodies in response to a
specific antigen through action of B & T lymphocytes. Requires more
time, but the immune response against that antigen in the future is more
efficient.
13.Immunity:
Active natural
Active artificial
Passive natural
Passive artificial: Active natural immunity: body produces antibodies in
response to exposure to live pathogen
Active artificial immunity: body produces antibodies in response to
vaccine Passive natural immunity: antibodies are passed from the mom
to her baby through the placenta or breastmilk
Passive artificial immunity: immunoglobulins are administered to an
individual after they have been exposed to a pathogen
14.Infections:
Chain of infection
Risk factors
What is virulence?: Chain of infection:
causative agent (ex: toxin, bacteria) --> reservoir (ex: human, soil) -->
portal of exit (ex: blood, resp tract) --> mode of transmission (ex: contac
droplet) --> portal of entry --> susceptible host
Risk factors: compromised immunity, chronic/acute disease, poor
personal & hand hygiene, crowded living environment, IV drug use,
unprotected sex, poor sanitation Virulence: the ability of a pathogen to
produce disease
15.Infections:
Stages of infection: Incubation: time from when the pathogen enters the
body until the first symptom appears
Prodromal stage: time from onset of general symptoms (i.e. malaise,
fatigue) to specific symptoms
Illness stage: time when specific symptoms occur
