NUR 311 - Final Exam Questions With Complete Solutions
Priority Nursing Actions - Discontinuing IV therapy
- check order
- turn off IV tubing clamp and disconnect form patient
- stabilize arm
- remove dressing
- pull out quickly and smoothly
- inspect site for redness, drainage, swelling, and check catheter
is intact
ADPIE - Nursing Process
A: Assessment
D: Diagnosis
P: Planning
I: Implementation
E: Evaluation
10 Guiding Principles of Person Centered Care
1. All team members are considered caregivers.
2. Care is based on continuous healing relationships.
3. Care is customized and reflects patient needs, values, and
choices.
4. Knowledge and information are freely shared between and
among patients, care partners, physicians, and other caregivers.
5. Care is provided in a healing environment of comfort, peace,
and support.
6. Families and friends of the patient are considered an essential
,part of the care team.
7. Patient safety is a visible priority.
8. Transparency is the rule in the care of the patient.
9. All caregivers cooperate with one another through a common
focus on the best interests and personal goals of the patient.
10. The patient is the source of control for one's care.
Blended Competencies
-cognitive competencies
-technical competencies
-interpersonal competencies
-ethical/legal competencies
QSEN Competencies
1. Patient-centered care
2. Teamwork and collaboration
3. Evidence-based practice
4. Quality improvement
5. Safety
6. Informatics
Tanner Model of Clinical Judgement
- Noticing: a perceptual grasp of the situation
- Interpreting: developing a sufficient understanding of the
situation to respond
- Responding: deciding on a course of action deemed
appropriate for the situation
,- Reflecting: attending to the patients responses to the nursing
action while in the process of acting
Characteristics of the Nursing Process
- Systematic: part of an orders sequence of activities
- Dynamic: great interaction and overlapping among the five
steps
- Interpersonal: human being is always at heart of nursing
- Outcome Oriented: nurses and patients work together to
identify outcomes
- Universally Applicable: a framework for all nursing activities
Steps in Concept Mapping
1. Collect patient problems and concerns in a list.
2. Connect and analyze the relationships.
3. Create a diagram.
4. Keep in mind key concepts: the nursing process, holism,
safety, and advocacy
Reflection in action
happens in the here and now of the activity and is also know as
thinking on your feet
Reflection on action
occurs after the fact and involves thinking through a situation
that has occurred in the past
Reflection for action
helps the person to think about how future actions might change
as a result of the reflection
, Objective Data
observable and measurable data that can be seen, heard, or felt
by someone other that the patient
- ex: elevated temperature, skin moisture, vomiting
Subjective Data
information perceived only by the patient
- ex: pain, feeling dizzy, feeling anxious
Nursing Observation
- determines the patient's current responses (physical and
emotional)
- determines the patient's current ability to manage care
- determines the immediate environment and its safety
- determines the larger environment (hospital or community)
Problems Related to Data Collection
-Inappropriate organization of the database
-Omission of pertinent data
-Inclusion of irrelevant or duplicate data, erroneous or
misinterpreted data
-Failure to establish rapport and partnership
-Recording an interpretation of data rather than observed
behavior
-Failure to update the database
Validating Inferences
-Performing a physical examination
-Using clarifying statements
Priority Nursing Actions - Discontinuing IV therapy
- check order
- turn off IV tubing clamp and disconnect form patient
- stabilize arm
- remove dressing
- pull out quickly and smoothly
- inspect site for redness, drainage, swelling, and check catheter
is intact
ADPIE - Nursing Process
A: Assessment
D: Diagnosis
P: Planning
I: Implementation
E: Evaluation
10 Guiding Principles of Person Centered Care
1. All team members are considered caregivers.
2. Care is based on continuous healing relationships.
3. Care is customized and reflects patient needs, values, and
choices.
4. Knowledge and information are freely shared between and
among patients, care partners, physicians, and other caregivers.
5. Care is provided in a healing environment of comfort, peace,
and support.
6. Families and friends of the patient are considered an essential
,part of the care team.
7. Patient safety is a visible priority.
8. Transparency is the rule in the care of the patient.
9. All caregivers cooperate with one another through a common
focus on the best interests and personal goals of the patient.
10. The patient is the source of control for one's care.
Blended Competencies
-cognitive competencies
-technical competencies
-interpersonal competencies
-ethical/legal competencies
QSEN Competencies
1. Patient-centered care
2. Teamwork and collaboration
3. Evidence-based practice
4. Quality improvement
5. Safety
6. Informatics
Tanner Model of Clinical Judgement
- Noticing: a perceptual grasp of the situation
- Interpreting: developing a sufficient understanding of the
situation to respond
- Responding: deciding on a course of action deemed
appropriate for the situation
,- Reflecting: attending to the patients responses to the nursing
action while in the process of acting
Characteristics of the Nursing Process
- Systematic: part of an orders sequence of activities
- Dynamic: great interaction and overlapping among the five
steps
- Interpersonal: human being is always at heart of nursing
- Outcome Oriented: nurses and patients work together to
identify outcomes
- Universally Applicable: a framework for all nursing activities
Steps in Concept Mapping
1. Collect patient problems and concerns in a list.
2. Connect and analyze the relationships.
3. Create a diagram.
4. Keep in mind key concepts: the nursing process, holism,
safety, and advocacy
Reflection in action
happens in the here and now of the activity and is also know as
thinking on your feet
Reflection on action
occurs after the fact and involves thinking through a situation
that has occurred in the past
Reflection for action
helps the person to think about how future actions might change
as a result of the reflection
, Objective Data
observable and measurable data that can be seen, heard, or felt
by someone other that the patient
- ex: elevated temperature, skin moisture, vomiting
Subjective Data
information perceived only by the patient
- ex: pain, feeling dizzy, feeling anxious
Nursing Observation
- determines the patient's current responses (physical and
emotional)
- determines the patient's current ability to manage care
- determines the immediate environment and its safety
- determines the larger environment (hospital or community)
Problems Related to Data Collection
-Inappropriate organization of the database
-Omission of pertinent data
-Inclusion of irrelevant or duplicate data, erroneous or
misinterpreted data
-Failure to establish rapport and partnership
-Recording an interpretation of data rather than observed
behavior
-Failure to update the database
Validating Inferences
-Performing a physical examination
-Using clarifying statements
