NUR 170 Final EXAM /NUR170 Final Exam Actual
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The nursing process is - ....ANSWER.....✓✓a critical
thinking method used by nurses to provide nursing care
that is individualized and holistic.
5 steps of the nursing process - ....ANSWER.....✓✓1.
assessment/data collection
2. analysis/ diagnosis
3. planning
4. implementation
5. evaluation
Times a nurse can collect data - ....ANSWER.....✓✓1.
initial assessment (baseline data)
2. Focused assessment
3. Ongoing assessments
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Methods of data collection include: -
....ANSWER.....✓✓Observation, interviews with clients
and families, medical history, comprehensive or
focused physical examination, diagnostic and laboratory
reports, and collaboration with other members of the
health care team.
subjective data - ....ANSWER.....✓✓what the person says
about himself or herself during history taking
objective data - ....ANSWER.....✓✓information that is
seen, heard, felt, or smelled by an observer; signs
Analysis/diagnosis - ....ANSWER.....✓✓- identify
patterns or trends
- compare data with expected standards or reference
ranges
- arrive at conclusions to guide nursing care
Planning - ....ANSWER.....✓✓- must establish priorities
and optimal outcomes of care they can readily measure
and evaluate
- direction interventions to include in a plan of care to
promote, maintain, or restore health of clients
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Three types of planning - ....ANSWER.....✓✓-
comprehensive: on admission, after assessment
- ongoing: throughout provision of care
- discharge: needs for after discharge
What guidelines are used to set priorities? -
....ANSWER.....✓✓Maslow's Hierarchy of needs
Maslow's Hierarchy of Needs Levels -
....ANSWER.....✓✓(level 1) Physiological Needs, (level 2)
Safety and Security, (level 3) Relationships, Love and
Affection, (level 4) Self Esteem, (level 5) Self
Actualization
Nurse-initiated/independent interventions -
....ANSWER.....✓✓nursing actions initiated by the nurse
that do not require direction or an order from a health
care provider
Provider-initiated/dependent interventions -
....ANSWER.....✓✓Interventions nurses initiate as a
result of a provider's prescription (written, standing, or
verbal) or the facility's protocol, such as blood
administration procedures.
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collaborative interventions -
....ANSWER.....✓✓interdependent nursing actions
performed jointly by nurses and other members of the
health care team
Implementation - ....ANSWER.....✓✓- nurses perform
nursing actions, delegate tasks, supervise other
healthcare staff, document delivery of care and client
responses
- put plan into action
Evaluation - ....ANSWER.....✓✓- nurses evaluate client
responses to nursing interventions to determine if any
modifications to nursing care plan is needed
Asepsis - ....ANSWER.....✓✓is the absence of illness-
producing micro-organisms
Medical asespsis - ....ANSWER.....✓✓clean technique:
techniques that inhibit the growth & spread of
pathogenic microorganisms...example hand washing,
changing pts beds
Surgical Asepsis - ....ANSWER.....✓✓sterile technique