HP
,2022
1022C Fundamentals of Nursing: Final Exam Study Guide
1. THE NURSING PROCESS: Apply each of the 5 steps to a question
Assessing
● Collect Data
● Organize data
● Validate data
● Document data
Diagnosing
● Analyze date
● Identify health problems, risks and strengths
● Formulate diagnostic statements
Planning
● Prioritize problems / diagnosis
● Formulate goals / desired outcomes
● Select nursing interventions
● Write nursing interventions
Implementing (action)
● Reassess the client
● Determine the nurse’s need for assistance
● Implement the nursing interventions
● Supervise delegated care
● Document nursing activities
Evaluating
● Collect data related to outcomes
● Compare data with outcomes
● Relate nursing actions to client goals / outcomes
● Draw conclusions about problem status
● Continue, modify or terminate the client’s care plan
2. NURSING DIAGNOSIS FORMATION: May have to develop a nursing
diagnosis
Data analysis + Problem Identification = Formulation of Nursing Diagnosis
3. THERAPEUTIC COMMUNICATION (DO NOT NEED TO KNOW SPECIFIC
NAMES OF TECHNIQUES)
See table 26-2
4. VITAL SIGNS: Know ranges- BP, Pulse, Temperature (Axillary, PO),
Respirations, Pulse Ox
, TEMP: 96.8-99.5 F (Oral, rectal, axillary, tympanic membrane-ear,
skin/temporal artery-forehead)
BP: 120/80
PULSE: 60-100 WNL: Temporal, carotid (never do both at once), Brachial,
radial, apical, femoral, popliteal, posterior tibia, dorsalis pedis)
RESPIRATIONS: 12-20
PULSE OXIMETRY: 95-100% RA
5. CLIENT HISTORY: Past Medications, Past Surgeries, Etc.
● Surgical History
● Medical History
● Social History
● Family History
● Allergies
● Medications
6. PHYSICAL ASSESSMENT: Genital Urinary (Inspection); Lungs
(Auscultating), GI = Observation, Auscultating, Palpation, Percussion
● Inspection: Visual examination using sight
● Auscultation: the process of listening to sounds produced within the
body.
● Direct auscultation: the used of the unaided ear, for example
listening to a respiratory wheeze or the grating of a moving joint.
● Indirect auscultation: the use of a stethoscope
● Percussion: the act of striking the body surface to elicit sounds that
can be heard or vibrations that can be felt
● Direct percussion: striking the area to be percussed directly with
the pads of 2, 3 or 4 fingers or with the pad of the middle finger
● Indirect percussion: the striking of an object held against the
body area to be examined
● Palpation: Examination of the body using the sense of touch. Used to
determine: texture, temperature, vibration, position, size, consistency and
mobility of organs, distention, pulsation and tenderness or pain.
Skin – Inspection and palpation
Ears and hearing – inspection and palpation
Nose – inspection and palpation
Lungs and thorax – inspection, palpation, percussion and auscultation
Heart – Inspection, palpation and auscultation (in this sequence)
,2022
1022C Fundamentals of Nursing: Final Exam Study Guide
1. THE NURSING PROCESS: Apply each of the 5 steps to a question
Assessing
● Collect Data
● Organize data
● Validate data
● Document data
Diagnosing
● Analyze date
● Identify health problems, risks and strengths
● Formulate diagnostic statements
Planning
● Prioritize problems / diagnosis
● Formulate goals / desired outcomes
● Select nursing interventions
● Write nursing interventions
Implementing (action)
● Reassess the client
● Determine the nurse’s need for assistance
● Implement the nursing interventions
● Supervise delegated care
● Document nursing activities
Evaluating
● Collect data related to outcomes
● Compare data with outcomes
● Relate nursing actions to client goals / outcomes
● Draw conclusions about problem status
● Continue, modify or terminate the client’s care plan
2. NURSING DIAGNOSIS FORMATION: May have to develop a nursing
diagnosis
Data analysis + Problem Identification = Formulation of Nursing Diagnosis
3. THERAPEUTIC COMMUNICATION (DO NOT NEED TO KNOW SPECIFIC
NAMES OF TECHNIQUES)
See table 26-2
4. VITAL SIGNS: Know ranges- BP, Pulse, Temperature (Axillary, PO),
Respirations, Pulse Ox
, TEMP: 96.8-99.5 F (Oral, rectal, axillary, tympanic membrane-ear,
skin/temporal artery-forehead)
BP: 120/80
PULSE: 60-100 WNL: Temporal, carotid (never do both at once), Brachial,
radial, apical, femoral, popliteal, posterior tibia, dorsalis pedis)
RESPIRATIONS: 12-20
PULSE OXIMETRY: 95-100% RA
5. CLIENT HISTORY: Past Medications, Past Surgeries, Etc.
● Surgical History
● Medical History
● Social History
● Family History
● Allergies
● Medications
6. PHYSICAL ASSESSMENT: Genital Urinary (Inspection); Lungs
(Auscultating), GI = Observation, Auscultating, Palpation, Percussion
● Inspection: Visual examination using sight
● Auscultation: the process of listening to sounds produced within the
body.
● Direct auscultation: the used of the unaided ear, for example
listening to a respiratory wheeze or the grating of a moving joint.
● Indirect auscultation: the use of a stethoscope
● Percussion: the act of striking the body surface to elicit sounds that
can be heard or vibrations that can be felt
● Direct percussion: striking the area to be percussed directly with
the pads of 2, 3 or 4 fingers or with the pad of the middle finger
● Indirect percussion: the striking of an object held against the
body area to be examined
● Palpation: Examination of the body using the sense of touch. Used to
determine: texture, temperature, vibration, position, size, consistency and
mobility of organs, distention, pulsation and tenderness or pain.
Skin – Inspection and palpation
Ears and hearing – inspection and palpation
Nose – inspection and palpation
Lungs and thorax – inspection, palpation, percussion and auscultation
Heart – Inspection, palpation and auscultation (in this sequence)
