NURS 3000 EXAM 2 UPDATED ACTUAL Questions and
CORRECT Answers
Maslow's Hierarchy of Human Needs 1 Physiological: Life-threatening
2. Safety / Security: fear, environmental hazards
3. Love and Belonging: isolation; loss of loved one
4. Self-Esteem
5. Ability to Achieve personal long term goals
Essential focus of goals to critique Goals must be SMART
- Specific
- Measurable
- Attainable
- Realistic / Resources
- Time Frame
Long term goal Patient outcomes over a week or more; Ideally aim at restoring normal functioning
in a problem area
- If normal is not possible, describe maximum / optimal level of functioning that
can be achieved
Short term goal Outcomes can be achieved within a few days or hours, usually must be achieved
before patient can achieve long term goals
Independent vs Dependent nursing actions Independent: Nurse legally able to carry out without another professional's order
Dependent: Prescribed by physician and carried out by nurse; medication
administration
Examples of Nursing orders Made up of: Date, subject, action / verb, descriptive qualifiers, specific times, and
signature
Addresses observation, prevention, treatment, and health promotion
, Purpose of implementation phase Helps to organize our personal schedule as nurses so we can provide the best
care possible to every patient; involves a daily plan, preparation, need
assessment, readiness, supplies, and our acquired knowledge / skills
- ALWAYS PLAN DAY AROUND MOST COMPLEX PATIENT
What are the five rights of delegation? 1. Right Task: tasks repetitively performed
2. Right Circumstances: appropriate patient setting with available resources /
timing
3. Right Person: right person delegating right task to right person performed on
right patient
4. Right Direction: clear description of task, incl. purpose, limits, and expectations
5. Right Supervision: appropriate monitoring, evaluation, intervention, and
feedback
Describe nurses role in Delegation Nurse can assign tasks, but not responsibility for total nursing care
- Can delegate tasks to UAP, including V/S, I/O, Transfer/Amb, Bathing/Feeding/
Weighing, Postmortem care, CPR, Attending to safety needs, and Height / Weight
What is the RN's ultimate responsibility for client care? The nurse is responsible for His / Her ASSIGNED PATIENTS and cannot pass off
specific tasks or overall care to another nurse without proper approval
Purpose of Evaluation of Outcomes A systematic process in which judgment made about quality, value, or worth by
comparing to previously identified criteria or standards; it is planned and ongoing
What are some appropriate nursing actions if a client - Goal met: occurs when problem resolved, risk problem is prevented, problem
goal / outcome is not met? exists at a lesser degree, possible prob ruled out, or all probs resolved; if goal
met and pt still in your care, must make a new goal
- Goal partially met: could occur if prop reduced or minimized; can continue goal
or make necessary adjustments
- Goal not met: could occur if prob still exists and need to continue plan, or prob
still exists and need to revise plan
Examples of evaluative statements to critique - Goal partially met AEB:
- Says only gets nervous when has "trouble breathing"
- Face relaxed except during periods of dyspnea
- No skeletal muscle tension except during episodes of dyspnea
- "I feel better since you explained the fire drill. I think I'm getting used to things
around here"
Guidelines for correct charting and documentation - Initial assessment / admission
- Reassessment / New findings
- Changes in pt status
- Hypotheses / Problem statements (actual, risk, possible)
- Short and Long term goals
- Nursing interventions
- Action / Implementation techniques; delegation
- Achievement of patient goals
- Supportive data specifically related to nursing interventions; necessary revisions
- Any patient teaching
CORRECT Answers
Maslow's Hierarchy of Human Needs 1 Physiological: Life-threatening
2. Safety / Security: fear, environmental hazards
3. Love and Belonging: isolation; loss of loved one
4. Self-Esteem
5. Ability to Achieve personal long term goals
Essential focus of goals to critique Goals must be SMART
- Specific
- Measurable
- Attainable
- Realistic / Resources
- Time Frame
Long term goal Patient outcomes over a week or more; Ideally aim at restoring normal functioning
in a problem area
- If normal is not possible, describe maximum / optimal level of functioning that
can be achieved
Short term goal Outcomes can be achieved within a few days or hours, usually must be achieved
before patient can achieve long term goals
Independent vs Dependent nursing actions Independent: Nurse legally able to carry out without another professional's order
Dependent: Prescribed by physician and carried out by nurse; medication
administration
Examples of Nursing orders Made up of: Date, subject, action / verb, descriptive qualifiers, specific times, and
signature
Addresses observation, prevention, treatment, and health promotion
, Purpose of implementation phase Helps to organize our personal schedule as nurses so we can provide the best
care possible to every patient; involves a daily plan, preparation, need
assessment, readiness, supplies, and our acquired knowledge / skills
- ALWAYS PLAN DAY AROUND MOST COMPLEX PATIENT
What are the five rights of delegation? 1. Right Task: tasks repetitively performed
2. Right Circumstances: appropriate patient setting with available resources /
timing
3. Right Person: right person delegating right task to right person performed on
right patient
4. Right Direction: clear description of task, incl. purpose, limits, and expectations
5. Right Supervision: appropriate monitoring, evaluation, intervention, and
feedback
Describe nurses role in Delegation Nurse can assign tasks, but not responsibility for total nursing care
- Can delegate tasks to UAP, including V/S, I/O, Transfer/Amb, Bathing/Feeding/
Weighing, Postmortem care, CPR, Attending to safety needs, and Height / Weight
What is the RN's ultimate responsibility for client care? The nurse is responsible for His / Her ASSIGNED PATIENTS and cannot pass off
specific tasks or overall care to another nurse without proper approval
Purpose of Evaluation of Outcomes A systematic process in which judgment made about quality, value, or worth by
comparing to previously identified criteria or standards; it is planned and ongoing
What are some appropriate nursing actions if a client - Goal met: occurs when problem resolved, risk problem is prevented, problem
goal / outcome is not met? exists at a lesser degree, possible prob ruled out, or all probs resolved; if goal
met and pt still in your care, must make a new goal
- Goal partially met: could occur if prop reduced or minimized; can continue goal
or make necessary adjustments
- Goal not met: could occur if prob still exists and need to continue plan, or prob
still exists and need to revise plan
Examples of evaluative statements to critique - Goal partially met AEB:
- Says only gets nervous when has "trouble breathing"
- Face relaxed except during periods of dyspnea
- No skeletal muscle tension except during episodes of dyspnea
- "I feel better since you explained the fire drill. I think I'm getting used to things
around here"
Guidelines for correct charting and documentation - Initial assessment / admission
- Reassessment / New findings
- Changes in pt status
- Hypotheses / Problem statements (actual, risk, possible)
- Short and Long term goals
- Nursing interventions
- Action / Implementation techniques; delegation
- Achievement of patient goals
- Supportive data specifically related to nursing interventions; necessary revisions
- Any patient teaching
