NUR 170 FINAL EXAM VERIFIED STUDY GUIDE
The nursing process is - Answers - a critical thinking method used by nurses to provide
nursing care that is individualized and holistic.
5 steps of the nursing process - Answers - 1. assessment/data collection
2. analysis/ diagnosis
3. planning
4. implementation
5. evaluation
Times a nurse can collect data - Answers - 1. initial assessment (baseline data)
2. Focused assessment
3. Ongoing assessments
Methods of data collection include: - Answers - 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 - Answers - what the person says about himself or herself during history
taking
objective data - Answers - information that is seen, heard, felt, or smelled by an
observer; signs
Analysis/diagnosis - Answers - - identify patterns or trends
- compare data with expected standards or reference ranges
- arrive at conclusions to guide nursing care
Planning - Answers - - 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
Three types of planning - Answers - - comprehensive: on admission, after assessment
- ongoing: throughout provision of care
- discharge: needs for after discharge
What guidelines are used to set priorities? - Answers - Maslow's Hierarchy of needs
Maslow's Hierarchy of Needs Levels - Answers - (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 - Answers - nursing actions initiated by the
nurse that do not require direction or an order from a health care provider
Provider-initiated/dependent interventions - Answers - 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.
collaborative interventions - Answers - interdependent nursing actions performed jointly
by nurses and other members of the health care team
Implementation - Answers - - nurses perform nursing actions, delegate tasks, supervise
other healthcare staff, document delivery of care and client responses
- put plan into action
Evaluation - Answers - - nurses evaluate client responses to nursing interventions to
determine if any modifications to nursing care plan is needed
Asepsis - Answers - is the absence of illness-producing micro-organisms
Medical asespsis - Answers - clean technique: techniques that inhibit the growth &
spread of pathogenic microorganisms...example hand washing, changing pts beds
Surgical Asepsis - Answers - sterile technique
3 essential components to hand hygiene - Answers - -soap
-water
-friction
Hand hygiene process - Answers - - wash for at least 15 seconds with warm water
- wet hands first
- use towel to turn water off
Proper order of donning PPE - Answers - gown, mask, goggles, gloves
Proper order of doffing PPE - Answers - gloves, goggles, gown, mask
Infection - Answers - invasion of the body by a pathogenic organism
Pathogens - Answers - organisms that cause disease
Types of pathogens - Answers - viruses, bacteria, parasites, fungi, prions
Virulence - Answers - is the ability of a pathogen to invade and injure a host
Native Immunity - Answers - Restricts entry or immediately responds to a foreign
organism through the activation of phagocytic cells, complement, and inflammation
The nursing process is - Answers - a critical thinking method used by nurses to provide
nursing care that is individualized and holistic.
5 steps of the nursing process - Answers - 1. assessment/data collection
2. analysis/ diagnosis
3. planning
4. implementation
5. evaluation
Times a nurse can collect data - Answers - 1. initial assessment (baseline data)
2. Focused assessment
3. Ongoing assessments
Methods of data collection include: - Answers - 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 - Answers - what the person says about himself or herself during history
taking
objective data - Answers - information that is seen, heard, felt, or smelled by an
observer; signs
Analysis/diagnosis - Answers - - identify patterns or trends
- compare data with expected standards or reference ranges
- arrive at conclusions to guide nursing care
Planning - Answers - - 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
Three types of planning - Answers - - comprehensive: on admission, after assessment
- ongoing: throughout provision of care
- discharge: needs for after discharge
What guidelines are used to set priorities? - Answers - Maslow's Hierarchy of needs
Maslow's Hierarchy of Needs Levels - Answers - (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 - Answers - nursing actions initiated by the
nurse that do not require direction or an order from a health care provider
Provider-initiated/dependent interventions - Answers - 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.
collaborative interventions - Answers - interdependent nursing actions performed jointly
by nurses and other members of the health care team
Implementation - Answers - - nurses perform nursing actions, delegate tasks, supervise
other healthcare staff, document delivery of care and client responses
- put plan into action
Evaluation - Answers - - nurses evaluate client responses to nursing interventions to
determine if any modifications to nursing care plan is needed
Asepsis - Answers - is the absence of illness-producing micro-organisms
Medical asespsis - Answers - clean technique: techniques that inhibit the growth &
spread of pathogenic microorganisms...example hand washing, changing pts beds
Surgical Asepsis - Answers - sterile technique
3 essential components to hand hygiene - Answers - -soap
-water
-friction
Hand hygiene process - Answers - - wash for at least 15 seconds with warm water
- wet hands first
- use towel to turn water off
Proper order of donning PPE - Answers - gown, mask, goggles, gloves
Proper order of doffing PPE - Answers - gloves, goggles, gown, mask
Infection - Answers - invasion of the body by a pathogenic organism
Pathogens - Answers - organisms that cause disease
Types of pathogens - Answers - viruses, bacteria, parasites, fungi, prions
Virulence - Answers - is the ability of a pathogen to invade and injure a host
Native Immunity - Answers - Restricts entry or immediately responds to a foreign
organism through the activation of phagocytic cells, complement, and inflammation
