307 Exam 1
Steps of the Nursing Process - answer Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - answer gather data from the client through interview, physical exam and
observation to make judgments
critical reasoning cycle - answer consider patient
collect information
process information
identify problems
establish goals
take action
evaluate outcomes
reflect on process
Nonmaleficence - answerto do no harm
Benefience - answerto act to promote the good of the client
autonomy - answerclients right to make decisions
Justice - answerto treat everyone fairly regardless of their ability to pay for treatment,
social status cultural or religious background
Confidentiality - answerrespecting the rights of the client to maintain privacy
Therapeutic communication - answer-keep questions focused and relevant to context
and situation
-redirect client as needed
-clarify to see if information is correct
-keep emotionally charged conversation for last
-be vigilant throughout the conversation
nontherapeutic communication - answer-give approval and disapproval
-asks for explanations
-give false reassurances
-use plural pronouns like "we"
-give personal opinions
,ISBARR - answer-Introduce
-Situation
-Assessment
-Recommendations
-Read back orders
tools for chest - answer-stethoscope
-doppler
-inspect
-auscultate
tools for abdomen - answer-stethoscope
-inspect
-palpate
-auscultate
-tape measure
tools for eye assessment - answer-inspect
-penlight
-palpate
tools for foot assessment - answer-inspect
-palpate
-doppler
-blood pressure cuff
select the actions the PN participates in with the nursing process
a. assists the RN with data collection from the client
b. perform a comprehensive assessment on the client
c. develop the client care plan using your best judgement
d. analyze the objective from the client - answera. assists the RN with data collection
from the client
What does HIPAA stand for?
a. health information privacy account act
b. health insurance portability and accountability act
c. health insurance paper account act
d. health information portability and accountability act - answerb. health Insurance
Portability and Accountability Act
therapeutic communication involves which of the following?
(select all that apply)
a. touch
b. open-ended questions
c. sharing your own personal experiences
, d. if the client speaks a different language than the nurse, finding someone in the facility
who speaks their language - answera. touch
b. open-ended questions
Which of the following technique is used for palpation?
a. palpate the tender area before other areas
b. use short, quick taps with palpation
c. use the palmar side of the hands or pads of fingers
d. use the stethoscope during palpation - answerc. use the palmar side of the hands or
pads of fingers
Which of the following actions by the nurse are examples of infection control?
a. hand washing with soap and water for 15 seconds
b. using an alcohol-based rub when hands are not visibly soiled
c. using an alcohol pad to wipe the diaphragm of the stethoscope between clients
d. wearing artificial nails
e. wearing sterile gloves when opening gauze dressing packages - answera. hand
washing with soap and water for 15 seconds
b. using an alcohol based rub when hands are not visibly soiled
c. using an alcohol pad to wipe the diaphragm of the stereoscope between clients
Which of the following tool are used with auscultation?
a. dorsal side of hands
b. stethoscope
c. penlight
d. doppler
e. tape measure - answer
Place the steps for communicating with members of health care team in correct order. -
answer-indentify
-provide information about the current situation
-provide information regarding the background situation
-give the most recent set of vitals to the team members
-provide suggestions that may be helpful tot he situation
-repeat the orders back that you are given by the provider
Match the ethical principle to the definition - answernonmaleficence-avoiding harm to all
clients
autonomy-allowing a client to make informed decisions
beneficence-promoting the best interests of the client
justice-fair treatment to all clients
fidelity-keeping a promise to a client
Which of the following is the first action during the physical assessment of the client?
a. ask the client about any allergies
b. inspecting the client
Steps of the Nursing Process - answer Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - answer gather data from the client through interview, physical exam and
observation to make judgments
critical reasoning cycle - answer consider patient
collect information
process information
identify problems
establish goals
take action
evaluate outcomes
reflect on process
Nonmaleficence - answerto do no harm
Benefience - answerto act to promote the good of the client
autonomy - answerclients right to make decisions
Justice - answerto treat everyone fairly regardless of their ability to pay for treatment,
social status cultural or religious background
Confidentiality - answerrespecting the rights of the client to maintain privacy
Therapeutic communication - answer-keep questions focused and relevant to context
and situation
-redirect client as needed
-clarify to see if information is correct
-keep emotionally charged conversation for last
-be vigilant throughout the conversation
nontherapeutic communication - answer-give approval and disapproval
-asks for explanations
-give false reassurances
-use plural pronouns like "we"
-give personal opinions
,ISBARR - answer-Introduce
-Situation
-Assessment
-Recommendations
-Read back orders
tools for chest - answer-stethoscope
-doppler
-inspect
-auscultate
tools for abdomen - answer-stethoscope
-inspect
-palpate
-auscultate
-tape measure
tools for eye assessment - answer-inspect
-penlight
-palpate
tools for foot assessment - answer-inspect
-palpate
-doppler
-blood pressure cuff
select the actions the PN participates in with the nursing process
a. assists the RN with data collection from the client
b. perform a comprehensive assessment on the client
c. develop the client care plan using your best judgement
d. analyze the objective from the client - answera. assists the RN with data collection
from the client
What does HIPAA stand for?
a. health information privacy account act
b. health insurance portability and accountability act
c. health insurance paper account act
d. health information portability and accountability act - answerb. health Insurance
Portability and Accountability Act
therapeutic communication involves which of the following?
(select all that apply)
a. touch
b. open-ended questions
c. sharing your own personal experiences
, d. if the client speaks a different language than the nurse, finding someone in the facility
who speaks their language - answera. touch
b. open-ended questions
Which of the following technique is used for palpation?
a. palpate the tender area before other areas
b. use short, quick taps with palpation
c. use the palmar side of the hands or pads of fingers
d. use the stethoscope during palpation - answerc. use the palmar side of the hands or
pads of fingers
Which of the following actions by the nurse are examples of infection control?
a. hand washing with soap and water for 15 seconds
b. using an alcohol-based rub when hands are not visibly soiled
c. using an alcohol pad to wipe the diaphragm of the stethoscope between clients
d. wearing artificial nails
e. wearing sterile gloves when opening gauze dressing packages - answera. hand
washing with soap and water for 15 seconds
b. using an alcohol based rub when hands are not visibly soiled
c. using an alcohol pad to wipe the diaphragm of the stereoscope between clients
Which of the following tool are used with auscultation?
a. dorsal side of hands
b. stethoscope
c. penlight
d. doppler
e. tape measure - answer
Place the steps for communicating with members of health care team in correct order. -
answer-indentify
-provide information about the current situation
-provide information regarding the background situation
-give the most recent set of vitals to the team members
-provide suggestions that may be helpful tot he situation
-repeat the orders back that you are given by the provider
Match the ethical principle to the definition - answernonmaleficence-avoiding harm to all
clients
autonomy-allowing a client to make informed decisions
beneficence-promoting the best interests of the client
justice-fair treatment to all clients
fidelity-keeping a promise to a client
Which of the following is the first action during the physical assessment of the client?
a. ask the client about any allergies
b. inspecting the client
