NS 500 Foundations of Nursing - Exam 1 || with error-free
answers.
What are the premises of Tanner's model of clinical judgement? correct answers Noticing,
interpreting, responding, reflecting
How do we add JEDI into Tanner's model of clinical judgement? correct answers Notice
intersectionality, interpret without bias, respond with sensitivity
What are the two types of reflection and what are examples? correct answers Reflection in action
and reflection on action. Reflection in action could be reflecting on past experiences and how to
apply that experience currently. Reflection on action is reflecting at the end of something about
how things went and what could be different.
What is the overall gist of the nursing process? correct answers To diagnose and treat human
responses to actual or potential health problem.
What are the components of the nursing process? correct answers Assessment, diagnosis,
planning, implementation, evaluation
What comprises the assessment component? correct answers Determines patient current and past
health status with two steps: collect information and interpret information. This is when you run
through an HPI, ROS, and exam.
What should you do prior to going in and assessing your patient? correct answers Review the
EMR, review isolation precautions, and sanitize your hands just prior to entering the room
What is a focused assessment? correct answers This assessment is problem-oriented.
,What are some interview techniques? correct answers Observation, open or closed ended
questions, leading questions, back channeling, probing
What is a nursing diagnosis? correct answers A clinical judgement made by an RN to describe a
patient response or vulnerability to health conditions or life events that an RN is licensed and
competent to treat.
What is a collaborative problem? correct answers A problem that requires both medical and
nursing interventions to treat.
What are the three types of nursing diagnoses? correct answers Problem focused, risk, and health
promotion
Write a PES statement for acute infection. correct answers Acute infection r/t wound from a
ground level fall as evidenced by purulent material, warmth, and erythema of the wound site.
What is wrong with this PES statement?
Risk for falls related to recent cerebrovascular accident. correct answers CVA is a medical
diagnosis and should not be included. This could be fixed by changing the statement to "Risk for
falls related to impaired balance."
What are the methods of prioritization? correct answers Consider the type of nursing diagnosis,
as problem focused tend to be of higher importance than others. Acute issues are the most
important. Consider the ABCs and Maslow's hierarchy of needs.
What is a goal? correct answers A goal is a broad statement of a desired change in a patient's
condition, perceptions, or behavior.
Give an example of a goal statement. correct answers Patient will report no difficulty breathing
by the end of the shift.
, What is an expected outcome? correct answers An expected outcome is a time limited,
measurable change that must be achieved in order to meet the broad goal. SMART. Specific -
Measurable - Achievable - Realistic - Timely
Give an example of an expected outcome. correct answers Patient will demonstrate proper use of
an incentive spirometer 10 times per hour while awake through the shift.
What are some examples of independent actions? correct answers Toileting, teaching, activities
of daily living
What are the two types of interventions? correct answers Direct and indirect
What are the five rights of delegation? correct answers Right task, right circumstance, right
person, right communication, right supervision
What occurs in the evaluation step of the nursing process? correct answers Seeing if
interventions caused the patient to meet the expected outcomes/goals. If not, modify the care
plan. If yes, then discontinue the care plan.
Who is accountable for interpreting and collecting vital signs? correct answers The RN. The task
can be delegated but in the end it is the RN's responsibility.
What is the normal range for temperature? correct answers 96.8-100.4 F or 36-38 C
What controls temperature? correct answers the hypothalamus
What is a temp greater than 38 C or 100.4 F considered? correct answers pyrexia. Patient is
febrile
answers.
What are the premises of Tanner's model of clinical judgement? correct answers Noticing,
interpreting, responding, reflecting
How do we add JEDI into Tanner's model of clinical judgement? correct answers Notice
intersectionality, interpret without bias, respond with sensitivity
What are the two types of reflection and what are examples? correct answers Reflection in action
and reflection on action. Reflection in action could be reflecting on past experiences and how to
apply that experience currently. Reflection on action is reflecting at the end of something about
how things went and what could be different.
What is the overall gist of the nursing process? correct answers To diagnose and treat human
responses to actual or potential health problem.
What are the components of the nursing process? correct answers Assessment, diagnosis,
planning, implementation, evaluation
What comprises the assessment component? correct answers Determines patient current and past
health status with two steps: collect information and interpret information. This is when you run
through an HPI, ROS, and exam.
What should you do prior to going in and assessing your patient? correct answers Review the
EMR, review isolation precautions, and sanitize your hands just prior to entering the room
What is a focused assessment? correct answers This assessment is problem-oriented.
,What are some interview techniques? correct answers Observation, open or closed ended
questions, leading questions, back channeling, probing
What is a nursing diagnosis? correct answers A clinical judgement made by an RN to describe a
patient response or vulnerability to health conditions or life events that an RN is licensed and
competent to treat.
What is a collaborative problem? correct answers A problem that requires both medical and
nursing interventions to treat.
What are the three types of nursing diagnoses? correct answers Problem focused, risk, and health
promotion
Write a PES statement for acute infection. correct answers Acute infection r/t wound from a
ground level fall as evidenced by purulent material, warmth, and erythema of the wound site.
What is wrong with this PES statement?
Risk for falls related to recent cerebrovascular accident. correct answers CVA is a medical
diagnosis and should not be included. This could be fixed by changing the statement to "Risk for
falls related to impaired balance."
What are the methods of prioritization? correct answers Consider the type of nursing diagnosis,
as problem focused tend to be of higher importance than others. Acute issues are the most
important. Consider the ABCs and Maslow's hierarchy of needs.
What is a goal? correct answers A goal is a broad statement of a desired change in a patient's
condition, perceptions, or behavior.
Give an example of a goal statement. correct answers Patient will report no difficulty breathing
by the end of the shift.
, What is an expected outcome? correct answers An expected outcome is a time limited,
measurable change that must be achieved in order to meet the broad goal. SMART. Specific -
Measurable - Achievable - Realistic - Timely
Give an example of an expected outcome. correct answers Patient will demonstrate proper use of
an incentive spirometer 10 times per hour while awake through the shift.
What are some examples of independent actions? correct answers Toileting, teaching, activities
of daily living
What are the two types of interventions? correct answers Direct and indirect
What are the five rights of delegation? correct answers Right task, right circumstance, right
person, right communication, right supervision
What occurs in the evaluation step of the nursing process? correct answers Seeing if
interventions caused the patient to meet the expected outcomes/goals. If not, modify the care
plan. If yes, then discontinue the care plan.
Who is accountable for interpreting and collecting vital signs? correct answers The RN. The task
can be delegated but in the end it is the RN's responsibility.
What is the normal range for temperature? correct answers 96.8-100.4 F or 36-38 C
What controls temperature? correct answers the hypothalamus
What is a temp greater than 38 C or 100.4 F considered? correct answers pyrexia. Patient is
febrile
