FUNDAMENTALS EXAM 1 STUDY GUIDE

NR 226 EXAM 1


MODULE 1: CLINICAL JUDGMENT &
THE NURSING PROCESS
(This is the FOUNDATION of everything — expect MANY questions)




What Is Clinical Judgment?
Clinical judgment is how nurses think.

It is:

 Ongoing
 Happening constantly
 Based on assessment → interpretation → action → evaluation

📌 NCLEX tests HOW you think, not what you memorize




The Nursing Process (NCLEX CORE)
ADPIE

You must know this cold

1️
⃣ ASSESSMENT

 Gather subjective data (what patient says)
 Gather objective data (what you see, hear, measure)
 Review:
o Vital signs
o Labs
o Physical exam
o Patient history

🚨 NCLEX RULE:
If assessment has NOT been done yet → ASSESS FIRST

, 2️
⃣ NURSING DIAGNOSIS (NOT MEDICAL)

 Identifies patient response
 Uses NANDA-I language
 NEVER restates a medical diagnosis

❌ Wrong: “Diabetes”
✅ Correct: “Impaired glucose regulation”




Types of Nursing Diagnoses
1. Actual (Problem-Focused)

Uses PES format

P – Problem
E – Etiology (cause)
S – Signs & symptoms

Example:
Acute pain related to tissue ischemia as evidenced by chest pain



2. Risk Diagnosis

 NO symptoms yet
 Only 2 parts

Example:
Risk for infection related to surgical incision



3. Health Promotion

 Focus on wellness
 1 part only

Example:
Readiness for enhanced nutrition