3 phases of a nurse-pt relationship correct answer 1. Orientation- trust and
understanding grow, nurse role is clarified, terms of termination are introduced,
transference/counter
2. Working- maintaining, gather further data, evaluate problems and goals
3. Termination- summarizing goals and objectives
3 sources of law correct answer 1. constitution- legal rights/ responsibility
2. legislation- federal or state ** effects nurses**
3. case- common law
3 types of assessment correct answer emergency
comprehensive
focused
4 components of cultural competence correct answer 1. cultural awareness:
understanding pt cultural needs
2. Cultural Knowledge: learning key aspects of cultures
3. Cultural Skill: collect relevant data
4. Cultural encounter
5 rights of delegation correct answer 1. Right task- policy and scope
2. Right circumstance- stable and safe
3. Right person
4. Right direction/communication- clear directions
,5. Right supervision/evaluation- feedback and followup
abdominal assessment correct answer 1. inspection- flat, round, protuberant,
concave, symmetry, skin
2. auscultation- listen for BS in all quads, RLQ-RUP-LUQ-LLQ, RLQ usually loudest,
normoactive BS- every 5-15 seconds, hyperactive BS- loud, prolonged gurgles
hypoactive BS- sluggish 3-4 BS/min
-absence of peristalsis= no BS heard after listening for 60 sec in each quad,
3. percussion
4. palpation- ask pt if any pain
Advanced Directive (AD) correct answer Legal document where a patient gives
written instructions about health care decisions in the future.
AHIPPEE correct answer - allergies
- hand hygiene
- ID X2 ( name/ DOB)
- patient privacy (HIPPA)
- physicians orders
- equipment
- explain all procedures
Airborne precautions correct answer -TB, COVID, measles, chicken pox, HSV,
- standard + gloves, mask, gown, N95, eye shield, negative pressure room
- we wont be caring for pt in airborne isolation
, Ambulation correct answer - pt should be ambulated as much as possible
- if not possible pt should be repositioned Q2h
- place wheelchair on pt stronger side
- assess pain level before moving
- pt hands on your shoulders
ANA Code of Ethics correct answer 1. The nurse practices with compassion and
respect for the inherent dignity, worth, and unique attributes of every person.
2. The nurse's primary commitment is to the patient, whether an individual,
family, group, community, or population.
3. The nurse promotes, advocates for, and protects the rights, health, and safety
of the patient.
4. The nurse has the authority, accountability, and responsibility for nursing
practice; makes decisions; and takes action consistent with the obligation to
promote health and to provide optimal care.
5. The nurse owes the same duties to self as to others, including the responsibility
to promote health and safety, preserve wholeness of character and integrity,
maintain competence, and continue personal and professional growth.
6. The nurse, through individual and collective effort, establishes, maintains, and
improves the ethical environment of the work setting and conditions of
employment that are conducive to safe, quality health care.
7. The nurse, in all roles and setting, advances the profession through research
and scholarly inquiry, professional standards development, and the generation of
both nursing and health policy.
8. The nurse collaborates with other health professionals and the public to
protect human rights, promote health diplomacy, and reduce health disparities.