NUR 168 Final Exam Questions with Verified
Correct Answers
What is the nursing process
A- assessment: collect information
D- Diagnosis: identify nursing problems
P- Planning: prioritize, establish goals/outcomes, choose interventions
I- implementation: perform interventions
E- Evaluation: determine whether interventions worked
Biggest rule for a new or sudden change
assess
Patient was A&O ×4 one hour ago and is suddenly confused and trying to climb out of
bed. (what do you do first)
FIRST: Assess the patient
- airway
- breathing
- circulation
- vital signs
- SpO2
- Neurological status
- blood glucose when appropriate
When do you NOT just assess first?
If there is an obvious immediate life threat requiring an intervention, intervene.
obvious airway/life-threatening emergency think:
,ACT
New vs. chronic problem
NEW first
acute vs chronic
ACUTE first
unstable vs. stable
UNSTABLE first
unexpected vs expected
UNEXPECTED first
respiratory compromise vs. pain
RESPIRATORY first
actual vs. potential
USUALLY actual first
life threat vs. comfort
life threat first
Subjective data
What the patient tells you (symptoms)
objective
what you can: observe, measure, verify
Primary source
, the patient
secondary source
family, caregiver, medical record, other nurses, providers, medication records
PES nursing diagnosis
P- Problem
E- Etiology
S- Signs/Symptoms
"problem related to cause as evidenced by evidence"
A proper outcome should be:
patient-centered, specific, measurable, realistic, time-specific
WHO, WHAT, HOW MUCH, HOW, WHEN
Short-term goals
achievable relatively quickly, often during the current hospitalizaiton/shift
Long-term goals
requires more time
Independent nursing interventions
nurse can initiate without a provider order
Dependent nursing interventions
requires a provider prescription/order
Care should reflect:
Correct Answers
What is the nursing process
A- assessment: collect information
D- Diagnosis: identify nursing problems
P- Planning: prioritize, establish goals/outcomes, choose interventions
I- implementation: perform interventions
E- Evaluation: determine whether interventions worked
Biggest rule for a new or sudden change
assess
Patient was A&O ×4 one hour ago and is suddenly confused and trying to climb out of
bed. (what do you do first)
FIRST: Assess the patient
- airway
- breathing
- circulation
- vital signs
- SpO2
- Neurological status
- blood glucose when appropriate
When do you NOT just assess first?
If there is an obvious immediate life threat requiring an intervention, intervene.
obvious airway/life-threatening emergency think:
,ACT
New vs. chronic problem
NEW first
acute vs chronic
ACUTE first
unstable vs. stable
UNSTABLE first
unexpected vs expected
UNEXPECTED first
respiratory compromise vs. pain
RESPIRATORY first
actual vs. potential
USUALLY actual first
life threat vs. comfort
life threat first
Subjective data
What the patient tells you (symptoms)
objective
what you can: observe, measure, verify
Primary source
, the patient
secondary source
family, caregiver, medical record, other nurses, providers, medication records
PES nursing diagnosis
P- Problem
E- Etiology
S- Signs/Symptoms
"problem related to cause as evidenced by evidence"
A proper outcome should be:
patient-centered, specific, measurable, realistic, time-specific
WHO, WHAT, HOW MUCH, HOW, WHEN
Short-term goals
achievable relatively quickly, often during the current hospitalizaiton/shift
Long-term goals
requires more time
Independent nursing interventions
nurse can initiate without a provider order
Dependent nursing interventions
requires a provider prescription/order
Care should reflect:
