NURS 302 Assessment 1 Questions and Correct Solutions | A+

The Nursing Process is a systematic five step framework nurses use to... What are the steps? plan and provide optimal patient care ADPIE Assessment Diagnosis/Analysis Planning Implementation Evaluation What is used to prioritize which patients should be seen first? ABCDEP Airway Breathing Circulation Disability or change in level of consciousness Environment - concerns around patient's body Pain What are your first two actions for treating a patient in respiratory distress? 1. First raise the head of the bed to allow the airway to open up 2. Second intervention is to put on oxygen What question helps build critical thinking skills when thinking about what intervention to perform? If I do "this" then "what" will happen? If I give IV fluids, what happens to a patients blood pressure? It increases If I give Oxygen to a patient, what should I see? An increase in oxygen saturation If patient has an infection, then what? They'll have a fever When making decisions, what four things should you do? 1. Review the set of all possible nursing interventions for a patient's problem 2. Review all possible consequences associated with each possible nursing action 3. Determine the probability of all possible consequences 4. Judge the value of the consequence to the patient Goals need to be SMART, which stands for? Specific Measurable Achievable Realistic Time limit-framed Nurses must make accurate and appropriate clinical decisions or judgements. Clinical judgement is defined as the outcome of critical thinking and clinical reasoning -Conclusion about a patient's needs or health problems -Influenced by a nurse's experience and knowledge -Partly relies on knowing the patient -Influenced by the context of clinical situations and the culture of patient and care settings The two forms of communication are verbal and nonverbal Why is it important to be culturally competent in regards to body language? Because body language varies by culture not looking someone in the eye in some cultures is considered a sign of respect whereas in others it's disrespectful, etc. etc. What are some types of therapeutic communication techniques? Active listening touch silence self disclosure open ended questions clarification If you didn't chart it, then... you didn't do it When do you fill out an incidence report? When something what wasn't supposed to happen, happens Equipment failure, wrong medication to wrong patient, etc. etc. Do incidence reports go in patient chart? no, they go in hospital database What is the most important thing to do when taking a telephone/verbal order? Repeat it back so the provider knows you heard everything because the nurse is the one entering the order Provider has to sign a telephone/verbal order within 24 hours The standards for Evidence Based Practice (EBP) are (2) -Problem-solving approach to clinical practice -Address clinical problems by using the best approach based on clinical evidence for managing the problem How can we determine if a patient understood what we just told them? Best way is to have the patient demonstrate it back to you Second best is the make sure they tell you in their own words Patient education is always written at what grade level? Why? 5th grade level So that every patient can understand what is going on with their care What can a UAP do? Do tasks and gather data (e.g "patient had this much urine") Can help with turning or ambulation if it isn't the first time What is QSEN? Quality and Safety Education for Nurses Developed to help prepare future nurses who will be needed in their health care environments to improve patient safety. Patients over the age of ____ are at an increased risk of a fall 65 What is the leading cause of fatal and nonfatal injuries for people over the age of 65? falls Patients on prolonged bedrest usually develop (hint: not pressure ulcers) Why is this a problem when they begin to ambulate? orthostatic hypotension -they get dizzy when they stand up They are at an increased risk of falling Most common means of transmission of pathogens is by the hands How often should you sanitize your hands? before and after every patient You only need to actually wash your hands (as opposed to sanitizer) when hands are visibly dirty or treating a patient that has C.diff