NUR 221- Foundations Exam 2 LATEST
UPDATE 2025
What is critical thinking? - ANSWER The process of problem solving
- We gather data, validate data, and weigh options
Ways in which nurses utilize critical thinking - ANSWER - Assessing our patients and
making decisions about their care
-Re-evaluating pt's condition and making changes to the plan
-Communicating changes in pt's status to the provider and collaborating in creating
solutions
-Determining relevant data and discarding irrelevant data
Theoretical knowledge - ANSWER -Science based facts
-Pathophysiologic principles
-Evidence which policies
and protocols are based on
Example of theoretical knowledge - ANSWER The FACT that Heparin is a medication
that reduces blood clots by increasing blood clotting time
Practical knowledge - ANSWER Knowing when and how to do tasks and skills safely.
Example of using practical knowledge - ANSWER when we use the technique of
pinching the skin inserting a 5/8-inch needle at a 45-degree angle of the abdominal fold
when giving a subcutaneous injection of Heparin.
Self-knowledge - ANSWER Our own preferences or biases that may influence our
thinking
Example of self-knowledge and possible repercussions - ANSWER -First time I gave a
sub-Q injection at clinical last week, the patient flinched and it made me nervous to do it
again.
-This self-knowledge is important to be aware about as it may influence decisions in an
unintended way.
Contextual awareness - ANSWER Reflection on past experiences
Ethical knowledge - ANSWER -Helps us to handle situations where there is an element
of right and wrong.
,-We can recognize the situations as sometimes we may need to provide care that it's
ethically confusing or not so black and white.
-Ethical knowledge of boundaries and guidelines will help us remain true to our
profession in providing this care.
5 steps of the nursing process - ANSWER 1. Assessment
2. Diagnosis
3. Planning
4. Implements
5. Evaluating
Assessment - ANSWER Data gathering; interpreting/analyzing data.
-This is a nursing professional responsibility as recommended by the American Nurses
Association and therefore cannot be delegated to assistive personnel.
Can assistive personnel perform assessments? - ANSWER NO!!!!
We can enlist the help of unlicensed assistive staff in the action of collecting the data -
such as taking vital signs, asking about the presence of pain or measuring the amount
of urine voided, but it is a nursing responsibility to interpret and analyze that data
What is involved in all steps of the nursing process? - ANSWER Assessment
- We assess data
- When we implement our interventions, we assess its effectiveness and patient's
response
- When we evaluate expected outcome, we are assessing their success
What is the frequency of assessments regulated by? - ANSWER Accrediting bodies
-Always check with your facility, as each hospital usually has their own guidelines about
how often and which assessments are done
Types of assessments - ANSWER 1. Initial
2. Ongoing
3. Comprehensive
4. Focused
5. Cultural
6. Nutritional
7. Psychosocial
8. Community
9. Functional ability
Initial Assessments - ANSWER Initiated upon first contact with the patient.
, -This may be in the emergency department or ED, pre-operatively, or upon admission to
the unit.
-The first time the patient has contact with the health care system an initial assessment
is completed.
-This is typically done within twelve hours of admission.
Ongoing Assessments - ANSWER Continuing the plan of care.
- Nurses generally are required to complete a head to toe assessment every shift, and
perhaps focused assessments more often in higher levels of care.
- These follow up assessment are ongoing assessments
What do we use to verify subjective data? - ANSWER We can use objective data to
verify subjective data
Example: Pt reports feeling anxious (SUBJECTIVE), and this is supported by their
shortness of breath and heart rate of 130 bpm (OBJECTIVE)
Primary sources of information - ANSWER When the information comes FROM THE
PATIENT
Secondary sources of information - ANSWER -From another source, whether it's a
medical device (blood pressure cuff), previous records and the computerized chart, a
family member, or another nurse in report,
ANYTHING/ANYONE THAT IS NOT THE PATIENT!
What should you do with information that doesn't make sense or is unexpected? -
ANSWER Validate it!
-It is our job to investigate further, bringing inconsistencies to light
-Always use your clinical judgment
What is key to making sure we gather all necessary data? - ANSWER Having a
questioning attitude!
Purpose of assessment - ANSWER to classify our patient's responses and experiences
into problems we can tackle.
What is created by naming our patient's problems? - ANSWER A nursing diagnosis
statement
-These drive the rest of our nursing care plan, so they must be thorough and accurate
UPDATE 2025
What is critical thinking? - ANSWER The process of problem solving
- We gather data, validate data, and weigh options
Ways in which nurses utilize critical thinking - ANSWER - Assessing our patients and
making decisions about their care
-Re-evaluating pt's condition and making changes to the plan
-Communicating changes in pt's status to the provider and collaborating in creating
solutions
-Determining relevant data and discarding irrelevant data
Theoretical knowledge - ANSWER -Science based facts
-Pathophysiologic principles
-Evidence which policies
and protocols are based on
Example of theoretical knowledge - ANSWER The FACT that Heparin is a medication
that reduces blood clots by increasing blood clotting time
Practical knowledge - ANSWER Knowing when and how to do tasks and skills safely.
Example of using practical knowledge - ANSWER when we use the technique of
pinching the skin inserting a 5/8-inch needle at a 45-degree angle of the abdominal fold
when giving a subcutaneous injection of Heparin.
Self-knowledge - ANSWER Our own preferences or biases that may influence our
thinking
Example of self-knowledge and possible repercussions - ANSWER -First time I gave a
sub-Q injection at clinical last week, the patient flinched and it made me nervous to do it
again.
-This self-knowledge is important to be aware about as it may influence decisions in an
unintended way.
Contextual awareness - ANSWER Reflection on past experiences
Ethical knowledge - ANSWER -Helps us to handle situations where there is an element
of right and wrong.
,-We can recognize the situations as sometimes we may need to provide care that it's
ethically confusing or not so black and white.
-Ethical knowledge of boundaries and guidelines will help us remain true to our
profession in providing this care.
5 steps of the nursing process - ANSWER 1. Assessment
2. Diagnosis
3. Planning
4. Implements
5. Evaluating
Assessment - ANSWER Data gathering; interpreting/analyzing data.
-This is a nursing professional responsibility as recommended by the American Nurses
Association and therefore cannot be delegated to assistive personnel.
Can assistive personnel perform assessments? - ANSWER NO!!!!
We can enlist the help of unlicensed assistive staff in the action of collecting the data -
such as taking vital signs, asking about the presence of pain or measuring the amount
of urine voided, but it is a nursing responsibility to interpret and analyze that data
What is involved in all steps of the nursing process? - ANSWER Assessment
- We assess data
- When we implement our interventions, we assess its effectiveness and patient's
response
- When we evaluate expected outcome, we are assessing their success
What is the frequency of assessments regulated by? - ANSWER Accrediting bodies
-Always check with your facility, as each hospital usually has their own guidelines about
how often and which assessments are done
Types of assessments - ANSWER 1. Initial
2. Ongoing
3. Comprehensive
4. Focused
5. Cultural
6. Nutritional
7. Psychosocial
8. Community
9. Functional ability
Initial Assessments - ANSWER Initiated upon first contact with the patient.
, -This may be in the emergency department or ED, pre-operatively, or upon admission to
the unit.
-The first time the patient has contact with the health care system an initial assessment
is completed.
-This is typically done within twelve hours of admission.
Ongoing Assessments - ANSWER Continuing the plan of care.
- Nurses generally are required to complete a head to toe assessment every shift, and
perhaps focused assessments more often in higher levels of care.
- These follow up assessment are ongoing assessments
What do we use to verify subjective data? - ANSWER We can use objective data to
verify subjective data
Example: Pt reports feeling anxious (SUBJECTIVE), and this is supported by their
shortness of breath and heart rate of 130 bpm (OBJECTIVE)
Primary sources of information - ANSWER When the information comes FROM THE
PATIENT
Secondary sources of information - ANSWER -From another source, whether it's a
medical device (blood pressure cuff), previous records and the computerized chart, a
family member, or another nurse in report,
ANYTHING/ANYONE THAT IS NOT THE PATIENT!
What should you do with information that doesn't make sense or is unexpected? -
ANSWER Validate it!
-It is our job to investigate further, bringing inconsistencies to light
-Always use your clinical judgment
What is key to making sure we gather all necessary data? - ANSWER Having a
questioning attitude!
Purpose of assessment - ANSWER to classify our patient's responses and experiences
into problems we can tackle.
What is created by naming our patient's problems? - ANSWER A nursing diagnosis
statement
-These drive the rest of our nursing care plan, so they must be thorough and accurate
