NUR 221- Foundations Exam 2 Questions With Complete
Solutions
1st step of evaluation Correct Answers Review the
goals/outcomes in the patient care plan.
-The goals and indicators you identified in the planning
outcomes phase suggests the kind of assessments you need to
make and provide criteria by which to judge the data.
-Example: ECO is "pt will walk 50 ft by lunch" then we are
evaluating their ambulatory ability at lunchtime
2nd step of evaluation Correct Answers Collect reassessment
data.
-Reassessments are always focused assessments and the care
plan goals determine their focus
3 phases of implementation Correct Answers Doing,
delegating, documenting
-Uses practical knowledge
-We are the last stop before something reaches the patient
-Manage how/when these interventions are used
3rd step of evaluation Correct Answers Make a judgment
Judge the goal achievement, comparing to re-assessment data
with the patient's goals and determining if the actual outcomes
achieved are the same as the desired outcome
,-If yes, the goal is met!
4th step of evaluation Correct Answers Revise as necessary
-Partially met goals: Some, but not all of desired behaviors are
observed (i.e. Pt walked, but not 50 ft. Or pt walked 50 ft but not
by lunchtime)
-Not met goals: Desired response did not occur
5 rights of delegation Correct Answers 1. right task
2. right circumstance
3. right person
4. right direction/communication
5. right supervision
5 steps of the nursing process Correct Answers 1. Assessment
2. Diagnosis
3. Planning
4. Implements
5. Evaluating
5 types of nursing diagnoses Correct Answers 1. Actual
2. Potential
3. Collaborative
4. Wellness
5. Syndrome
6 categories that are scored on Braden scale Correct Answers
1. Sensory perception
,2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and shear
Achievable (ECO) Correct Answers Outcome is possible
Action Interventions Correct Answers something the patient or
the nurse will perform in order to effect a change.
-i.e. Ambulating in the hallway, applying SCDs, administering a
medication, or changing a dressing, these are all examples of
actions that either the nurse or the patient are actively doing,
Activity on Braden scale Correct Answers Is the patient
moving?
4=pt moving freely and walking several times a day
3=pt walks to bathroom and back to bed
2=pt can get to chair with assistance
1=pt on complete bed rest
Adolescent special nutritional needs Correct Answers At risk
for malnutrition as a result of body image issues or excessive
exercise
Albumin Correct Answers Large protein molecule in blood
, -low levels of albumin associated with malnutrition or
malabsorption, acute and chronic liver disease, and losses of
proteins through burns or other full-thickness loss skin wounds
-half life of 18-21 days; affected by fluid levels
- NOT most accurate way of pt's nutritional balance
Another name for a 3 part nursing diagnosis statement Correct
Answers PES statment
Problem, etiology, symptom
Antigen-avoidance diets Correct Answers - patients who are
allergic to or intolerant of certain foods, such as a gluten-free
diet for patients with celiac disease
Are pressure injuries preventable? Correct Answers Yes- 100%
preventable with good, meticulous nursing care
-If pt acquires pressure injury at hospital, hospital may be
required to pay cost of treatment of pressure injury, even if it
requires surgical intervention
Assess interventions Correct Answers monitoring the patient or
collecting data to evaluate their status; trying to notice changes
and prevent further deteoriation
Solutions
1st step of evaluation Correct Answers Review the
goals/outcomes in the patient care plan.
-The goals and indicators you identified in the planning
outcomes phase suggests the kind of assessments you need to
make and provide criteria by which to judge the data.
-Example: ECO is "pt will walk 50 ft by lunch" then we are
evaluating their ambulatory ability at lunchtime
2nd step of evaluation Correct Answers Collect reassessment
data.
-Reassessments are always focused assessments and the care
plan goals determine their focus
3 phases of implementation Correct Answers Doing,
delegating, documenting
-Uses practical knowledge
-We are the last stop before something reaches the patient
-Manage how/when these interventions are used
3rd step of evaluation Correct Answers Make a judgment
Judge the goal achievement, comparing to re-assessment data
with the patient's goals and determining if the actual outcomes
achieved are the same as the desired outcome
,-If yes, the goal is met!
4th step of evaluation Correct Answers Revise as necessary
-Partially met goals: Some, but not all of desired behaviors are
observed (i.e. Pt walked, but not 50 ft. Or pt walked 50 ft but not
by lunchtime)
-Not met goals: Desired response did not occur
5 rights of delegation Correct Answers 1. right task
2. right circumstance
3. right person
4. right direction/communication
5. right supervision
5 steps of the nursing process Correct Answers 1. Assessment
2. Diagnosis
3. Planning
4. Implements
5. Evaluating
5 types of nursing diagnoses Correct Answers 1. Actual
2. Potential
3. Collaborative
4. Wellness
5. Syndrome
6 categories that are scored on Braden scale Correct Answers
1. Sensory perception
,2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and shear
Achievable (ECO) Correct Answers Outcome is possible
Action Interventions Correct Answers something the patient or
the nurse will perform in order to effect a change.
-i.e. Ambulating in the hallway, applying SCDs, administering a
medication, or changing a dressing, these are all examples of
actions that either the nurse or the patient are actively doing,
Activity on Braden scale Correct Answers Is the patient
moving?
4=pt moving freely and walking several times a day
3=pt walks to bathroom and back to bed
2=pt can get to chair with assistance
1=pt on complete bed rest
Adolescent special nutritional needs Correct Answers At risk
for malnutrition as a result of body image issues or excessive
exercise
Albumin Correct Answers Large protein molecule in blood
, -low levels of albumin associated with malnutrition or
malabsorption, acute and chronic liver disease, and losses of
proteins through burns or other full-thickness loss skin wounds
-half life of 18-21 days; affected by fluid levels
- NOT most accurate way of pt's nutritional balance
Another name for a 3 part nursing diagnosis statement Correct
Answers PES statment
Problem, etiology, symptom
Antigen-avoidance diets Correct Answers - patients who are
allergic to or intolerant of certain foods, such as a gluten-free
diet for patients with celiac disease
Are pressure injuries preventable? Correct Answers Yes- 100%
preventable with good, meticulous nursing care
-If pt acquires pressure injury at hospital, hospital may be
required to pay cost of treatment of pressure injury, even if it
requires surgical intervention
Assess interventions Correct Answers monitoring the patient or
collecting data to evaluate their status; trying to notice changes
and prevent further deteoriation
