|Verified Practice Questions with A+ Answers |
Final Exam Guide FOR 2025/2026 (the most recent
quizzes)
plan priorites based on - Purpose of care
Current clinical picture
Picture of the outcome or result
ABCDE principle:
used when?
define parts? - -used this when figuring out which patient goes first!
A (Airway): Ensure patent airway. Stabilize cervical spine if neck/head trauma is suspected
B (Breathing): Assess for respirations & ventilatory effort
C (Circulation): Check heart rate, blood pressure, cap refill, check for bleeding too
D (Disability): Assess client's level of consciousness. Think neuro*
E (Exposure): Undress patient, assess client's body. Also could be under environment in the
book. Assess the whole body
Maslow's Hierarchy of Needs - (level 1) Physiological Needs, (level 2) Safety and
Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self
Actualization
,levels of priority setting:
level 1?
level 2?
level 3? - level 1: ABCs
level 2: mental status changes, acute pain, abnormal labs/tests
level 3: risk categories, at risk groups- safety and infection along with chronic problems
prioritization of client care:
just review - UNSTABLE over STABLE
ACUTE over CHRONIC problems
SYSTEMIC over LOCAL problems
compliation over expected findings what does this mean? - Complication: medical
emergency Stroke patient, ICP is a complication. Expected findings would be unsteady gait and
numbness. We would pick ICP over numbness
delegation - The assignment of new or additional responsibilities to a subordinate
assignment nurse? - distribution of work to each staff member
RN can delegate what? - what you can EAT:
-evaluate
-assess
-teach
, -nursing process
-initial client education or assessment
-tasks the required clinical judgement
Five Right of Delegation - 1. Right task
2. Right circumstances
3. Right person
4. Right direction/communication
5. Right supervision
five right of delegation:
right direction and communication- Four C's of this - -clear
-concise
-correct
-complete
RN delegate to PN - -medication everything besides IV
-Enteral feeding
-all task excepts blood administion and IV push
-reassessment, reinforcement of patient teaching
RN delegate to AP - -ADLS
-ambulating
-feeding patient without swallowing precautions
-positioning
-vitals on stable
-bed making
speciment collection (not sterile)
-I/O
-basic CPR
ethics - the principles of right and wrong that guide an individual in making decisions