Exam 1 - Fundamentals of Nursing
Didactic
What is the acronym ADPIE mean? - -Assessment
Diagnosis
Planning
Implementing
Evaluation
-What is ADPIE used for? - -The nursing process
-What is occuring during the "Assessment" phase of ADPIE? - -Collecting
patient data (subjective and objective)
Vital signs
Chief complaint for visit
Other forms of assessment (Ex. heart and lung assessment)
-What is occuring in the "Diagnosis" phase of ADPIE? - -Nursing diagnosis is
made during assessment (NANDA)
NOT A MEDICAL DIAGNOSIS
-What is NOT an example of a NANDA diagnosis?
A) Constipation
B) Ineffective gas exchange
C) COPD exacerbation
D) Risk for infection - -C) COPD exacerbation
-What is occuring during the "Planning" phase of ADPIE? - -Formulating
short and long term goals for the patient
(SMART goals)
-What does the acronym SMART goals mean? - -Specific
Measureable
Attainable
Relevant
Timeframe
-Which of these goals follow the SMART acronym?
A) The patient will not be in pain.
B) The patient will walk by 1800.
C) The patient will walk 20 feet.
D) The patient will walk 20 feet by 1800. - -D) The patient will walk 20 feet
by 1800.
, -What occurs during the "Evaluate" phase of ADPIE? - -Check to see if
patient has met planned out goals
If patient has not met the goals, reassessment has to occur and new goals
need to be made
-What is a negative air flow room for? - -Airborne precautions
-What are some disease processes that require airborne precautions? - -
Measles, tuberculosis
-What are some disease processes that require droplet precautions? - -
Influenza virus
-What is a disease process that requires contact precautions? - -C. diff
-Which patients require standard precautions? - -ALL PATIENTS
-What are some fall preventions? - -Place tables and call light near in
patient's reach
Nonskid footwear
Purposeful rounding
Tidy environment
-The nurse prepares to provide oral care to a 20-month-old client. Which
action should the nurse take when completing this care?
A) Lower the head of the bed
B) Place the client in a side-lying position
C) Use a soft-bristled toothbrush moistened with water
D) Use a syringe to apply mouthwash to the oral cavity - -C) Use a soft-
bristled toothbrush moistened with water
-A client becomes dizzy while ambulating with a nurse for the first time after
surgery and starts falling forward. Which action should the nurse take first?
A) Widen his or her stance
B) Pull up on the client's arm
C)Tighten the grip on the gait belt
D) Have the client look at the floor - -A) Widen his or her stance
-A client with right leg weakness is prescribed to use a walker. Which
direction should the nurse provide when instructing on the use of this
device?
A) Move the walker ahead of the right foot
B) Move the right foot and the walker together
C) Move the right foot up to the walker first
D) Move the left foot and the walker together - -B) Move the right foot and
the walker together
Didactic
What is the acronym ADPIE mean? - -Assessment
Diagnosis
Planning
Implementing
Evaluation
-What is ADPIE used for? - -The nursing process
-What is occuring during the "Assessment" phase of ADPIE? - -Collecting
patient data (subjective and objective)
Vital signs
Chief complaint for visit
Other forms of assessment (Ex. heart and lung assessment)
-What is occuring in the "Diagnosis" phase of ADPIE? - -Nursing diagnosis is
made during assessment (NANDA)
NOT A MEDICAL DIAGNOSIS
-What is NOT an example of a NANDA diagnosis?
A) Constipation
B) Ineffective gas exchange
C) COPD exacerbation
D) Risk for infection - -C) COPD exacerbation
-What is occuring during the "Planning" phase of ADPIE? - -Formulating
short and long term goals for the patient
(SMART goals)
-What does the acronym SMART goals mean? - -Specific
Measureable
Attainable
Relevant
Timeframe
-Which of these goals follow the SMART acronym?
A) The patient will not be in pain.
B) The patient will walk by 1800.
C) The patient will walk 20 feet.
D) The patient will walk 20 feet by 1800. - -D) The patient will walk 20 feet
by 1800.
, -What occurs during the "Evaluate" phase of ADPIE? - -Check to see if
patient has met planned out goals
If patient has not met the goals, reassessment has to occur and new goals
need to be made
-What is a negative air flow room for? - -Airborne precautions
-What are some disease processes that require airborne precautions? - -
Measles, tuberculosis
-What are some disease processes that require droplet precautions? - -
Influenza virus
-What is a disease process that requires contact precautions? - -C. diff
-Which patients require standard precautions? - -ALL PATIENTS
-What are some fall preventions? - -Place tables and call light near in
patient's reach
Nonskid footwear
Purposeful rounding
Tidy environment
-The nurse prepares to provide oral care to a 20-month-old client. Which
action should the nurse take when completing this care?
A) Lower the head of the bed
B) Place the client in a side-lying position
C) Use a soft-bristled toothbrush moistened with water
D) Use a syringe to apply mouthwash to the oral cavity - -C) Use a soft-
bristled toothbrush moistened with water
-A client becomes dizzy while ambulating with a nurse for the first time after
surgery and starts falling forward. Which action should the nurse take first?
A) Widen his or her stance
B) Pull up on the client's arm
C)Tighten the grip on the gait belt
D) Have the client look at the floor - -A) Widen his or her stance
-A client with right leg weakness is prescribed to use a walker. Which
direction should the nurse provide when instructing on the use of this
device?
A) Move the walker ahead of the right foot
B) Move the right foot and the walker together
C) Move the right foot up to the walker first
D) Move the left foot and the walker together - -B) Move the right foot and
the walker together
