Nursing Fundamentals Exam 1

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

what should go into a risk diagnosis (contains what language)

Two Parts "risk for..." "related to ..." Example: Risk for falls related to history of dizziness This Nursing Diagnosis contains two parts

Identify in this statement where is the a) problem {diagnostic label} b) cause of the problem (etiology) c)symptoms of the problem

"Impaired gas exchange related excessive secretions as evidenced by O2 saturation of 84%."

Critical Thinking in Nursing Steps

- -Essential in the nursing process -Involves knowing as much as possible about each patient -Need to sort out the information into patterns to clarify problems, recognize changes, and make appropriate care decisions under pressure. -essential process for safe efficient and skillful nursing interventions -improves PT outcomes

What are three parts of an actual nursing diagnosis?

1. Problem (diagnostic label?) 2.Cause of problem (etiological factors) 3.Defining Characteristics (signs and symptoms)

What are the four steps in Planning and Outcome Identification?

1. Set priorities according to Maslow's Hierarchy of Needs 2. Identify and Write PT outcomes 3. Select evidence-based nursing interventions 4. Communicate the plan of care

clinical judgement

Conclusions and opinions about patients health drawn from patient data. Influenced by the nurses experience/knowledge to enhance PT outcomes

critical thinking

the ability to think systemically/logically a continuous process based on inquiry, open-mindedness, and willingness to look at each situation

A nurse is assisting with client triage at the scene of a mass casualty event. Which of the following clients should the nurse recommend for transport first?

a. a client who reports a possible sprained wrist and is walking around b. a client who has an open fore-arm fracture without visible drainage c. a client who has a respiratory rate of 6/min and no pupil response d. a client who has an abdominal wound that is actively bleeding

A nurse is caring for a client who reports a new onset of abdominal pain. The nurse should assign the clients' condition to which of the following categories when prioritizing care?

a. chronic b. minimal c. urgent d. expectant

A patient is suffering from shortness of breath. The correct goal statement would be written as:

a. the patient will be comfortable by morning b. the patient will breath unlabored at 14 to 18 breaths per minute by the end of shift c. the patient will not complain of breathing problems within the next 8 hours d. the patient will have a respiratory rate of 14 to 18 breaths per minute

independent nursing interventions

actions that a nurse initiates without supervision or direction from others (Example: sitting PT up in the bed)

A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize clients assessment

a. acute vs chronic b. ABCDE c. least restrictive/least invasive d. survival potential

A nurse is caring for a client in an acute care facility. The nurse should recognize that the client's care requires clinical reasoning when it is complicated by which of the following? SATA

a. complex clinical situations b. ongoing client and family concerns c. cost of health care d. decreased need for advanced health care practitioner intervention e. availability of computerized medical records

The nursing process organizes your approach to delivering nursing care. To provide care for your patients you will need to incorporate the nursing process and:

a. decision making b. problem-solving c. interview process d. intellectual standards

A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first?

a. develop a nursing diagnosis b. perform a physical assessment c. administer prescribed meds d. develop goals and outcomes

A nurse in an urgent care clinic is auscultating the lungs in a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?

a. evaluation b. implementation c. analysis d. assessment

A nurse is caring for a client who reports feeling inferior and states that they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of Maslow's Hierarchy of Needs?

a. love and belonging b. self-actualization c. safety d. self-esteem

A nurse has received and end of shift report on four clients. Which of the following

a. a client who is scheduled for abdominal surgery b. a client who needs a urine specimen sent to the lab c. a client who has audible wheezing during respirations d. a client who request their routine pain meds

A nurse has received a change of shift report for a group of clients. Which of the following clients should the nurse plan to see first?

a. a client who received a blood transfusion and reports urticaria b. a client who has back pain and is requesting a muscle relaxant c. a client who has an ankle sprain and requests toileting assistance d. a client who has chronic migraines and requests a headache

The nurse is reviewing the medical records of four clients. Which of the following clients should the nurse identify as a priority client?

a. a client who received digoxin and heart rate of 48/min b. a client who received pain medication and has a respiratory rate of 14/min c. a client who has a urinary tract rate infection and a temperature of 37.9 C (102 F) d. a client who has anemia and a BP of 118/78 mm HG