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48 Cards in this Set
- Front
- Back
An actual nursing diagnosis contains 3 parts: what are they?
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1. Problem (NANDA format)
2. Etiology ("related to") 3. Defining characteristics (AEB) |
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True or False:
If a nursing diagnosis contans "at risk for," then there will be no signs or symptoms, or "AEB." |
True
|
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An "at risk for" diagnosis contains 2 parts: what are they?
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1. Problem (NANDA format)
2. Etiology ("related to") |
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A wellness diagnosis has only one part: what is it?
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Problem (NANDA format)
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The "planning" phase of the nursing process requires the nurse to perform four important functions: what are they?
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1. Set priorities, in order of importance
2. Establish client goals 3. Select nursing interventions 4. Determine resources |
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In setting priorities, the nurse's #1 priority is what?
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Keep the patient alive! (Breathing, Circulation and Safety)
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"A specific aim planned by the nurse AND the client to assist the client in achieving maximal level of wellness" is the definition of what?
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Goal Setting
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When setting goals, we should remember the acronym S.M.A.R.T. What do these letters stand for?
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S = specific
M = measurable A = attainable R = realistic T = timed |
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When setting goals, the nurse should avoid which words in order to ensure that the goals are specific and measurable?
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adequate
fewer/more understand(s) increase/decrease improve frequent appropriate "Pt. will be free of..." |
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Goals should begin with what statement?
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"The client will..."
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Goals should answer what 3 questions?
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Who?
What? When? |
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Goals should always match what?
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the Nursing Diagnosis
|
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What are the 4 factors involved in selecting the appropriate nursing interventions?
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1. Defining characteristics of the nursing dx.
2. Research associated with interventions 3. Client's acceptance of disease, health cond., handicap, etc. 4. Least amount of risk/discomfort for the client |
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According the the Nurse Practice Act, the RN will do what regarding pt. education?
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"Promote and participate in client education, based on health needs."
|
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What should a nurse include in educating a client who will be undergoing chemotherapy?
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hair loss
decrease in energy side effects survival chances (if appropriate) |
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What should a nurse include in educating new parents who are about to take their baby home?
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car seat safety
breast feeding |
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What should a nurse include in educating a newly diagnosed diabetes patient?
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1. explain the disease process of diabetes
2. explain signs/symptoms of complications 3. explain what to do if glucose gets too high/low 4. how to use glucometer 5. diet |
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The term "survival skills" usually refers to whom?
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Newly diagnosed diabetics
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This semester, our role as student nurses will include what five principles?
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1. Demonstrating effective communication
2. Providing things for the pt. 3. Competency in clinical skills 4. Critical thinking in assessment 5. Applying the nursing process to clinical situations |
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The key principle of Nursing I was "formulating the nursing diagnosis." What is the key principle of Nursing II?
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Implementation
|
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What types of tasks can be delegated to unlicensed hospital personnel (CNA, etc.)?
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* ADL's
* Baths * Bed changes * Data collection * Recording pain scale |
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What are the "4 C's" of Delegation?
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1. Clear
2. Concise 3. Correct 4. Complete |
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What are the "4 rights" of Delegation?
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1. Right task
2. Right person 3. Right communication 4. Right feedback/follow-up |
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What does "Accountability" refer to in the role of the nurse?
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1. Knowing the rules / regulations of being an RN
2. How supplies are used |
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The nurse should always chart as if he/she were charting for whom?
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A jury
|
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On a Flow Sheet, the "Time" column is used to record what?
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The actual time of the assessment
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How often should a nurse make entries in the Narrative Notes?
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At least every 2 hours
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Documentation such as "visiting with family," or "watching TV," are examples of what?
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Fillers - those things that a nurse charts when he/she can't think of anything else to chart
|
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Instead of using "fillers," what would a nurse chart INSTEAD of "client is sleeping quietly?"
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"Checked on client at xx:xx (time), to assess IV site."
|
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When performing a neuro check, what should be assessed and documented?
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* Level of Consciousness
* Alert & Oriented x 3 * Mental status * PERLA * Motor function * Sensory function |
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When auscultating in a cardio assessment, what should the nurse listen for?
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* Extra (split) sounds
* Murmurs * Rate * Regular/irregular rhythm |
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Besides auscultating, what other things are included in a cardio assessment?
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* Telemetry #
* Rhythm * Pulse * Capillary refill * Periphery (is skin wet/dry) * Pt. status * Pacemaker settings (capture/non-capture) |
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What should be DOCUMENTED in a cardio assessment?
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* Rate
* Rhythm * Telemetry * Auscultation * Abnormalities in skin periphery * Cyanosis * Pt. status * Pacemaker settings (capture/non-capture) |
|
This semester, our role as student nurses will include what five principles?
|
1. Demonstrating effective communication
2. Providing things for the pt. 3. Competency in clinical skills 4. Critical thinking in assessment 5. Applying the nursing process to clinical situations |
|
The key principle of Nursing I was "formulating the nursing diagnosis." What is the key principle of Nursing II?
|
Implementation
|
|
What types of tasks can be delegated to unlicensed hospital personnel (CNA, etc.)?
|
* ADL's
* Baths * Bed changes * Data collection * Recording pain scale |
|
What are the "4 C's" of Delegation?
|
1. Clear
2. Concise 3. Correct 4. Complete |
|
What are the "4 rights" of Delegation?
|
1. Right task
2. Right person 3. Right communication 4. Right feedback/follow-up |
|
What does "Accountability" refer to in the role of the nurse?
|
1. Knowing the rules / regulations of being an RN
2. How supplies are used |
|
The nurse should always chart as if he/she were charting for whom?
|
A jury
|
|
On a Flow Sheet, the "Time" column is used to record what?
|
The actual time of the assessment
|
|
How often should a nurse make entries in the Narrative Notes?
|
At least every 2 hours
|
|
Documentation such as "visiting with family," or "watching TV," are examples of what?
|
Fillers - those things that a nurse charts when he/she can't think of anything else to chart
|
|
Instead of using "fillers," what would a nurse chart INSTEAD of "client is sleeping quietly?"
|
"Checked on client at xx:xx (time), to assess IV site."
|
|
When performing a neuro check, what should be assessed and documented?
|
* Level of Consciousness
* Alert & Oriented x 3 * Mental status * PERLA * Motor function * Sensory function |
|
When auscultating in a cardio assessment, what should the nurse listen for?
|
* Extra (split) sounds
* Murmurs * Rate * Regular/irregular rhythm |
|
Besides auscultating, what other things are included in a cardio assessment?
|
* Telemetry #
* Rhythm * Pulse * Capillary refill * Periphery (is skin wet/dry) * Pt. status * Pacemaker settings (capture/non-capture) |
|
What should be DOCUMENTED in a cardio assessment?
|
* Rate
* Rhythm * Telemetry * Auscultation * Abnormalities in skin periphery * Cyanosis * Pt. status * Pacemaker settings (capture/non-capture) |