Nursing Process

Question 1

ASSESS

Answer 1

Gather information
Verify the information
collected is clear & accurate

Question 2

DIAGNOSE

Answer 2

Interpret the information collected
Identify & prioritize the problem
through a nursing diagnosis
(be sure it’s NANDA approved

Question 3

PLAN

Answer 3

Set goals to solve the problem.
Prioritize the outcomes of care

Question 4

IMPLEMENT

Answer 4

Reaching those goals through
performing the nursing actions
“Implementing” the goals set above
in the planning stage

Question 5

EVALUATE

Answer 5

Determine the outcome of goals
Evaluate client’s compliance
Document client’s response to pain
Modify & assess for needed changes

Question 7

SUBJECTIVE DATA

Answer 7

What the client tells the nurse

Question 8

OBJECTIVE DATA

Answer 8

Data the nurse obtains
through their assessment and observations

Question 9

SET SMART GOALS

Answer 9

Specific
Measurable
Achievable
Relevant
Time frame

Question 10

ABCS

Answer 10

AIRWAY
BREATHING
CIRCULATION

Question 11

1 PATENT AIRWAY
• Patent means “open”; the airway is clear!

Answer 11

ASK YOURSELF: Can they successfully breathe oxygen in and breathe CO2 out?

Question 12

2 BREATHING

Answer 12

Gas exchange taking place inside the lungs
• ASK YOURSELF: Can gas exchange successfully happen in their lungs?

Question 13

3 CIRCULATION

Answer 13

Can they circulate blood through their body and are their organs being perfused?
• ASK YOURSELF: Is there a reason that the blood isn’t pumping/circulating in the body?
(Example: The heart is working to pump the blood to the vital organs)

Question 14

Self Actualization

Answer 14

• Hope
• Spiritual well-being
• Enhanced growth

Question 15

Self Esteem

Answer 15

Control
• Competence
• Positive regard
• Acceptance/worthiness

Question 16

LOVE & BELONGING

Answer 16

Maintain support systems
• Protect from isolation

Question 17

SECURITY SAFETY & SECURITY
bas

Answer 17

Airway
• Respiratory effort
• Heart rate, rhythm, and strength of contraction

Question 18

PHYSIOLOGICAL needs

Answer 18

Oxygen fluids nutrition, shelter

Question 19

AUTONOMY

Answer 19

Respect for an individual’s right
to make their own decisions

Question 20

NONMALEFICENCE

Answer 20

Obligation to do & cause no harm to others

Question 21

BENEFICENCE

Answer 21

Duty to do good to others

Question 22

Justice

Answer 22

Distribution of benefits and services fairly

Question 23

Veracity

Answer 23

Obligation to tell the truth

Question 24

Fidelity

Answer 24

Following through with a promise

Question 25

Serotonina

Answer 25

Is responsible for melatonin

Question 26

Circadian de synchronization

Answer 26

Happens when sleep wake patterns are frequently altered

Question 27

Insomnia

Answer 27

Difficulty falling asleep or early awakening from sleep

Question 28

Five Rights of Delegation

Answer 28

Right Task, Right Circumstance, Right Person, Right Direction, Right Supervision.

Question 29

Malpractice

Answer 29

Is a type of negligence where a nurse fails to meet a care of a patient

Question 30

Assault

Answer 30

Is creating fear of harm.

Question 31

Battery

Answer 31

Is intentional physical contact without permission.

Question 32

Samaritan law

Answer 32

Protect nurses and other providers when they give emergency care outside the work place

Question 33

Stage 1

Answer 33

Non blanchable

Question 34

Stage 2

Answer 34

Partial thickness

Question 35

Stage 3

Answer 35

Full thickness skin loss

Question 36

Stage 4

Answer 36

Full thickness skin and tissue loss Osteomyelitis

Question 37

Unstageable

Answer 37

Cannot be staged the tissues is loss and it’s at full thickness

Question 38

Stage 3

Answer 38

Stage 3 is deep non- REM sleep

Question 39

CAUTI .

Answer 39

Catheter-associated urinary tract infection

Question 40

SSI

Answer 40

Surgical site infection

Question 41

CLABSI

Answer 41

Central line-associated blood infection

Question 42

VAP

Answer 42

Ventilator-associated pneumonia

Question 43

Causative Agent

Answer 43

Bacteria Virus Fungus Prion Parasite

Question 44

Reservoir

Answer 44

• Human • Animal • Surfaces • Food • Soil • Insects

Question 45

Portal of entry

Answer 45

• How it gets to the host • same as the portal of exit

Question 46

Portal of Exit

Answer 46

• Skin (wound) • How it gets to the host • Mouth (Vomit, Saliva) • Same as portal of exit Mode Of Mode Of • Blood (Cuts on the skin) Transmission Transmission • Respiratory tract

Question 47

Mode Of Transmissi

Answer 47

Contact Droplet Airborne Vector borne

Question 48

incentive spirometer

Answer 48

a handheld device that measures how deeply you inhale, helping to keep lungs active and prevent pneumonia after surgery or illness.