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EXAM 1 Reviewer Fundamentals
Nursing Fundamental Concepts (Herzing University)
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FUNDAMENTALS EXAM 1 REVIEWER
Modules 1,2,3, Realizeit Fundamentals of Nursing-Carol Taylor
Nursing Profession: Nurses are advocates, teachers, listeners, and skilled providers of competent, evidence-based
care.
Florence Nightingale- elevated the status of nurses
Definition of Nursing: a person who nourishes, fosters, and protects and who is prepared to take care of sick,
injured, aged, and dying people
BOARD OF NURSING: Documented in Rules and Regulations, Position statements, Declaratory rulingsDelegation, med administration, unprofessional conduct, licensing
Nursing Aims and Competencies:
To promote health
To prevent Illness
To restore health
To facilitate coping with disability or death (family centered care)
Credentialing- refers to ways in which professional competence is ensured and maintained
Accreditation- the process by which an educational program is evaluated and recognized as having met certain
standards
Licensure- the process by which a state determines that a candidate meets certain minimum requirements to
practice in the profession and grants a license to do so.
Certification- the process by which a person who has met certain criteria established by a nongovernmental
association is granted recognition in a specified practice area.
Nursing as a professional discipline:
Autonomy and self-regulation
Which organization is the best source of information when a nurse wishes to determine whether an action is
within the scope of nursing practice?
American Nurses Association (ANA)
What guidelines do nurses follow to identify the client's health care needs and strengths, to establish and carry out
a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes?
Nursing process
A nurse is assessing the urine on a newborn's diaper. What would be a normal assessment finding?
light in color and odorless
Which of the following describes the term micturition?
emptying the bladder
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What is the primary purpose of standards of nursing practice?
to ensure knowledgeable, safe, comprehensive nursing care
Effective Learning Techniques:
Lectures, discussions, audiovisual, printed material, computer programs, role modeling, role playing,
demonstration
Factors that affect patients’ ability to Learn
Age/Developmental level, Family support and financial resources, Cultural and language, Healthy literacy level
Example of Directing Questions/Comments (asking more information to assess the patient)
"You mentioned your dad had complications from high BP earlier" "What kind of complications" "Are you
worried this will happen to you?"
Example of clarifying question/comment ( allows nurse to gain understanding on pt comment)
"Is this the first health problem you have had?"
Negative: Patient might think the nurse don’t listen or not knowledgeable
Reflective Question/Comment (repeating what the patient says, encourage pt to elaborate thoughts)
"You've been in pain...."
Sequencing Question/Comment ( timeline of the situation, chronological order)
"Your dizziness began after taking this medication?"
Open-Ended Question/Comment (prevent the questions that only answer yes or no)
"What did your health care provider tell you about your hospitalization?"
Closed Question/Comment (Answerable by yes or no)
“What medicines have you been taking at home?"
Validating Question/Comment (nurse validate what heard or observe)
“At home, you have been taking both a water pill and BP at home. Did you take one today?"
Negative: overusing this technique might lead that nurse is not listening
Validating Data- To keep data as free from error, bias, and misinterpretation.
Primary Data- Patient
Secondary- Family, Medical records
Etiology- Related risk factors, identifies probable causes and gives direction to interventions
Initial Assessment- Signs necessary forms, then health history and physical assessment
Client-Centered Care Assessment- empower client to encourage to manage own care
Focused Assessment- one body part-non emergent
Time-lapsed Assessment- an assessment that is scheduled to compare a patient's current status to baseline data
obtained earlier
Set Priorities- Emergent first, then stable patient
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(EBP) Evidence Based Practice
Scientific data collected to support practices ( research)Ex: If patient develop infection while admitted , facility will not be paid/reimbursed
Goal: Better outcome for patients
Steps of EBP:
Cultivate a spirit of inquiry
Asks the clinical questions
Search and collect evidence (sorting out resources)
Critically appraise the evidence
Integrate the best evidence (expertise)
Evaluates outcome based on evidence
Challenges of EBP:
Acuity level of patient- how committed the patient
Quality Improvement: is a systematic and continuous process that leads to measurable improvements in the
healthcare setting (the goal is the best outcome for the patient)
Pay for performance:
Financial incentives to reward providers for the achievement of delivery efficiencies
HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
Satisfaction survey given to the patient
Purpose of Teaching: To help patients develop self-care abilities (knowledge, attitude, skills) & maximize their
functioning and quality of life (or dignified death)
(3) Learning domains:
CognitivePsychomotor- physical
Affective-Feelings
Non-adherence- resistance to care plan
Non-compliant- not participating with the treatment plan
LEGAL CONCEPTS IN NURSING
A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type of activity?
Criminal
Two nurses are discussing a client's condition in an elevator full of visitors. With what crime might the nurses be
charged?
Invasion of privacy
A nurse is providing client care in a hospital setting. Who has full legal responsibility and accountability for the
nurse's actions?
Select all that apply.
The hospital
The nurse
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The "Rights of Medication Administration" help to ensure accuracy when administering medications. What are
some of these six rights? (Select all that apply.)
Patient
Dosage
Route
Medication
Time
A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is
abnormally high. What should the nurse do next?
Question the medication order.
A nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and
compare the label on the medication with the MAR at least three times (before, during, and after) while preparing
the medication for administration?
Ensures that the right medication is given at the right time by the right route
A nurse fails to administer a medication that prevents seizures, and the client has a seizure. The nurse is in
violation of the Nurse Practice Act. What type of law is the nurse in violation of?
Civil
A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you
the shot, I will get help to hold you down and give it." What crime may the nurse be committing?
Assault ( Threat or attempt to do bodily harm- no physical-threat only)
Which of the following is the most frequent reason for revocation or suspension of a nurse's license?
all are correct - what is the most common/frequent?
Alcohol or drug abuse ( CRIMINAL LAW)
During a clinical placement on a subacute, geriatric medicine unit, a student nurse fed a stroke client some beef
broth, despite the fact that the client's diet was restricted to thickened fluids. As a result, the client aspirated and
developed pneumonia. Which statement underlies the student's potential liability in this situation?
The same standards of care that apply to a registered nurse apply to the student.
A health care facility determined that a nurse employed on a medical unit was documenting care that was not
being given, and subsequently reported the action to the State Board of Nursing. How might this affect the nurse's
license to practice nursing?
The nurse's license may be revoked or suspended.
An on-duty nurse discovers that a colleague is pilfering medicines. According to the Nurse Practice Acts, what
should the nurse do?
Report the incident to the supervisor
Which is the nurse's best legal safeguard?
Competent practice
What type of law regulates the practice of nursing?
Civil law
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A nurse does not assist with ambulation for a postoperative client on the first day after surgery. The client falls
and fractures a hip. What charge might be brought against the nurse?
Negligence
Duty- What nurses would do in the same situation and is guided by standards of care
Breach of Duty- Failure to meet the standards of care
Causation- Proves that the failure to meet standards of care actually caused injury
Damages- Harm or injury resulting to the client
Which nursing diagnosis would be appropriate for educational interventions for a single mother who leaves her
toddler unattended in the bathtub?
Risk for Suffocation
A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. These
medications should be stored in a:
double-locked drawer.
A group of nurses working in a long-term care facility fails to keep the narcotic medications in a secure location.
The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies
and procedures. These failures may result in disciplinary action against the:
Nurses' license
The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs).
Nurse is teaching an older adult at home about taking newly prescribed medications. Which information would be
included?
"I have written the names of your drugs with times to take them."
A nurse is caring for a client who is a chronic alcoholic. The nurse educates the client about the harmful effects of
alcohol and educates the family on how to cope with the client and his alcohol addiction. Which type of skill is
the nurse using?
Counseling
In comparison with licensure, which measures entry-level competence, what does certification validate?
specialty knowledge and clinical judgment
When the nurse inserts an ordered urinary catheter into the client's urethra after the client has refused the
procedure, and then the client suffers an injury, the client may sue the nurse for which type of tort?
Battery ( with physical contact- Physically touching someone or his/her possessions without consent)
After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the
nurse a legal right to practice?
Being licensed by the State Board of Nursing
What is the legal source of rules of conduct for nurses?
Nursing Practice Acts
Standard Nursing Practice- Allows nurses to carry out roles and serves as protection for nurse, client, and
institution
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Nurse Practice Law- Made in each state to regulate nursing practice
Which of the following aspects of nursing would be most likely defined by legislation at a state level?
The differences in the scope of practice between RNs and LPNs
CODE OF ETHICS: Values that epitomize the caring professional nurse
ACRONYMS:
Nursing Care Plans:
S- Specific
M- Measurable
A- Achievable
R- Realistic
T- Time frame
ABC
A - airway
B- breathing
C- circulation
Steps in Nursing Assessment:
Inspection - observation
Palpation - touch
Percussion- striking to create sounds
Auscultation- using stethoscope
Hand-off
I - Identification
S-Situation
B- Background
A - Assessment
R- Recommendation
R- Readback
ADPIE: Nursing Process
A – Assess to determine the need for nursing care (COLLECT)
D – Diagnosis determines nursing diagnosis for actual and potential health problems (IDENTIFY)
P – Planning identifies expected outcomes and plan care (DEVELOP)
I – Implementation implement the care (EXECUTE)
E – Evaluation the results (EVALUATE)
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PICOT: (Clinical Research Question)
P Patient, Population, Problem of Interest
I Intervention of Interest
C Comparison of Interest
O Outcome of Interest
T Time
COPE:
C- Creativity ( Help family overcome obstacles)
O- Optimism ( Help the family caregivers learn how to view the situation with confidence)
P- Planning (Help to plan for future problems )
E- Expert Information ( Help family to obtain expert information from health care providers)
Maslow’s Hierarchy of Needs ( Upside Down from Bottom-Top)
Physiological Needs
Safety
Love/Belongingness
Esteem
Self-Actualization
WEEK 3: SAFETY COLLABORATION IN NURSING PRACTICE
CUS Nurse Safety Concern: When a nurse feels there is unsafe situation and needs to communicate the concerns
C- I am concern
U- I am Uncomfortable
S- I believe that safety is at risk
QSEN- Institute for Quality and Safety Education for Nurses-prepare nurses with knowledge, skills, and attitude
to improve quality and safety of the health care system.
Team STEPPS- Evidence based teamwork to improve safety and communication
Elder abuse- failure to act by a caregiver or another person that causes risk of harming the older adult
Adult IPV ( Intimate Partner Abuse) – physical, sexual violence, and psychological aggression.
Types of Child Abuse:
Physical, Neglect, Emotional, sexual
Intrinsic factors- within a person e.g. poor vision
Extrinsic factors- things that causes it e.g. uneven floors
Restraints- must be the last resort after sorted out the alternatives options and must need an order from provider
not unless during emergency situations
Definition: physical devises to limit patient movement
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Chemical restraints: medication used to control behavior and are not included in a normal medical
regimen.
Nurses’ role in emergency preparedness: support patient-centered safety culture to maintain a safe environment
Therapeutic communication: interaction focuses on patient and patient concerns
Assertive- expressing yourself in a non-defensive manner
Aggressive- negative manner that violates right of others -verbal or physical
Culture- common lifestyles, languages, behaviors pattern, traditions, beliefs that are learned and passed from one
generation to the next
Proxemics- study of distance zones between people during communication
AMA- patient must sign the consent that protects the provider from any legal responsibility
PLANNING OF DISCHARGE BEGINS IN ADMISSION
Nurse will coordinate and communicate among patient, caregivers, and other parties
MEDICATION RECONCIALATION MUST BE COMPLETED BEFORE ADMISSION
Discharge Planning- the purpose of planning for continuity of care in hospitals or community facilities.
Helping relationship- not spontaneously, specific purpose and specific person.
Phases of helping relationship:
Orientation
Working
Termination
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