exam #1

Question 1

nursing process

what does ADPIE stand for ?

Answer 1

• assesment
• diagnosis/ data collection
• planning
• implementation
• evaluation

Question 2

nursing process

what is assesment used for in ADPIE?

subjective and objective

Answer 2

it is the patient interview, comprised of health history (subjective) and diagnostic test results (objective)

Question 3

nursing process

what is diagnosis used for in ADPIE?

Answer 3

idetifies problem/ potential problem

Question 4

diagnosis

what is the PES format?

Answer 4

-problem
- etiology
- syptoms

problem___ related to ____ etiology_____ as evidpenced by___ syptoms

Question 5

what is the format of a two part nursing diagnosis?

RK, RS

Answer 5

• risk for ____ related to
• readiness for _____ as evidenced by

Question 6

what is the diffrence between a risk for statement and a readiness for statement?

Answer 6

• risk for: is it used for potential problems, therfore will not have syptoms
• focuses more on primairy prevention

Question 7

nursing process

what is planning used for in ADPIE?

Answer 7

establish goals in collab w/ pt

Question 8

nursing process

what is implementation used for in ADPIE?

Answer 8

putting plan into action

Question 9

nursing process

what is evaluation used for in ADPIE?

Answer 9

determining if plan is progressing and changing plan if not

Question 10

medical records

what is the diffrence between a electronic medical record and a health record?

Answer 10

• MR: miniute clinic or 1 hospital visit
• HR: entirity of a health record

Question 11

documentation

what is narrative charting?

Answer 11

paragraph charting

Question 12

documentation

what are the diffrent forms of formatted charting?

PN, AN, SN, DN

Answer 12

• pie notes
• adpie
• soap
• dar

Question 13

documentation

What does PIE stand for?

Answer 13

• problem
• intervention
• evaluation

Question 14

documentation

what does SOAP stand for?

Answer 14

• subject
• objective
• assesment
• plan

Question 15

documentation

why is charting important?

Answer 15

• No charting = it didn’t happen
• no charting = no pay
• can be used in a court of law as a legal document

Question 16

documentation

if a nurse takes a verbal order what is required for documentation?

Answer 16

• date
• time
• physicians name
• RN signature

Question 17

law

What is criminal law?

Renewal of license/ practicing w/o license

Answer 17

Intentional misconduct or a serious violation of professional standards of care

Question 18

law

What are civil laws?

malpractice, slander, negligence, defamation

Answer 18

Court decisions which are created through precedents, rather than written statues

Question 19

law

What is a tort?

Answer 19

Private civil action that causes personal injury to a private party

Question 20

law

what is the diffrence between intentionl/ unintentional torts?

I: anger UI: wheelchair, giving celebrex to pt allergic to sulfa

Answer 20

intentional- assault, battery, defamation
unintentional- negligance and malpractice

Question 21

saftey

what are the four D’s pg negligence/ malpratice?

Answer 21

• duty
• dereliction
• damages
• direct cause

Question 22

when are potential problems a priority over real problems?

Answer 22

never

Question 23

infection control

what are the 6 aseptic interventation/ infection control?

HH, P/I, PPE, I, M/SA, D/S

Answer 23

• hand hygiene
• precautions and isolation
• personal protective equipment
• immunizations
• medical and surgipcal asepsis
• disinfection and sterlization

Question 24

assesment

what is a comprehensive assesment?

Answer 24

• a complete assesment that reviews health history and review all body systems ( head to toe)

Question 25

# assesment when are comprehensive assesments preformed? | HA, APE

Answer 25

- hospital adminssion - annual physical exam

Question 26

# assesment what is an emergency assesment? | ABC

Answer 26

- focuses on the ABC's - airway, breathing, circulation

Question 27

# assesment when is an emergency assesment completed? | PME, TMBI

Answer 27

- priorites must be established quickly - treatment must begin immediatly

Question 28

# assesment what is a focused assesment?

Answer 28

a brief individualized physical exam

Question 29

# assesment when a focused assesment completed? | BOS, CIPC, DONC

Answer 29

- beginning of shift - change in patient condition - development of new condition

Question 30

# safety what devices are used to promote saftey w/o the use of restraints? | R, B/CA, EV, MES, S, M, C/DT

Answer 30

- relocate pt closer to nursing station - bed/ chair alarms - encourage vistitors - minimize envoirmental stimuli - sitter - mitts - cover/ disguise tubes

Question 31

what are the two reasons when physical restraints can be applied?

Answer 31

- harm to self or others

Question 32

# saftey what are the two factors that affect safety? | IF, EF

Answer 32

- individual factors - envoirmental factors

Question 33

what are some examples of individual factors that affect safety? | BSI, LSF

Answer 33

- body system intergrity - life span factors

Question 34

# safety what are some examples of envoirmental factors that affect safety? | P, L, CD, WPH

Answer 34

- pollution - lighting - communicable diseases - workplace hazards

Question 35

# saftey What causes a risk for safety in the hospital? | F, UOR, ME, RE, DRM, PE

Answer 35

- falls - use of restraints - medication error - radiation exposure - drug resistant microorganisms - procedural errors

Question 36

# safety what is the hendrich II fall risk model?

Answer 36

- falls assesment tool

Question 37

# sterile what are the characteristics of a sterile field?

Answer 37

- above the waist - below elbows - chest - sterile touching sterile - tables are sterile at waist level

Question 38

# sterile What are characteritsics of a contaminated field?

Answer 38

- broken seals/ packaging - wet or damp surface - sterile touching clean - outside 1 in - if it flaps back - below the wasit - above elbows - back - reaching over field