Fundamentals Exam

The SBAR Communication tool stands for

In the diagnostic process, analysis and synthesis are considered opposite types of reasoning

The NANDA Int'l nursing diagnoses relating to clients who have skin wounds include

By standing over, looking down at the patient during an interview, the nurse risks

Heat has what result to an affected wound area

Only one possible intervention can be identified for each nursing goal

A(n) _______ is a deviation from what was planned on the critical pathway.

Respirations that attempt to blow off acid in the form of CO2

A cephalocaudal exam is a head to toe approach

The standardized NANDA name for diagnoses are called

Which of the following RN diagnosis contains proper components

It is acceptable to document prior to completing an intervention?

The purpose of a diagnostic label is NOT to to direct formation of client goals

An RN is about to teach young adults about safety. Which topic shall be the priority

The following age group is most at risk for falls

Objective data is NOT referred to as overt data?

In validating activity of the assessing phase, the RN performs which of the following?

Basic two-part statement includes only problem and etiology

A multidisciplinary care plan is also known as a collaborative care plan

Basic three-part statement includes all except

Just before implementing an intervention, the RN must

The intrapleural pressure is ____ in relation to atmospheric pressure

The process of critical thinking requires the nurse use

RN recognizes which of the following as a benefit of using a standardized care plan?

Which is the appropriate meaning of NKA?

Data collection must be both systematic and continuous?

SMART Goals include Specific, Measurable, Attainable, Realistic and Timely

The evidence-based principal given as the reason for selecting a particular RN diagnosis is

An appropriate flow rate for a non-rebreather is

If bronchioles are dilated 1st, more tissue is exposed and anti-inflammatory drugs can act

Evaluating is determining both client's progress AND the effectiveness of the care plan?

The RN is not responsible to oversee delegated tasks are carried out appropriately

The valsava maneuver is

Breathing pattern refers to

Etiology is defined as

Which element is best reflective of secondary subjective data?

Data clustering is not the beginning of synthesis

Etiology of a nursing diagnosis identifies > 1 causes of the health problems & gives direction

Principal methods used to collect data are

This position allows for maximum chest expansion of pts who are confined to bed

Pressure ulcers are caused by

Mongomery _____ is/are for bandages that require frequent changes

The following is used to assess pressure ulcers

The RN is performing an assessment of an immobile client. Which sign causes a need for action

To promote wound healing, intake should be atleast __ mL of fluid daily unless contraindicated

Planning begins with the first client contact but ends prior to discharge

Critical thinking is ...

The inflammatory phase of wound healing lasts approx

Defining characteristics are the cluster of signs and symptoms that indicate...

Carbon dioxide diffuses from the blood in to the

Unused muscles can cause

An uncontrolled neurological discharge of electrical neuronal discharge of the brain is

To use a three-point gate the client must be able to

Complications of wound healing include all but

Examples of subjective data are

Types of cues include: deviation of population norms, developmental delay and

"I feel weak all over" is an example of

The use of trial-and-error methods in nursing care will be dangerous because

When recording a mistake, it is lawful to erase or blot out the remark.

An evaluation statement consists of two parts:

CPAP stands for Central Positive Airway Pressure

Restraints are an appropriate device to consider for a pt on fall precautions

Orthostatic hypotension is a problem with the

Care that is omitted b/c of client's inability or refusal to partake doesn't have to be charted

Purpose of goals and desired outcomes include

Ongoing, systematic process designed to evaluate and promote excellence in health is

Goal and desired outcome may be used interchangably

"What brought you to the hospital today?" is what type of interview question

Specific labels to provide clear direction for RN care

Components of a NANDA nursing diagnosis include

Activities that nurses are licensed to initiate on the basis of their knowledge are

The final step of evaluating client responses is

Large amounts of exudate consisting of large amounts of RBCs is called

Which critical thinking attitude helps RN reconsider plan of pt. worried about affording care?

A medical diagnosis is made by a Dr and refers to conditions only a Dr can treat

Rolled up blankets or towels are considered acceptable support devices

Which is not a cognitive skill?

Which stage of a pressure ulcer is a partial-thickness skin loss involving the epidermis

When physiological needs are placed above more basic needs, it's referred to as

Restating in other words than the client's increases chance of changing original meaning

In order to use restraints, a Dr. order must state a time frame in which they shall be utilized

Muscle contraction occurs without moving the joint and muscle length does not change during

Creativity is thinking that results are the development of new ideas and products.

The nursing process includes: assessing, diagnosing, planning, implementing and ...