Exam 1

Nursing Process

A systematic, client-centered method composed of five sequential phases: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

The systematic collection, verification, and communication of client data, involving subjective and objective data.

Diagnosis/Problem Identification

The analysis of assessment data to identify actual or potential health problems and inform planning.

Planning/Outcome Identification

The phase that prioritizes client problems, establishes SMART outcomes, and formulates nursing interventions.

Implementation

The execution of the nursing care plan through direct care delivery, indirect actions, coordination, and documentation.

Evaluation

The systematic measurement of client progress towards outcome goals, determining if the care plan needs to be continued, modified, or discontinued.

Independent Nursing Interventions

Actions initiated by nurses based on their knowledge and judgment, without requiring a prescription.

Dependent Nursing Interventions

Actions that require a prescription or order from an authorized healthcare provider.

Delegation

The process of assigning tasks to other healthcare providers while maintaining accountability for client care outcomes.

Therapeutic Communication

Effective nurse-client communication that is client-centered, goal-oriented, and empathetic.

Medical Asepsis

Practices designed to reduce the number and transfer of pathogens, such as hand hygiene.

Surgical Asepsis

Practices that render objects and areas free of all microorganisms and spores.

Standard Precautions

Infection control practices applied to all patients regardless of diagnosis.

Contact Precautions

Infection control measures used for patients with infections that are spread by direct or indirect contact.

Droplet Precautions

Infection control measures used to prevent transmission of diseases spread through respiratory droplets.

Airborne Precautions

Infection control measures used to prevent the spread of diseases that are transmitted through the air.

Pain Assessment (PQRST)

A comprehensive pain assessment tool that includes Provocation, Quality, Region, Severity, and Timing.

Vital Signs

Measurements of the body's most basic functions, including temperature, pulse, respirations, blood pressure, and oxygen saturation.

Comfort and Pain-management Measures

Nonpharmacological interventions such as repositioning, heat/cold therapy, and relaxation techniques.

Personal Hygiene Actions

Nursing actions that promote client hygiene, including bathing, oral care, and perineal care.

Doffing PPE

The correct sequence for removing Personal Protective Equipment: Gloves → Goggles/Face Shield → Gown → Mask/Respirator.

Client Teaching

Providing information and guidance to clients regarding health conditions and care plans.

Aseptic Technique

A procedure designed to eliminate the presence of pathogens in a controlled environment.

Reassessment

The process of re-evaluating a patient's condition to monitor progress or make changes.

Isolation Precautions

Measures taken to prevent the spread of infection from one patient to another.