first test nurse process

What is subjective data?

Information the client reports (feelings, pain, nausea, symptoms).

What is objective data?

Information the nurse observes or measures (vitals, labs, physical findings)

What does ADPIE stand for?

Assessment, Diagnosis, Planning, Implementation, Evaluation.

What happens during the Assessment step?

Collect subjective and objective data.

What happens during the Diagnosis step?

Identify the client’s problem using NANDA (North American Nursing Diagnosis Association) nursing diagnoses.

What happens during the Planning step?

Set measurable goals and choose interventions.

What happens during the Implementation step?

Carry out the interventions.

What happens during the Evaluation step?

Determine if goals were met and modify the plan if needed.

What is a nursing diagnosis?

A clinical judgment about a client’s response to a health condition.

What is the highest priority type of nursing diagnosis?

Actual problems (vs. risk).

What framework helps determine priority?

ABCs (Airway, Breathing, Circulation).

Which is higher priority: acute or chronic?

Acute.

Which is higher priority: unstable or stable?

Unstable.

What is the first level of Maslow’s hierarchy?

Physiological needs (air, food, water, sleep).

What is the second level of Maslow’s hierarchy?

Safety and security. (physical safety, financial security, health, job security, protection from danger.)

What is the third level of Maslow’s hierarchy?

Love and belonging. (friendship, intimacy, family, community, feeling accepted.)

What is the fourth level of Maslow’s hierarchy?

Self‑esteem. (Confidence, achievement, respect, recognition, feeling valued)

What is the fifth level of Maslow’s hierarchy?

Self‑actualization. (personal growth, creativity, fulfilling your potential, living your values.)

Which Maslow level is ALWAYS the first priority in nursing?

Physiological.

What does ABCs stand for?

Airway, Breathing, Circulation.

What is the first priority in an emergency?

Airway.

What is the second priority after airway?

Breathing.

What is the third priority after breathing?

Circulation.

Which is higher priority: safety or comfort?

Safety.

Which client is seen first: one with an actual problem or a risk problem?

Actual problem.

Which client is seen first: one with acute pain or chronic pain?

Acute pain.

Which client is seen first: one with a new onset symptom or a long‑standing stable symptom?

New onset symptom.

What does autonomy mean in nursing ethics?

Right of the client to make their own decisions; nurse must respect choices.

What is beneficence?

Acting for the good of the client and promoting their well‑being.

Define Nonmaleficence

The duty to “do no harm” and protect client safety.

What does Justice require of nurses?

Fair and equal treatment for all clients.

What is Fidelity in nursing practice?

Keeping promises; being dependable.

Define veracity.

Telling the truth and being honest with clients in communication.

What is Advocacy?

Speaking up for clients’ rights, safety, and preferences.

What is professionalism in nursing?

Behaviors and attitudes that reflect nursing values, ethics, and standards.

What does accountability mean?

Taking ownership of decisions and being answerable for outcomes.

Define responsibility.

Being reliable and following through with tasks and commitments.

What are professional boundaries?

Limits that protect the nurse–client relationship and prevent personal involvement.

What is reflection?

Restating the client’s feelings to show understanding.

Define empathy.

Understanding and validating the client’s emotions.

What is clarifying?

Asking for more detail to ensure accurate understanding.

What does focusing do?

Directs the conversation to important topics.

What is paraphrasing?

Restating the client’s message in your own words.

What is summarizing?

Reviewing key points of the conversation.

What are examples of nontherapeutic communication?

Giving advice, false reassurance, minimizing feelings, changing subjects, or asking “why” questions.

What is professional accountability?

A legal and ethical obligation to do the right thing every time, ensuring safe and competent care.

What tasks are appropriate for an RN?

Assessment, nursing diagnosis, teaching, IV pushes, complex care.

What can an LPN/PN safely perform?

Focused assessments, data collection, wound care, PO/IM meds, care for stable clients.

What tasks can a UAP (Unlicensed Assistive Personnel) perform?

ADLs (Activities of Daily Living), hygiene, feeding, ambulation, and non‑interpretive vital signs.

What characterizes a transactional leader?

Focuses on rules, rewards, and punishments to ensure compliance.

What defines a transformational leader?

Inspires and motivates others toward a shared vision and improvement.

What is a laissez‑faire leader?

Hands‑off style; allows independent decision‑making with minimal oversight.

What is a bureaucratic leader?

“By the book” leader who enforces strict adherence to policies and procedures.

What is a situational leader?

Adapts leadership style based on the situation and team needs.

What is the Nurse Practice Act?

The state law that defines nursing scope of practice, licensure requirements, and legal responsibilities for nurses.

Who enforces the Nurse Practice Act?

The State Board of Nursing (BON), which creates rules, regulations, and disciplinary actions.

What does the NPA (Nurse Practice Act) legally require nurses to do?

Practice within their defined scope, maintain competence, and follow state regulations.

What are nurses legally responsible for?

Providing safe, competent care within scope, following standards, documenting accurately, and protecting client rights.

What is negligence?

Failure to provide the care a reasonably prudent nurse would provide, resulting in harm.

What is malpractice?

Professional negligence—failure to meet professional standards that causes client harm.

What is assault in nursing?

Threatening to harm a client without touching them.

What is battery in nursing?

Touching or performing a procedure without consent.

What is false imprisonment?

Restricting a client’s movement without legal justification (e.g., restraining without an order).

What is defamation?

Damaging someone’s reputation through false statements.

• Slander: Spoken defamation

• Libel: Written defamation

What is invasion of privacy?

Sharing private client information without permission.

What is informed consent?

The client’s voluntary agreement to a procedure after receiving understandable information. (Nurses verify understanding and witness the signature; providers obtain consent.)

What are the standards for nursing documentation?

Documentation must be factual, complete, timely, objective, and reflect actual care provided.

Why is accurate documentation legally important?

It serves as a legal record and protects the nurse in cases of complaints or investigations.

What does HIPAA require nurses to do?

Protect client information, avoid unauthorized disclosure, and prevent identifiable information from being shared.

What are examples of HIPAA violations?

Snooping in charts, posting client info online, leaving screens unlocked, sharing details with unauthorized people.

How does Maslow’s hierarchy guide patient care?

It prioritizes physiological and safety needs first before addressing psychosocial and self‑fulfillment needs.

Which needs are ALWAYS priority in nursing care?

Airway, breathing, circulation (physiological needs).

What is the highest priority in patient care?

Life‑threatening physiological problems (ABCs).

What comes after physiological and safety needs?

Love/belonging, esteem, and self‑actualization needs.

What is the difference between acute vs. chronic prioritization?

Acute problems take priority over chronic, stable conditions.

What is interdisciplinary collaboration?

Multiple health professionals working together to improve patient outcomes.

Why is collaboration important?

It reduces errors, improves communication, and enhances patient safety

Which team member should the nurse consult for diet changes?

The dietitian.

What is patient‑centered care?

Care that respects and responds to the patient’s preferences, needs, and values.

What is an example of patient‑centered care?

Requesting a diet based on the patient’s religious or cultural needs.

What is primary care?

Routine care, wellness, prevention, and management of chronic conditions.

What is secondary care?

Specialist care after referral (e.g., cardiology, dermatology).

What is tertiary care?

Highly specialized care (e.g., ICU, trauma centers, advanced surgeries).

What is a sentinel event?

An unexpected event causing death or severe harm (e.g., wrong‑site surgery).

What is quality improvement (QI)?

Processes designed to improve patient care and outcomes.

What is evidence‑based practice (EBP)?

Using current research and data to guide clinical decisions.

What is the purpose of National Patient Safety Goals (NPSGs)?

To improve patient safety through standardized requirements.

What is systems‑based practice?

Understanding how health care systems operate and using resources effectively.

What is an example of systems‑based practice?

Following facility policies for infection control to reduce HAIs (Health‑Care–Associated Infections.).

What is the nurse’s role in systems‑based practice?

Recognizing system barriers, advocating for safe care, and using resources efficiently.

What is communication?

The transfer of information between sender and receiver through verbal, nonverbal, emotional, and technological means.

Why is effective communication vital in nursing?

It prevents medical errors, improves patient safety, and supports teamwork among caregivers.

What are the six parts of the Shannon‑Weaver model?

Sender, encoder, channel, decoder, receiver, and noise.

What does Schramm’s model add to communication?

Feedback—showing communication is a two‑way process.

What does Newcomb’s ABX model focus on?

The social relationship between sender (A), receiver (B), and topic (X).

What are the four parts of Berlo’s SMCR model?

Sender, message, channel, receiver (one‑way, no feedback).

What are the five levels of communication?

Verbal, physical, auditory, energetic, and emotional.

What is verbal communication?

Spoken or written words used to convey a message.

What is nonverbal communication?

Body language—eye contact, posture, gestures—that can reinforce or contradict verbal messages.

What is auditory communication?

What the receiver hears—tone, speed, and clarity of voice.