Nursing Process and Clinical Judgment Fundamentals

Comprehensive flashcards covering the nursing process, clinical judgment model, fluid/electrolytes, prioritization frameworks, ethics, legal standards, and communication models based on lecture notes.

Who developed the nursing process in 1958?

Ida Jean Orlando

What are the five steps of the RN nursing process in order?

1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation

What are the four steps of the PN nursing process?

1. Data collection 2. Planning 3. Implementation 4. Evaluation

How does NCSBN define the Clinical Judgment Action Model (CJAM) stages corresponding to the nursing process?

1. Recognize Cues (Assessment) 2. Analyze Cues (Analysis) 3. Prioritize Hypotheses (Analysis) 4. Generate Solutions (Planning) 5. Take Actions (Implementation) 6. Evaluate Outcomes (Evaluation)

What is the difference between objective and subjective data?

Objective data are measurable and based on facts/observations (e.g., vital signs), while subjective data are the client's self-reports or verbatim remarks (e.g., pain ratings).

What does the SMART acronym stand for in goal setting?

Specific, Measurable, Attainable, Realistic, and Timely

What are the five levels of Maslow’s Hierarchy of Needs from base to peak?

1. Physiological 2. Safety and Security 3. Love and Belonging 4. Self-Esteem 5. Self-Actualization

What are the components of the ABCDE priority framework?

Airway, Breathing, Circulation, Disability, and Exposure

In disaster triage, what do the Red, Yellow, Green, and Black tags represent?

Red: Emergent/Immediate; Yellow: Urgent/Delayed; Green: Nonurgent/Walking Wounded; Black: Expectant (deceased or not expected to survive).

What are the five 'rights' of delegation?

1. Right Task 2. Right Circumstance 3. Right Person 4. Right Directions/Communication 5. Right Supervision/Evaluation

What does PICOT stand for in evidence-based practice research?

Population, Intervention, Comparison, Outcome, and Time

What are the expected reference ranges for Potassium ($K^+$), Sodium ($Na^+$), Calcium ($Ca^{2+}$), and Magnesium ($Mg^{2+}$)?

$K^+$: $3.5$ to $5.0\,mEq/L$; $Na^+$: $136$ to $145\,mEq/L$; $Ca^{2+}$: $9$ to $10.5\,mg/dL$; $Mg^{2+}$: $1.3$ to $2.1\,mEq/L$

What are the expected arterial blood gas (ABG) reference ranges for $pH$, $PaCO_2$, and $HCO_3^-$?

$pH$: $7.35$ to $7.45$; $PaCO_2$: $35$ to $45\,mm\,Hg$; $HCO_3^-$: $22$ to $26\,mEq/L$

What do the SBAR and SOAP communication tools stand for?

SBAR: Situation, Background, Assessment, Recommendation. SOAP: Subjective, Objective, Assessment, Plan.

What is the difference between an intentional and unintentional tort?

Unintentional torts include negligence and malpractice. Intentional torts include assault, battery, defamation, and invasion of privacy.

What are the primary eye conditions found in aging populations?

Cataracts (cloudy lens), Glaucoma (increased IOP), Macular Degeneration (loss of central vision), and Diabetic Retinopathy (vessel damage).

What is the difference between expressive and comprehensive (receptive) aphasia?

Expressive (Broca’s): Understands but cannot speak words. Comprehensive (Wernicke’s): Speaks fluently but without meaning and cannot understand others.

What is the serum osmolality reference range?

$285$ to $295\,mOsm/kg$

What is the mission of the OSHA regulatory agency in nursing?

To set and enforce safe and healthful working conditions, such as protecting workers from bloodborne pathogens and needle-stick injuries.

What does HIPAA protect?

An individual's identifying private information and personal health information (PHI).