Fundamentals of Nursing Exam 1 Study Guide (Yoost & Crawford, 3rd Edition)

1. Nursing Process

• Steps:
  • Assessment: Gather data about the patient's health status.
  • Diagnosis: Analyze the data to determine the patient’s issues.
  • Planning: Set goals and identify expected outcomes for the patient.
  • Implementation: Carry out the planned interventions.
  • Evaluation: Assess the effectiveness of the interventions and modify the care plan as needed.
• Each step is patient-centered and cyclical, meaning that the process is ongoing and may require modifications over time.

2. Skin Assessment

• Parameters to Assess:
  • Color: Observe the skin tone and any variations.
  • Moisture: Check for dryness or excessive moisture.
  • Temperature: Use the back of the hand to assess warmth.
  • Turgor: Pinch the skin to assess elasticity and hydration.
  • Edema: Look for swelling and document using the edema scale:
  • 1+ (2 mm indentation)
  • 2+ (4 mm indentation)
  • 3+ (6 mm indentation)
  • 4+ (8 mm indentation)
  • Lesions: Identify types of skin lesions, including:
  • Macule: Flat, discolored spot.
  • Papule: Raised bump.
  • Nodule: Firm, raised mass.
  • Vesicle: Blister filled with fluid.
  • Pustule: Pus-filled lesion.
  • Ulcer: Loss of skin integrity.

3. Respiratory Sounds

• Types:
  • Crackles: Indicate fluid in the airways.
  • Rhonchi: Suggests mucus accumulation.
  • Wheezing: Caused by narrowed airways.
  • Stridor: Indicative of airway obstruction.

4. Heart Valve Landmarks

• Anatomical Locations:
  • Aortic: 2nd Right Intercostal Space (ICS).
  • Pulmonic: 2nd Left Intercostal Space (ICS).
  • Tricuspid: 4th Left Intercostal Space (ICS).
  • Mitral: 5th ICS at the midclavicular line.

5. Physical Assessment Order

• General Sequence:
  • IPPA: Inspect, Palpate, Percuss, Auscultate for general assessments.
  • For the abdomen: Perform in the order: Inspect, Auscultate, Percuss, Palpate.

6. Restraints

• Regulations:
  • Require a provider order before application.
  • Assess the patient every 2 hours to ensure safety.
  • Use the least restrictive method appropriate for patient care.
  • Document all actions and observations thoroughly.

7. Personal Protective Equipment (PPE)

• Donning Sequence:
  • Gown → Mask → Goggles → Gloves
• Doffing Sequence:
  • Gloves → Goggles → Gown → Mask
• Types of Precautions:
  • Airborne: Use N95 mask and negative pressure rooms.
  • Droplet: Requires wearing a mask.
  • Contact: Don gown and gloves.

8. Hand Hygiene

• Techniques:
  • Use soap and water for visible soil or C. difficile infection.
  • Use alcohol-based sanitizer for routine hand hygiene (≥20 seconds of scrub time).

9. Safety & Positioning

• Best Practices:
  • Utilize proper body mechanics to prevent injury.
  • Use lifting aids when necessary.
  • Maintain an appropriate stance and bed height for patient comfort.
• Common Positions:
  • Fowler’s: Sitting position.
  • Semi-Fowler’s: Reclined position, about 30 degrees.
  • Supine: Laying flat on back.
  • Prone: Laying flat on stomach.
  • Sims’: A side-lying position used for rectal examinations.
  • Lateral: Laying on one side.

10. Communication & Teamwork

• Interdisciplinary Roles:
  • Include RN, LPN, CNA, RT, PT, pharmacist, and dietitian among the care team.
• Therapeutic Communication:
  • Incorporates empathy and active listening to foster understanding.
• ISBAR: A structured communication method that includes:
  • Identify: Who you are and who you’re talking about.
  • Situation: Describe the current situation.
  • Background: Provide relevant background information.
  • Assessment: State your professional assessment.
  • Recommendation: Suggest a course of action.

11. Maslow’s Hierarchy

• Levels of Needs:
  1. Physiologic: Basic needs such as food, water, and warmth.
  2. Safety: Security, stability, and freedom from fear.
  3. Love/Belonging: Social connections and relationships.
  4. Esteem: Recognition and respect.
  5. Self-Actualization: Achieving one’s full potential.
• Application: Used to prioritize nursing care based on patient needs.

12. Infection Control

• Signs of Infection:
  • Local: Redness, warmth, swelling.
  • Systemic: Fever, elevated white blood cell (WBC) count.
• At-Risk Situations:
  • Patients with catheters, wounds, IVs, or those who are immunosuppressed are more susceptible to healthcare-associated infections (HAIs).

13. Vital Signs & Terms

• Respiratory Rates:
  • Bradypnea: Respiratory rate <12 breaths per minute.
  • Tachypnea: Respiratory rate >20 breaths per minute.
  • Eupnea: Normal respiratory rate of 12–20 breaths per minute.
• Heart Rates:
  • Bradycardia: Heart rate <60 beats per minute.
  • Tachycardia: Heart rate >100 beats per minute.
• Reporting: Always report abnormal or life-threatening values to appropriate personnel.

14. Documentation

• Electronic Health Record (EHR): Acts as a legal record of patient care.
• HIPAA Compliance: Emphasizes the importance of maintaining patient confidentiality.
• Charting Methods:
  • Focus: Use the DAR (Data, Action, Response) format.
  • Exception: Document only abnormalities.
  • Complete: Provide a thorough, objective, and timely account of patient care.

15. Activities of Daily Living (ADLs)

• Basic ADLs Include:
  • Bathing, dressing, eating, toileting, and mobility.
• Bath Types:
  • Full Bath: Involves washing the entire body.
  • Partial Bath: Involves washing select areas of the body.
• Assessment of ADLs: Evaluated using ADL scales or through patient observation for difficulty in performance.