Exam 1

1. Nursing Process
Review the five phases of the nursing process and know the correct sequence:
Assessment → Diagnosis/Problem Identification → Planning/Outcome Identification → Implementation → Evaluation
Be prepared to apply the nursing process to client-care scenarios.
Review:
• Initial, focused, and ongoing assessments
• Subjective versus objective data
• Nursing diagnosis/problem identification
• Outcome identification and planning
• Implementation of nursing interventions
• Evaluation of client outcomes
• Determining when the plan of care should be continued, modified, or discontinued
2. Independent and Dependent Nursing Actions
Understand the difference between:
• Independent nursing interventions – actions the nurse can initiate based on nursing knowledge and judgment
• Dependent nursing interventions – actions that require a prescription or order from an authorized healthcare provider
Be able to identify these interventions when presented in a clinical scenario.
3. Delegation and Supervision
Review the roles and responsibilities of the:
• Registered Nurse (RN)
• Licensed Practical Nurse (LPN)
• Unlicensed Assistive Personnel (UAP)
Know which client-care activities may be appropriately delegated to the LPN or UAP and which responsibilities must remain with the RN.
Remember that the RN is responsible for appropriate delegation and supervision. Pay particular attention to assessment, nursing judgment, client teaching, evaluation, and care of unstable clients when answering delegation questions.
4. Therapeutic Communication
Review principles of effective and therapeutic nurse-client communication.
Be able to recognize:
• Therapeutic communication techniques
• Open-ended questions
• Active listening
5. Asepsis and Infection Control
Review the signs and symptoms of infection and nursing interventions used to prevent the transmission of microorganisms.
Know:
• Clients who are at increased risk for infection
• Medical and surgical asepsis
• Hand hygiene
• Standard Precautions
• Contact Precautions
• Droplet Precautions
• Airborne Precautions
• Appropriate use and removal of Personal Protective Equipment (PPE)
o Gloves
o Gowns
o Masks/respirators
o Goggles/eye protection
Review nursing care and appropriate precautions for clients with infections such as:
• Tuberculosis (TB)
• E. coli
• HIV
• MRSA
Be prepared to determine the appropriate isolation precaution and PPE for different clinical situations.
6. Hygiene and Personal Care
Review factors that affect a client's hygiene and the nurse's responsibilities when assisting with personal care.
Topics include:
• Factors affecting hygiene
• Hygiene practices
• Hand hygiene
• Bed baths
• Oral care
• Denture care
• Perineal care
• Male and female perineal care
• Positioning clients safely
• Maintaining client privacy, comfort, dignity, and safety during hygiene care
7. Pain Assessment and Management
Review how to perform a comprehensive pain assessment using PQRST:
• P – Provocation/Palliation: What makes the pain better or worse?
• Q – Quality: What does the pain feel like?
• R – Region/Radiation: Where is the pain? Does it travel?
• S – Severity: How severe is the pain?
• T – Timing: When did it begin? Is it constant or intermittent?
Also review:
• 0–10 Numeric Pain Rating Scale
• Appropriate pain assessment
• Reassessment after nursing interventions
• Nonpharmacological comfort and pain-management measures
• Positioning
• Relaxation techniques
• Distraction
• Heat and cold, when appropriate
• Other comfort measures
8. Vital Signs
Know the expected adult ranges and recognize normal versus abnormal findings for:
• Temperature
• Pulse
• Respirations
• Blood pressure
• Oxygen saturation (SpO₂)
Be prepared to identify abnormal findings and determine the appropriate nursing action when a client's vital signs change.

1. Nursing Process

The nursing process is a systematic, client-centered method composed of five sequential phases:

1. Assessment

   • Definition: Systematic collection, verification, and communication of client data.

   • Data Types:

     • Subjective Data: Information stated directly by the client or family (e.g., self-reported pain levels, feelings, symptoms).

     • Objective Data: Observable and measurable findings obtained through physical examination, laboratory values, and vital signs.

   • Assessment Categories:

     • Initial (Baseline): Completed upon admission to establish a baseline health status.

     • Focused: Targets a specific body system or problem area (e.g., cardiac assessment during acute chest pain).

     • Ongoing / Emergency: Continuous reassessment during care delivery or during acute clinical deterioration.

2. Diagnosis / Problem Identification

   • Analysis of assessment data to identify actual or potential client health problems.

   • Uses clinical judgment to guide outcome identification and care planning.

3. Planning / Outcome Identification

   • Prioritizes client problems using frameworks such as Maslow's Hierarchy of Needs (prioritizing physiological and life-threatening needs first).

   • Establishes SMART outcomes (Specific, Measurable, Achievable, Relevant, Time-bound).

   • Formulates individualized nursing interventions aimed at achieving outcomes.

4. Implementation

   • Execution of the agreed-upon nursing care plan through direct care delivery, indirect actions, coordination, delegation, and thorough documentation.

5. Evaluation

   • Systematic and continuous measurement of client progress toward outcome goals.

   • Determines whether the plan of care should be continued, modified, or discontinued based on client response.

2. Independent, Dependent, and Interdependent Nursing Actions

• Independent Nursing Interventions

  • Actions initiated by the nurse based on professional knowledge, skill, and legal scope of practice without requiring a prescription or order from another healthcare provider.

  • Examples: Repositioning a bedbound client, elevating an edematous extremity, performing skin risk assessments, providing client education, and initiating fall prevention safety measures.

• Dependent Nursing Interventions

  • Actions requiring a written prescription, protocol, or direct order from an authorized healthcare provider (physician, nurse practitioner, physician assistant).

  • Examples: Administering prescription medications, inserting an indwelling Foley catheter, applying sterile wound care dressings, starting IV fluids, and ordering diagnostic imaging.

• Interdependent (Collaborative) Interventions

  • Actions carried out in cooperation with other interprofessional team members.

  • Examples: Implementing physical therapy mobility protocols, consulting with a speech therapist regarding dysphagia diet adjustments, or coordinating respiratory therapy treatments.

3. Delegation and Supervision

The Five Rights of Delegation

1. Right Task: The task is within the delegatee's scope and appropriate for the client.

2. Right Circumstance: The client's condition is stable and predictable; resources support delegation.

3. Right Person: The delegatee possesses the required competency and credentials.

4. Right Direction / Communication: Clear, concise descriptions of the task, objectives, limits, and reporting expectations are provided.

5. Right Supervision / Evaluation: Proper monitoring, evaluation, intervention, and feedback are performed by the RN.

Scope of Practice and Task Division

• Registered Nurse (RN)

  • Retains primary accountability for client care outcomes.

  • Responsibilities that cannot be delegated include: initial clinical assessment, nursing diagnosis, care plan formulation, outcome evaluation, care of unstable clients, client education, IV push medication administration, and blood product transfusions.

• Licensed Practical / Vocational Nurse (LPN / LVN)

  • Provides care for stable clients with predictable outcomes.

  • Tasks include: Performing focused assessments, updating care plans, administering oral, subcutaneous, and intramuscular medications, applying clean/sterile dressings, and reinforcing prior RN teaching.

• Unlicensed Assistive Personnel (UAP)

  • Performs routine, non-invasive, standard tasks for stable clients.

  • Tasks include: Measuring vital signs, calculating intake and output (I&O), performing bed baths and personal hygiene, assisting with transfers and ambulation, and feeding clients without swallowing difficulties.

4. Therapeutic Communication

• Core Principles: Client-centered, goal-oriented, non-judgmental, empathetic, and respectful of boundaries.

• Therapeutic Communication Techniques

  • Open-Ended Questions: Encourages detailed client expression (e.g., "Tell me more about what brought you to the hospital today.").

  • Active Listening: Maintaining eye contact, leaning forward, nodding, and paying attention to non-verbal cues.

  • Restating / Reflecting: Directing thoughts or feelings back to the client to encourage deeper reflection.

  • Clarification: Asking for verification when messages are ambiguous (e.g., "Could you explain what you mean by that?").

  • Therapeutic Silence: Provides time for the client to organize thoughts and process emotional responses.

• Non-Therapeutic Barriers (Avoid)

  • Asking "Why?" questions (induces defensiveness).

  • Offering false reassurance (e.g., "Don't worry, everything will be fine.").

  • Expressing personal opinions or giving unsolicited advice.

  • Changing the subject abruptly or minimizing client feelings.

5. Asepsis and Infection Control

Aseptic Principles

• Medical Asepsis ("Clean Technique"): Practices designed to reduce the number and transfer of pathogens (e.g., hand hygiene, routine environmental cleaning, clean glove use).

• Surgical Asepsis ("Sterile Technique"): Practices that render objects and areas completely free of all microorganisms and spores (e.g., sterile glove application, Foley catheter placement, sterile field maintenance).

Isolation Precautions & Personal Protective Equipment (PPE)

• Standard Precautions: Applied to all clients regardless of diagnosis. Hand hygiene before/after client contact; gloves worn for contact with blood, body fluids, non-intact skin, or mucous membranes.

• Contact Precautions

  • Indications: MRSA, C. difficile, VRE, scabies, major non-contained wound infections.

  • Requirements: Private room (or cohorting), gown, and gloves.

• Droplet Precautions

  • Indications: Influenza, Pertussis, Mumps, Rubella, Bacterial Meningitis.

  • Requirements: Private room, surgical mask within $3 - 6\text{ feet}$ of client, face shield/goggles if splash risk exists.

• Airborne Precautions

  • Indications: Tuberculosis (TB), Measles (Rubeola), Varicella (Chickenpox).

  • Requirements: Airborne Infection Isolation Room (AIIR) with negative air pressure, fitted N95 respirator or PAPR.

PPE Sequences

• Donning (Putting On): Gown $\rightarrow$ Mask/Respirator $\rightarrow$ Goggles/Face Shield $\rightarrow$ Gloves

• Doffing (Taking Off): Gloves $\rightarrow$ Goggles/Face Shield $\rightarrow$ Gown $\rightarrow$ Mask/Respirator

6. Hygiene and Personal Care

• Personal Hygiene Actions

  • Bed Baths: Wash from cleanest to dirtiest areas. Maintain warmth and privacy by exposing only the body part currently being cleaned.

  • Perineal Care:

  • Females: Clean from anterior to posterior (front to back) to prevent urinary tract contamination from fecal organisms.

  • Males: Clean from the urethral meatus outward in a circular motion. If uncircumcised, retract foreskin, clean, and immediately replace foreskin to prevent paraphimosis.

  • Oral Care: Position unconscious or semi-conscious clients in a lateral (side-lying) position with the head turned to the side to prevent aspiration; keep oral suction active and nearby.

  • Denture Care: Line the sink basin with a towel or fill with water prior to cleaning to cushion dentures against accidental drops.

7. Pain Assessment and Management

Comprehensive Pain Assessment (PQRST Protocol)

• P – Provocation / Palliation: What causes or worsens the pain, and what brings relief?

• Q – Quality: What does the pain feel like? (e.g., sharp, dull, burning, throbbing, aching)

• R – Region / Radiation: Where is the pain located, and does it radiate to other regions?

• S – Severity: Pain intensity rating using validated tools (e.g., $0 - 10$ Numeric Rating Scale, Wong-Baker FACES scale for pediatric or non-verbal clients).

• T – Timing: Onset, duration, frequency (constant or intermittent).

Pain Management Interventions

• Pharmacological: Administer prescribed analgesics (NSAIDs, opioids) and monitor for adverse effects (e.g., respiratory depression with opioid administration).

• Non-Pharmacological: Repositioning, heat/cold therapy, guided imagery, relaxation exercises, distraction, and cutaneous stimulation (TENS).

• Reassessment: Reevaluate pain score within $30 - 60\text{ minutes}$ following intervention delivery.

8. Vital Signs

Adult Reference Ranges and Clinical Nursing Considerations

• Body Temperature

  • Normal Range: $36.5^\text{o}\text{C} - 37.5^\text{o}\text{C}$ ($97.7^\text{o}\text{F} - 99.5^\text{o}\text{F}$).

  • Clinical Note: Pyrexia reflects immune response to infection or inflammation; hyperthermia requires physical cooling measures.

• Pulse Rate

  • Normal Range: $60 - 100\text{ beats/min}$.

  • Clinical Note: Assess apical pulse at the 5th intercostal space, left midclavicular line for 1 full minute prior to administering cardiac medications (e.g., digoxin) or if pulse is irregular.

• Respirations

  • Normal Range: $12 - 20\text{ breaths/min}$.

  • Clinical Note: Count breaths silently immediately following pulse assessment so the client does not alter respiratory pattern.

• Blood Pressure (BP)

  • Normal Range: Systolic $< 120\text{ mmHg}$ and Diastolic $< 80\text{ mmHg}$.

  • Clinical Note: Ensure proper cuff sizing (cuff width covers $40\text{\%}$ of arm circumference and bladder covers $80\text{\%}$ of arm length) to prevent false high or low readings.

• Oxygen Saturation ($\text{SpO}_2$)

  • Normal Range: $95\text{\%} - 100\text{\%}$.

  • Clinical Note: Verify probe positioning, pulse wave clarity, peripheral capillary refill, and tissue perfusion if readings are abnormally low.