Nursing Process #1 (NP+VS)
What are the two primary methods used to collect data? - correct answer
✔Interview: reasoning for seeking care, history of present illness, health
history, biological data, family history, environmental history, and psychosocial
history.
Physical examination: head to toe assessment
What is the approach you use to complete a physical assessment? - correct
answer ✔head to toe
Define ADPIE - correct answer ✔Assessment: gather info
Diagnosis: identify problems
Plan: set goals of care and desired outcomes and identify appropriate nursing
actions
Implement: perform nursing actions identified in planning
Evaluation: determine if goals met and outcomes achieved
What are the different basic documentation formats used during
documentation - correct answer ✔Traditional (Block) Chart
Problem-Oriented Medical Record
Focused Charting Format
Charting by Exception
What are the factors influencing pulse rate - correct answer ✔acute pain,
anxiety, age, exercise, fever, heat, hemorrhage, medications, metabolism,
postural changes, pulmonary conditions, and unrelieved severe pain, chronic
pain
, What are the different ways to take temperature - correct answer ✔Oral:
most accessible site.
Rectal: argued to be most accurate when oral cannot be obtained.
Axilla: safe, noninvasive; less accurate
Tympanic: noninvasive, safe, provides core reading; excessive cerumen can
interfere.
Temporal Artery: provides core temp. rapid, noninvasive; diaphoresis and
airflow across face may affect accurancy.
Where can you take a patient's pulse - correct answer ✔temporal, carotid,
apical, brachial, radial, femoral, popliteal, and pedal areas
What are the signs of dehydration - correct answer ✔can result in decreased
kin turgor and is manifested by lax skin that, when grasped and raise between
two fingers, slowly returns to its previous position (skin tenting)
techniques used in assessing a patient - correct answer ✔Inspection:
purposeful observation, used by visually inspecting a patient's body and
mood.
Palpation: uses hands and sense of touch to gather data about patient's body.
Auscultation: process of listening to sounds produced by patient's
cardiovascular, respiratory, and gastrointestinal systems.
Percussion: use of fingertips to tap the body's surface to produce vibration
and sound.
What is the basic rule for late entry regarding documentation? - correct
answer ✔note it as a late entry and then proceed with your notation: "late
entry ___" or as direction by company policy
What are the two primary methods used to collect data? - correct answer
✔Interview: reasoning for seeking care, history of present illness, health
history, biological data, family history, environmental history, and psychosocial
history.
Physical examination: head to toe assessment
What is the approach you use to complete a physical assessment? - correct
answer ✔head to toe
Define ADPIE - correct answer ✔Assessment: gather info
Diagnosis: identify problems
Plan: set goals of care and desired outcomes and identify appropriate nursing
actions
Implement: perform nursing actions identified in planning
Evaluation: determine if goals met and outcomes achieved
What are the different basic documentation formats used during
documentation - correct answer ✔Traditional (Block) Chart
Problem-Oriented Medical Record
Focused Charting Format
Charting by Exception
What are the factors influencing pulse rate - correct answer ✔acute pain,
anxiety, age, exercise, fever, heat, hemorrhage, medications, metabolism,
postural changes, pulmonary conditions, and unrelieved severe pain, chronic
pain
, What are the different ways to take temperature - correct answer ✔Oral:
most accessible site.
Rectal: argued to be most accurate when oral cannot be obtained.
Axilla: safe, noninvasive; less accurate
Tympanic: noninvasive, safe, provides core reading; excessive cerumen can
interfere.
Temporal Artery: provides core temp. rapid, noninvasive; diaphoresis and
airflow across face may affect accurancy.
Where can you take a patient's pulse - correct answer ✔temporal, carotid,
apical, brachial, radial, femoral, popliteal, and pedal areas
What are the signs of dehydration - correct answer ✔can result in decreased
kin turgor and is manifested by lax skin that, when grasped and raise between
two fingers, slowly returns to its previous position (skin tenting)
techniques used in assessing a patient - correct answer ✔Inspection:
purposeful observation, used by visually inspecting a patient's body and
mood.
Palpation: uses hands and sense of touch to gather data about patient's body.
Auscultation: process of listening to sounds produced by patient's
cardiovascular, respiratory, and gastrointestinal systems.
Percussion: use of fingertips to tap the body's surface to produce vibration
and sound.
What is the basic rule for late entry regarding documentation? - correct
answer ✔note it as a late entry and then proceed with your notation: "late
entry ___" or as direction by company policy
