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Nursing Fundamentals Exam 1: Questions and Answers, Exams of Nursing

Edinburgh College of Art (ECA)Nursing

A comprehensive set of questions and answers related to nursing fundamentals, covering topics such as standardized nursing interventions and outcomes, nursing diagnosis, data interpretation, and the nursing process. It serves as a valuable resource for nursing students preparing for their first exam in the subject.

Typology: Exams

2024/2025

Available from 03/05/2025

NurseTakshif
NurseTakshif 🇬🇧

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Ccbc nursing fundamental exam 1
1. List Advantages of using a standard classification of nursing interventions
and outcomesAnswer AdvantagesAnswer
•Helps demonstrate the impact that nurses have on the system of healthcare
delivery
•Standardizes and defines the knowledge base for nursing curricula and practice
•Facilitates the appropriate selection of a nursing intervention
•Facilitates communication of nursing treatments to other
nurses and other providers
2. Describe the rationale for standardized outcomes (NOC) and interventions
(NIC) for nursingAnswer NOC - first comprehensive standardized language used to
de- scribe the patient out- comes that are responsive to nursing intervention
NIC - first comprehensive, validated list of nursing interventions applica- ble to all
settings that can be used by nurses in multiple spe- cialties, greatly facilitates the
work of identifying appropriate interventions
3. Describe how patient goals/expected outcomes and nursing orders are
derived from nursing diagnosesAnswer Initial Planning
1. Developed by the nurse who performs the nursing history and physical assess-
ment
2. Addresses each problem listed in the prioritized nursing diagnoses
3. Identifies appropriate patient goals and related nursing care
Ongoing Planning
1. Carried out by any nurse who interacts with patient
2. Keeps the plan up to date
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Download Nursing Fundamentals Exam 1: Questions and Answers and more Exams Nursing in PDF only on Docsity!

Ccbc nursing fundamental exam 1

  1. List Advantages of using a standard classification of nursing interventions and outcomesAnswer AdvantagesAnswer
  • Helps demonstrate the impact that nurses have on the system of healthcare delivery
  • Standardizes and defines the knowledge base for nursing curricula and practice
  • Facilitates the appropriate selection of a nursing intervention
  • Facilitates communication of nursing treatments to other nurses and other providers
  1. Describe the rationale for standardized outcomes (NOC) and interventions (NIC) for nursingAnswer NOC - first comprehensive standardized language used to de- scribe the patient out- comes that are responsive to nursing intervention NIC - first comprehensive, validated list of nursing interventions applica- ble to all settings that can be used by nurses in multiple spe- cialties, greatly facilitates the work of identifying appropriate interventions
  2. Describe how patient goals/expected outcomes and nursing orders are derived from nursing diagnosesAnswer Initial Planning
  3. Developed by the nurse who performs the nursing history and physical assess- ment
  4. Addresses each problem listed in the prioritized nursing diagnoses
  5. Identifies appropriate patient goals and related nursing care Ongoing Planning
  6. Carried out by any nurse who interacts with patient
  7. Keeps the plan up to date
  1. States nursing diagnoses more clearly
  2. Develops new diagnoses
  3. Makes outcomes more realistic and develops new outcomes as needed
  4. Identifies nursing interventions to accomplish patient goals Discharge Planning
  5. Carried out by the nurse who worked most closely with the patient
  6. Begins when the patient is admitted for treatment
  7. Uses teaching and counseling skills effectively to ensure home care behaviors are performed competently
  8. Describe how patient goals/expected outcomes and nursing orders are derived from nursing diagnoses?Answer From the problem statement you get the goals, outcomes, objectives. Etiology we get our interventions. Patient goals/expected outcomes- nursing orders are derived from nursing Dx.

results in prevention, reduction, or resolution of the patient's health problems and attainment of patient's health expectations, as identified in patient outcomes BenefitsAnswer

  1. Individualized patient care
  2. Continuity of care
  3. Priorities set
  4. Coordinate care
  5. Promote nurse's professional development
  6. Create record used for evaluation, reimbursement, and legal purposes
  7. Facilitate communication
  8. Describe means to validate nursing diagnosisAnswer 1. Is patient database accu- rate?
  1. Does the data demonstrate a existence of pattern?
  2. Are the subjective and objective data characteristic of the health problem?
  3. Is nursing diagnosis based on scientific nursing knowledge and clinical expertise?
  4. Is the nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action?
  5. Is my degree of confidence above %50?
  6. Identify five types of nursing diagnosisAnswer Actual, Risk, Health promotion, Well- ness
  7. Use the guidelines for writing nursing diagnoses when developing diagnos- tic statements.Answer 1. phrase the nursing diagnosis as a patient problem rather than a patient need 2.Check to make sure patient problem preceds the etiology and the two are linked by "related to"
  8. write in legally advisable terms
  9. use nonjudgmental language
  10. be sure to include what is unhealthy about the patient 6.avoid using medical diagnosis, defining characteristics
  11. Describe the four steps involved in data interpretation and analysis.Answer
  12. (1) Changes in a pts usual health patterns that are unexplained by expected norms for growth & developmentAnswer ex infant who took to breastfeeding easily as newborn suddenly stops sucking when put to breast & begins to lose wt. (2) Deviation from an appropriate population normAnswer ex A first-year college student begins to accelerate her exercise habits dramatically & starts inducing vomiting after binge eating. She rapidly loses wt. (3) Behavior that is nonproductive in the whole-person contextAnswer Ex college
  1. Describe the importance of knowing when to report significant patient data and of proper documentation.Answer ReportingAnswer data should be reported verbally imme- diately whenever assessment findings reveal a critical change in pts health status that necessitates the involvement of other nurses or health care professionals. Ex. Nurse who observers elevated temp 103.2 F in pt scheduled for sx that morning must report this to charge nurse & surgeon, who might cancel sx. DocumentationAnswer Pts initial databse is entered in computer or recorded in ink, using designated agency protocol or forms, the same day pt is admitted to agency. If for any reason, impt data cannot be obtained during initial assessment, this should be doc. so that the are obtained as soon as possible.
  2. Identify common problems encountered in data collection, noting their possible causes.Answer Inappropriate organization of the database, omission of pertinent data, inclusion of irrelevant or duplicate data, erroneous or misinterpreted data, failure to estb rapport & partnership w/pt, recording an interpretation of data rather than observed behavior, & failure to update the database
  3. identify common prolems encountered in data collection, noting possible causesAnswer database inappropriately organized- failure to plan for assessment by identifying needed data, pertinent data omitted-not following up on cues during data collection, inappropriate guidelines erroneuous or misinterpretted data collection- failure to observe carefully or validate during data collection, interviewer prejudice or stereotypes

failure to establish rapport-failure to know what info is wanted interpretation of data is recorded rather than the observed behavior- nurse jumps to conclusions failure to update the database- erroneuous belief that assessment is concluded after intitial database is recorded

  1. obtain a nursing history using effective interviewing techniques?Answer The nursing history should clearly identify the patients strengths and weaknesses; health risk, such as hereditary and environmental factors; and potential and existing health problems. The nursing history focuses on getting to know the person. Patient interviewAnswer -preparatory phaseAnswer the nurse should insure the environment that the interview is being conducted is private and relaxed.

specific care for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-used in ALL settings

  1. Describe evidence-based practice in nursing including the rationale for its use.Answer Evidence-based practice (EBP) in nursing is a problem-solving approach to making clinical decisions, using the best evidence available (considered "best" because it is collected from sources such as published research, national standards and guidelines, and reviews of targeted literature). EBP blends both the science and the art of nursing so that the best patient outcomes are achieved. The information that is collected is analyzed and used to answer questions (the science of nursing), taking into consideration patient preferences and values, as well as the clinical experiences of the nurse (the art of nursing). EBP may consist of specific nursing interventions or may use guidelines established for the care of patients with certain illnesses, treatments, or surgical procedures.
  2. List the 6 step in implement evidence-based practiceAnswer a. Ask a clinical question

b. Collect the most relevant evidence c.Clinically appraise the evidence d. Integrate all the evidence with one's clinical expertise, patient preferences, and values in making a practice decision e. Evaluate the practice decision or change f. Share the outcome of EBP changes with others

  1. Explain each of the QSEN CompetenciesAnswer 1. Patient-centered care
  2. Teamwork and collaboration
  3. Evidence-based practice
  4. Quality improvement
  5. Safety
  6. Informatics
  7. Describe the historic evolution of the nursing processAnswer 1955 the term ""nurs- ing process"" first appeared 1960s nursing theorists began to describe nursing as a distinct entity among the healthcare professions 1967 first comprehensive book on nursing process was published 1973 steps of nursing process legitimized when ANA developed Standards of Practice
  8. Contrast three approaches to problem solvingAnswer 1.Trial and Error Problem solving-testing any number of solutionuntil one is ound that works
  9. Scientific Problem solving- seven step problem process. 1. problem identification
  10. data collection 3. hypothesis formulation 4. plan of action 5. hypothesis testing 6. interpretation of results and 7. evaluation resulting in conclusion or revision of the hypothesis

Domain 2 Answer physiologic complex (electrolyte, drug maintenance, tissue perfusion) Domain 3 Answer Behavioral - care that facilitates lifestyle changes

  1. Steps in concept map care planningAnswer 1. Develop a basic skeleton diagram.
  2. Analyze and categorize data.
  3. Analyze nursing diagnoses relationships.
  4. Identify goals, outcomes, and interventions.
  5. Evaluate patient's responses.
  6. Value reflective practice as an aid to self-improvement.Answer Reflection in action, Reflection on action, and Reflection for action
  7. Explain the relationship between assessment and medical assessmentAnswer - Nursing AssessmentAnswer focus on pt responses to health problems Medical AssessmentAnswer target data pointing to pathologic conditions
  8. Identify factors affecting personal hygiene.Answer Culture, socioeconomic class, spiritual practices, developmental level, health state, and personal preferences
  9. Assess the adequacy of hygiene practices and self-care behaviors using appropriate interview and physical assessment skills.Answer Hygiene practices in- clude bathing and care of the skin and specific body areas, including the oral cavity, eyes, ears, nose, hair, nails, feet, and perineal and vaginal areas. Ask if the patient has noticed changes in or problems with these areas. Ask the patient about personal hygiene routines and products used. Inquire about any problems the patient may be experiencing related to completion of personal hygiene.
  1. Assess the condition of the patient's skin, oral cavity, hair, and nails using appropriate interview and physical assessment skillsAnswer SkinAnswer bilateral symmetry, identify variables known to cause problems (immobility, dehydration, decreased sensation, sun exposure, vascular problems, chemical exposure oral cavityAnswer color, moisture, lesions, nodules, edema, texture, intactness, movement of uvula HairAnswer texture, cleanliness, oiliness, scaling, lesions, inflammation, infection Nails and FeetAnswer Intactness and cleanliness, capillary refill, redness, swelling, bleed- ing, discharge, tenderness, swelling, lesions, orthopedic problems
  2. Describe the priorities of scheduled hygiene careAnswer Early Morning CareAnswer assist with toileting, comfortable for breakfast Morning Care (AM care)Answer toileting, bathing, skin care; refreshed and comfortable, safe environment
  1. Describe agents commonly used on the skin and scalp, including any precautions necessary for their use.Answer The use of chlorhexidine gluconate for bathing has been shown to reduce colonization of skin with pathogens and is becoming part of personal hygiene policies in some facilities. Topical emollient agents—also known as moisturizers—can be applied to the skin as a lotion, cream, gel, or ointment. Skin barrier products include creams, ointments, and films; they are used to protect vulnerable skin and to protect skin at risk for damage caused by excessive exposure to water and irritants, such as urine and feces.
  2. Plan, implement, and evaluate nursing care for common problems of the skin and mucous membranes.Answer Oral, Eyes, Ears, Noses, Vaginal, and other mu- cous membranes as well as the skin each require their own version of care. Performing or assisting with the performance of hygiene measures provides a

means of at least daily contact with the patient to determine whether the patient is achieving outcomes related to hygiene and skin care. Indicators that can be used to determine outcome achievement include the followingAnswer Level of patient's participation in hygiene program Elimination of, reduction in, or compensation for factors interfering with the patient's independent execution of hygiene measures, for example, weakness, decreased motivation, and lack of knowledge Changes related to specific skin problems, for example, healing of skin lesions, elimination or reduction in causative factors, and independent patient management of the prescribed treatment program

  1. Factors that affect safety in a person's environmentAnswer Developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, phys- ical health state, and psychosocial state
  2. Identify patients at risk for injury.Answer For children, potential hazards multiply as their motor skills develop and their environment expands. Adolescents face great dangers when they abuse drugs or alcohol or engage in high-risk sexual activity including depression and suicide. Older adults experiencing altered balance or decline in cognitive abilities are in- creasingly vulnerable to falls and episodes of confusion.
  3. Describe health-teaching interventions to promote safety for each devel- opmental stage.Answer The patient willAnswer Identify unsafe situations in his or her environment Identify potential hazards in his or her environment Demonstrate safety measures to prevent falls and other accidents Establish
  1. what are some things that might serve as restraint alternativesAnswer giving a massage or manicure, answering call lights promptly, providing diversional activities or increased family presence.bed alarms; use low bed heights; allow patients to walk when desired after ensuring the environment is safe; reduce stimulation, noise, and light; use night lights; floor mats on each side of the bed; ensure glasses and hearing aid use; use therapeutic touch; assist with toileting in frequent intervals; relocate patients closer to nursing station
  2. Resources for developing and evaluating an emergency management planAnswer National Disaster Medical System (NDMS); Federal Emergency Management Agency (FEMA); Centers for Disease Control and Prevention (CDC);The Joint Com- mission (TJC); American Red Cross; American Hospital Association; Department of Homeland Security
  3. Evaluate the effectiveness of safety interventionsAnswer If expected patient out- comes have been met, the patient should be able to accomplishAnswer correctly identify real and potential unsafe environmental situations; implement safety measures in the environment; use available resources to obtain safety info; incorporate accident prevention practices into activities of daily living; remain free of injury.
  4. Explain the infection cycleAnswer An infection is a disease state that results from the presence of pathogens (disease -producing microorganisms) in or on the body. An infection occurs as a result of a cyclic process, consisting of six componentsAnswer
  5. Infectious agent
  6. Reservoir
  7. Portal of Exit
  1. Means of transmission
  2. Portals of entry
  3. Susceptible host
  4. infection cycleAnswer infectious agentAnswer The most prevalent agents that cause infec- tion are bacteria, viruses, and fungi BacteriaAnswer most significant and most commonly observed infection-causing agent in health care institutions VirusAnswer smallest of all microorganisms, visible only with an electron microscope -cause many infections including the common cold, Hep. B, Hep. C and AIDS FungiAnswerplant-like organisms (molds and yeasts) that also can cause infection. Present in the air, soil, and water ex. (athlete's foot, ringworm, and yeast infections)
  5. Infection cycle Answer reservoirAnswer The reservoir for growth and multiplication of mi- croorganisms is the natural habitat of the organism. Possible reservoirs that support organisms pathogenic to humansAnswer