16. Nursing diagnostic involves four elements.
Analysis & Interpretation of data, Clustering of
Data, Identification of Pt. Problems, Formulation
of Nsg. Dx.
30. In implementation of the NCP, what actions are
taken.
Assist Pt. on ADL, Counsel & support Pt. &
family, Guide Pt., Teach Pt. & Family, Provide
care to achieve NCP, Provide Environment that is
62. Neurovascular, circulatory & skin integrity is
assessed in using restraints when?
Then removed at least every?
Every 30 minutes
Removed @ least q 2 hrs. to promote circulation
64. Who are those prone to accidental poisoning?
Toddlers
Preschoolers
Young school age
65. In older adults, poisoning & overdose of
prescribed medz. will yield?
66. In older adults, poisoning & overdose of
prescribed medz. will yield?
Diminished eyesight
Impaired memory
67. If lye, grease, petroleum or household cleaner is
ingested, a nurse should?
68. If lye, grease, petroleum or household cleaner is
ingested, a nurse should?
Never induce vomit especially to an unconscious
person
If vomit occurs, bring vomitus to CDC
84. Smallpox is a droplet type with S&S of fever, back
pain, vomiting, malaise, headache & papules that
turn into?
85. Smallpox is a droplet type with S&S of fever, back
pain, vomiting, malaise, headache & papules that
turn into?
Pustular vessicles in the face & extremities
106. Unconscious pregnant needing defibrilation should
have the paddles placed 1-rib higher than the usual
because?
Heart is displaced during pregnancy
107. This is used to convert ventricular fibrilation into a
perfusing rhythm?
108. This is used to convert ventricular fibrilation into a
perfusing rhythm?
Automated External Defibrillator
111. A surgeon is responsible for getting consent & a
nurse can be a witness provided the pt. understood
the procedures explained by the doctor. What is
the next step?
112. A surgeon is responsible for getting consent & a
nurse can be a witness provided the pt. understood
the procedures explained by the doctor. What is
the next step?
Document the witnessing of consent signing
139. Conceptualized the behavioral system model. Each
person is composed of 7 subsystem (ingestive,
eliminative, affiliative, aggressive, dependence,
achievement and sexual).
140. Conceptualized the behavioral system model. Each
person is composed of 7 subsystem (ingestive,
eliminative, affiliative, aggressive, dependence,
achievement and sexual).
Dorothy Johnson
151. Health as expanding consciousness. Humans are
unitary beings in whom disease is a manifestation
of the pattern of health.
152. Health as expanding consciousness. Humans are
unitary beings in whom disease is a manifestation
of the pattern of health.
Margaret Newman
153. Health care system model. Nursing is concerned
with all the variables affecting an individual's
response to stress, which are interpersonal,
intrapersonal, and extrapersonal in nature.
154. Health care system model. Nursing is concerned
with all the variables affecting an individual's
response to stress, which are interpersonal,
intrapersonal, and extrapersonal in nature.
Betty Neuman
160. Humanistic nursing practice theory. Nursing is an
existential experience.
Josephine Paterson & Loreta Zderad
161. Identified 14 basic needs. Nurse functions to assist
client in performing activities contributing to
health, recovery, or peaceful death.
162. Identified 14 basic needs. Nurse functions to assist
client in performing activities contributing to
health, recovery, or peaceful death.
Virginia Henderson
163. Identified 21 nursing problems. Defined nursing as
service to individuals and families, therefore,
society.
164. Identified 21 nursing problems. Defined nursing as
service to individuals and families, therefore,
society.
Faye Abdellah
165. Interpersonal model. Nursing is an interpersonal
process of the therapeutic interactions between
sick and nurse.
166. Interpersonal model. Nursing is an interpersonal
process of the therapeutic interactions between
sick and nurse.
Hildegard Peplau
175. Presented grand theory of nursing. All persons are
caring and nursing is a response to unique social
call.
176. Presented grand theory of nursing. All persons are
caring and nursing is a response to unique social
call.
Anne Boykin & Savina Schoenhofer
177. Psychosexual theory (oral, anal, phallic, latent,
genital stage). Psychoanalytical theory (Libido is
the psychic reservoir of psychic energy, id, ego, &
superego).
178. Psychosexual theory (oral, anal, phallic, latent,
genital stage). Psychoanalytical theory (Libido is
the psychic reservoir of psychic energy, id, ego, &
superego).
Sigmund Freud
179. Psychosocial development (trust vs. mistrust,
autonomy vs. shame/doubt, initiative vs. guilt,
industry vs. inferiority, identity vs. role confusion,
intimacy vs. isolation, generativity vs. stagnation,
integrity vs. despair).
180. Psychosocial development (trust vs. mistrust,
autonomy vs. shame/doubt, initiative vs. guilt,
industry vs. inferiority, identity vs. role confusion,
intimacy vs. isolation, generativity vs. stagnation,
integrity vs. despair).
184. The science of unitary human beings. Human
beings are more than and different from the sum of
their parts.
185. The science of unitary human beings. Human
beings are more than and different from the sum of
their parts.
Martha Rogers
186. Theory based on bodily characteristics
(endomorphic, mesomorphic, ectomorphic).
187. Theory based on bodily characteristics
(endomorphic, mesomorphic, ectomorphic).
William Sheldon
188. Transcultural nursing. Nursing is a humanistic and
scientific mode of helping a client through specific
cultural caring process.
189. Transcultural nursing. Nursing is a humanistic and
scientific mode of helping a client through specific
cultural caring process.
Madeleine Leininger
349. What is the purpose of IV fluid therapy?
Maintenance, to replace or correct deficits, to
restore ongoing loss, for meds, nutrition,
phlebotomy, transfusions or blood product therapy.
357. What can expand the intravascular compartment?
Hypertonic fluids.
358. What is the problem with using hypertonic fluids?
359. What is the problem with using hypertonic fluids?
If done too fast will draw too much fluid into the
intravascular, dehydrating intracellular, especially
the brain?
360. What is a S/sx of fluids administered too fast?
361. What is a S/sx of fluids administered too fast?
decreased LOC / Confusion.
362. What happens if you expand the intra Cellular
compartment too fast?
363. What happens if you expand the intra Cellular
compartment too fast?
Deplete the intravascular, decreasing BP and
causing edema.
364. What are the two basic types of parenteral fluids?
365. What are the two basic types of parenteral fluids?
Crystalloid and Colloid
403. What is dangerous about hypertonic dextrose
saline solutions?
they can move fluids very quickly.
404. What is a hypertonic dextrose saline fluid solution
used for?
405. What is a hypertonic dextrose saline fluid solution
used for?
TPN and PPN. Nutrition.
406. What type IV line do you use with Hypertonic
dextrose saline?
407. What type IV line do you use with Hypertonic
dextrose saline?
10% solutions can go peripheral but all others 20%
and above must use a central line?
408. Why must most hypertonic dextrose saline
solutions be used with a central line?
409. Why must most hypertonic dextrose saline
solutions be used with a central line?
Because the fluids are very irritating to veins.
410. How do you infuse hypertonic dextrose saline
solutions?
411. How do you infuse hypertonic dextrose saline
solutions?
You must use an infusion pump.
433. How do you know TPN is working?
By weighing daily.
434. What is the consideration with IVs and glucose?
435. What is the consideration with IVs and glucose?
Must use the appropriate IV access for
concentration of glucose, must use pump, don't
play catch up, taper TPN, accu-checks, used
micron filters
514. Sitting quietly (or walking with PT) and waiting
attentively until client is able to put thoughts and
fments or questions that (a) encourage the client to
verbalize, (b) choose a topic of conversation, and
feelings into words
515. Sitting quietly (or walking with PT) and waiting
attentively until client is able to put thoughts and
fments or questions that (a) encourage the client to
verbalize, (b) choose a topic of conversation, and
feelings into words
518. Providing general leads
Using statements or questions that (a) encourage
the client to verbalize, (b) choose a topic of
conversation, and facilitate continued
verbalization.
519. "Perhaps you would like to talk about..." ; "would
it help to discuss your feelings?"; "and then...."; "I
know what you are saying"
520. "Perhaps you would like to talk about..." ; "would
it help to discuss your feelings?"; "and then...."; "I
know what you are saying"
Providing General leads (example)
522. Using specific and tentative
making statements that are specific rather than
general, tentative rather than absolute
523. "You scratched my arm" instead of "you are
clumsy as an ox" OR "you seem concerned about
mary" rather than "you don't care about mary"
524. "You scratched my arm" instead of "you are
clumsy as an ox" OR "you seem concerned about
mary" rather than "you don't care about mary"
Specific & Tentative (examples)
526. Open-ended question
ASKING BROAD QUESTIONS that lead or
invite the client to explore, elaborate, clarify,
define, and describe thoughts or feelings. Client's
answers are longer than 1 or 2 words
527. "I'd like to hear more about that"; "What brought
you to the hospital today?"; "you said you were
frightened yesterday, how are you feeling today?"
528. "I'd like to hear more about that"; "What brought
you to the hospital today?"; "you said you were
frightened yesterday, how are you feeling today?"
Open-ended question (example)
535. Client: "I couldn't manage to eat any dinner last
night- not even dessert" Nursing- "you couldn't
manage to eat any dinner last night- not even
dessert?"
536. Client: "I couldn't manage to eat any dinner last
night- not even dessert" Nursing- "you couldn't
manage to eat any dinner last night- not even
dessert?"
Restating (example)
542. Seeking clarification
Making the clients overall meaning of the msg
understandable. It is used when paraphrasing is
difficult or when communication is rambling or
garbled. To clarify, the RN may restate the msg or
547. Perception Checking/ Consensual Validation
A method similar to clarifying that verifies the
meaning of specific words rather than the overall
message
548. C: "it just won't stop" N: "I'm not sure what you
mean - it won't stop" OR C: "my husband never
gives me presents" N: "He never gives you gifts
for your birthday or christmas?"
549. C: "it just won't stop" N: "I'm not sure what you
mean - it won't stop" OR C: "my husband never
gives me presents" N: "He never gives you gifts
for your birthday or christmas?"
552. Offering Self
Suggesting ones' presence, interest, or wish to
understand the client without making any depands
or attaching conditions that the client must comply
with to receive nurse's attention
553. "I'll stay with you till your daughter arrives"; "we
can sit here quietly for awhile, we don't need to
talk unless you would like to"
554. "I'll stay with you till your daughter arrives"; "we
can sit here quietly for awhile, we don't need to
talk unless you would like to"
Offering Self (example)
556. Giving Information
Providing, in simple and direct manner, specific
factual information the client may or may not
request. When information is not known, the nurse
states this and indicates how the nurse will obtain
558. "Your surgery is scheduled for 11am tomorrow"; I
don't know the answer to that, but I'll find out from
the unit manager, when she comes in"
559. "Your surgery is scheduled for 11am tomorrow"; I
don't know the answer to that, but I'll find out from
the unit manager, when she comes in"
Giving information (example)
565. Clarifying time or sequence
Helping the client clarify and event, situation, or
happening in relationship to time
566. C: "I puked this morning" N: "before or after
breakfast?"
567. C: "I puked this morning" N: "before or after
breakfast?"
Clarifying time or sequence(example)
568. It is a style or process of persuading a group of
people, usually his followers to attain a desired
objective.
569. It is a style or process of persuading a group of
people, usually his followers to attain a desired
objective.
Leadership
570. A leader that is chosen by the administration or a
group which are given the official capacity to act.
571. A leader that is chosen by the administration or a
group which are given the official capacity to act.
Formal / appointed / elected / designated
572. A leader that does not have official appointments
or designations but is usually chosen by the group
itself.
573. A leader that does not have official appointments
or designations but is usually chosen by the group
itself.
Informal
574. It states that leaders are born and not developed
because some people are born with characteristics
to be great.
575. It states that leaders are born and not developed
because some people are born with characteristics
to be great.
Great Man Theory
576. A person can be an effective leader if he has all the
intellectual, emotional, physical and other personal
traits of an effective leader.
577. A person can be an effective leader if he has all the
intellectual, emotional, physical and other personal
traits of an effective leader.
Trait Theory
578. He is a leader who makes other people feel better
in his/her presence which is an inspirational
quality that the leader possessed.
579. He is a leader who makes other people feel better
in his/her presence which is an inspirational
quality that the leader possessed.
Charismatic Theory
580. It states that there is no personality, traits to be a
good leader, but rather leadership is the
relationship that exists among people in a social
situation.
581. It states that there is no personality, traits to be a
good leader, but rather leadership is the
relationship that exists among people in a social
situation.
Situational Theory
582. A leader that can immediately resolve a sudden
crisis, emergency or critical situation.
583. A leader that can immediately resolve a sudden
crisis, emergency or critical situation.
Contingency Theory
584. A leader that knows how to determine the maturity
of his followers.
585. A leader that knows how to determine the maturity
of his followers.
Life-Cycle Theory
587. A leader who uses a support system method.
Path Goal Theory
588. A style where the leader makes all the decisions
and disallows his members to influence him.
Followers dislike this leader and leader has little
trust to his members. His aim is to develop Self.
Uses trial & error and a critic.
589. A style where the leader makes all the decisions
and disallows his members to influence him.
Followers dislike this leader and leader has little
trust to his members. His aim is to develop Self.
Uses trial & error and a critic.
591. A leadership style where it is loose and permissive.
His approach is "Do your own thing". His
reference is "You" and has the desire to develop
only "Friendship".
592. A leadership style where it is loose and permissive.
His approach is "Do your own thing". His
reference is "You" and has the desire to develop
only "Friendship".
Laissez-Faire
593. A leader whose authority is from the group. Gives
importance to participation, involvement and
development of the group. He is a helper and uses
"We" as his reference of leadership.
594. A leader whose authority is from the group. Gives
importance to participation, involvement and
development of the group. He is a helper and uses
"We" as his reference of leadership.
Democratic
595. A leadership style that uses repetition and tries to
develop the system as his objective. His reference
is "they" and acts as a ruler and a regulator type of
leader.
596. A leadership style that uses repetition and tries to
develop the system as his objective. His reference
is "they" and acts as a ruler and a regulator type of
leader.
Bureaucratic
597. A power whereby the leader has the official
capacity to exercise rights and demand obligations
from subordinates.
598. A power whereby the leader has the official
capacity to exercise rights and demand obligations
from subordinates.
Legitimate Powers
658. Teaching focused on Autonomy Self direction
Critical thinking
Young adult (18-25yrs)
659. Teaching focused on Competency based learner
(can make decision personally & socially)
660. Teaching focused on Competency based learner
(can make decision personally & socially)
Young Adult (18-25yrs)
661. Teaching focused on Physical changes Alternative
lifestyle Sense of well developed (questions
achievements & contributions to family & society,
confident)
662. Teaching focused on Physical changes Alternative
lifestyle Sense of well developed (questions
achievements & contributions to family & society,
confident)
Middle Adult (25-45yrs)
663. Teaching focused on Cognitive & physical
changes No formal learning (decreased S.T.M.,
risk taking, easily fatigue)
664. Teaching focused on Cognitive & physical
changes No formal learning (decreased S.T.M.,
risk taking, easily fatigue)
Older Adult (45-death)
677. PRE-OPERATIVE CARE, a nurse can be a
witness in consent signing & document the same
only if the client understood surgeon's explanations
and the client?
701. PRE-OPERATIVE CARE (checklist), ensure that
informed consent forms were signed for the
operative procedure and for what other reasons?
702. PRE-OPERATIVE CARE (checklist), ensure that
informed consent forms were signed for the
operative procedure and for what other reasons?
Blood transfusions, disposal of a limb, or for
surgical sterilization procedures.
703. PRE-OPERATIVE CARE (checklist), ensure that
history, P.E., consultation requests, prescribed
laboratory results, EKG, chest radiography are
documented & recorded plus?
704. PRE-OPERATIVE CARE (checklist), ensure that
history, P.E., consultation requests, prescribed
laboratory results, EKG, chest radiography are
documented & recorded plus?
Blood type, screened & cross matching is
706. PRE-OPERATIVE CARE (checklist), after
removing everything unnecessary, documented it,
kept or given to family members, the nurse must
document the?
707. PRE-OPERATIVE CARE (checklist), after
removing everything unnecessary, documented it,
kept or given to family members, the nurse must
document the?
Last time client ate or drank, voided before
712. PRE-OPERATIVE CARE (medications), after
administering medications, next to the client, place
what?
Call bell, instruct client not to get out of bed and
call for assistance if needed
713. PRE-OPERATIVE CARE (inside O.R.), after
verifying identification bracelet & verbal response,
the nurse will review chart and then confirm what?
714. PRE-OPERATIVE CARE (inside O.R.), after
verifying identification bracelet & verbal response,
the nurse will review chart and then confirm what?
Operative procedure & site
715. PRE-OPERATIVE CARE (inside O.R.), the
clients chart will be reviewed for completeness and
taking a note about what?
716. PRE-OPERATIVE CARE (inside O.R.), the
clients chart will be reviewed for completeness and
taking a note about what?
Allergic reactions information
719. POST-OPERATIVE CARE (immediate), monitor
airway patency & adequate ventilation because
prolonged mechanical ventilation during
anesthesia may affect what?
720. POST-OPERATIVE CARE (immediate), monitor
airway patency & adequate ventilation because
prolonged mechanical ventilation during
anesthesia may affect what?
Postoperative Lung function, extubated patients
725. POST-OPERATIVE CARE (immediate),
encourage Deep Breathing & Coughing exercises,
monitor pulse oximetry, O2 administration and
then observer for?
Chest movements for symmetry and use of
732. POST-OPERATIVE CARE (immediate), a breath
sound of crackles or ronchi may indicate?
Pulmonary Edema, monitor signs of Atelectasis or
Pulmonary embolism
733. POST-OPERATIVE CARE (immediate), check
capillary refill, assess the skin, peripheral pulses &
edema and monitor for bleeding. A bounding pulse
may indicate what?
734. POST-OPERATIVE CARE (immediate), check
capillary refill, assess the skin, peripheral pulses &
edema and monitor for bleeding. A bounding pulse
may indicate what?
Hypertension, Fluid overload, or excitement.
736. POST-OPERATIVE CARE (immediate), unless
contraindicated, client is placed on Fowler's
position after surgery to increase?
Size of the thorax for lung expansion
742. POST-OPERATIVE CARE (immediate), assess
L.O.C., wake client periodically until awaken and
if awaken?
Orient client to the environment in a soft tone
746. POST-OPERATIVE CARE (immediate), an
exposed skin, cool OR, or maybe from anesthesia
may result to?
Hypothermia, keep blanket on & continue O2 if
shivering
749. POST-OPERATIVE CARE (immediate), record
I&O, monitor for Fluid & Electrolyte imbalance,
N&V, NGT patency, abdominal distention and the
return of what?
750. POST-OPERATIVE CARE (immediate), record
I&O, monitor for Fluid & Electrolyte imbalance,
N&V, NGT patency, abdominal distention and the
return of what?
Bowel sounds
752. POST-OPERATIVE CARE (immediate), how
many hours is it that the client is expected to void
urine after the surgery?
6-8 hours, note color, quantity & quality
753. POST-OPERATIVE CARE (immediate), assess
for pain, PRE-OP & POST-OP medz, then inquire
about the type & location of pain by asking the
client to?
754. POST-OPERATIVE CARE (immediate), assess
for pain, PRE-OP & POST-OP medz, then inquire
about the type & location of pain by asking the
client to?
Rate the pain from 1-10, note facial expression,
760. POST-OPERATIVE CARE (intermediate),
monitor airway patency, encourage Deep
Breathing & Coughing exercises, monitor
circulatory status encourage the use of what?
761. POST-OPERATIVE CARE (intermediate),
monitor airway patency, encourage Deep
Breathing & Coughing exercises, monitor
circulatory status encourage the use of what?
Antiembolism stockings if not C/I
762. POST-OPERATIVE CARE (intermediate), assess
for mobility on all extremities & encourage early
ambulation by first sitting on the edge of the bed
with feet supported. But if client is unable to
move, what do you do next?
763. POST-OPERATIVE CARE (intermediate), assess
for mobility on all extremities & encourage early
ambulation by first sitting on the edge of the bed
with feet supported. But if client is unable to
move, what do you do next?
767. POST-OPERATIVE CARE (intermediate),
monitor I&O, N&V and if vomiting, have a
suctioning equipment available and ready to use.
NPO status is observed until?
768. POST-OPERATIVE CARE (intermediate),
monitor I&O, N&V and if vomiting, have a
suctioning equipment available and ready to use.
NPO status is observed until?
Gag reflex & peristalsis returns
770. POST-OPERATIVE CARE (intermediate), when
oral fluids are permitted, start with?
Ice chips & water, then advance to Clear Liquids
up to Regular Diet as prescribed
775. POST-OPERATIVE CARE (intermediate), if with
Foley Catheter, client is expected to void within 6-
8 hours. Ensure that the amount is at least?
776. POST-OPERATIVE CARE (intermediate), if with
Foley Catheter, client is expected to void within 6-
8 hours. Ensure that the amount is at least?
200mL
780. POST-OPERATIVE CARE (extended), on this
stage, you monitor for signs of infection such as?
Redness, swelling, & tenderness at the surgical
site, fever & leukocytes
781. POST-OPERATIVE CARE (extended), the client
is advised to do R.O.M. exercises every 2 hours
and encourage ambulation to promote?
782. POST-OPERATIVE CARE (extended), the client
is advised to do R.O.M. exercises every 2 hours
and encourage ambulation to promote?
Peristalsis & passage of flatus
783. POST-OPERATIVE CARE (extended), the client
is encouraged to perform A.D.L. & eat foods that
will promote wound healing. What are the foods?
784. POST-OPERATIVE CARE (extended), the client
is encouraged to perform A.D.L. & eat foods that
will promote wound healing. What are the foods?
Protein & Vitamin C
785. Inflammation of the alveoli caused by an
infectious process that may develop as a result of
infection, aspiration or immobility?
786. Inflammation of the alveoli caused by an
infectious process that may develop as a result of
infection, aspiration or immobility?
Pneumonia, usually around 3-5 days
postoperatively
787. Collapse of the alveoli with retained mucous
secretions and is the most common postoperative
complication?
788. Collapse of the alveoli with retained mucous
secretions and is the most common postoperative
complication?
Atelectasis, usually around 1-2 days
postoperatively
789. POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Assessment / increase risk for
dyspnea/ elevated temperature/ productive cough/
and what more?
790. POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Assessment / increase risk for
dyspnea/ elevated temperature/ productive cough/
and what more?
Increased R.R. & chest pain
791. POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Nsg Inter / assess for lung & breath
sounds/ reposition client every 1-2 hour/ inc O.F.I.
/ early ambulation and what more?
792. POST-OPERATIVE CARE (Pneumonia &
Atelectasis) Nsg Inter. / assess for lung & breath
sounds/ reposition client every 1-2 hour/ inc O.F.I.
/ early ambulation and?
Deep breathing & coughing exercises/ incentive
798. POST-OPERATIVE CARE (Hypoxia) Nursing
Intervention, monitor signs of hypoxia/ eliminate
cause/ monitor lung sounds/ administer oxygen/
D.B. & C. E. and what more?
799. POST-OPERATIVE CARE (Hypoxia) Nursing
Intervention, monitor signs of hypoxia/ eliminate
cause/ monitor lung sounds/ administer oxygen/
D.B. & C. E. and what more?
Monitor pulse oximetry & reposition client
800. It blocks the pulmonary artery and disrupts blood
flow to one or more lobes of the lung?
801. It blocks the pulmonary artery and disrupts blood
flow to one or more lobes of the lung?
Pulmonary Embolism
803. POST-OPERATIVE CARE (Pulmonary
Embolism) Assessment / dyspnea/ cyanosis/
tachycardia and what more else?
Decreased blood pressure & sudden chest or upper
abdominal pain
805. POST-OPERATIVE CARE (Pulmonary
Embolism) Nursing Intervention / what is the first
thing that you should do?
1)Notify the physician 2)Monitor V.S.
3)Administer O2 & medications
806. Loss of large amount of blood externally or
internally in a short time?
