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FPCC EXAM1, 2 AND 3 ||- 2025 /ACTUAL EXAM WITH
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Nursing process - answer - a systematic problem-solvingprocess that guides all nursing actions Assessment - answer- the systematic gathering of information related to the physiological, psychiological, sociocultural, devlopmental, and spiritual status of anindividual, group, or community. What is the purpose of an assessment? - answer - obtaindata to allow you to help the patient Where do we get Primary sources from? - answer- Subjective and Objective Where do we get secondary sources from? - answer- Family/friends, health record, healthcare team Subjective Data (Client States) Objective Data (Nurse observes) - answer-" My throathurts when i swallow" Parenteral - answer - any route other than through thealimentary canal (passage from mouth to anus) IV therapy - answer- the administration of fluids, electrolytes,
medications, or nutrients by the venousroute What type of technique is used every time you start (initiate) or work with (maintain) an IV site or infusion?
- answer - Parenteral
What happens to the $$ your facility receives if a clientin your care gets a CRBSI (catheter releated bloodstream infection)? - answer- The hospital must pay Lab value for serum osmolality - answer - 275 - 295 Primary source ( Client states or Nurse Observes) Secondarysource (everything else) - answer-" My heartfeels like it's beating fast" "I am feeling short of breath at night"
- EKG: Sinus tachycardia rate of 200 beats/min
- In transfer report, nurse states client is on oxygen atnight for dyspnea Who is responsible for assessment of a client? Nurse LPN AIDE - answer - Nurse What activities can a LPN, and Aide do? Select all
norms (oral temp of 103)
- Changes in usual behaviors in roles or relationships ( Apreviosly successful student begins to skip classes. She
stays up late partying and sleeps most of teh day. Despite a previous close relationship with her parents,she barley talks to them when they contact her.
- Nonproductive or dysfunctional behavior (A man has been abusing alcohol for many years, even though it iscausing many problems with his family and job and hasbegun to damage his liver) Nursing Diagnosis Statement - answer- clinical judgmentabout individual, family, or communiy RESPOSNE to actual and potential health problems or life processes that the nurse is licensed and compotent to treat. Cluster - answer - a group of cues that are related toeach other in some way Inference - answer - is not a fact, are conclusions (judgements, interpretations) that are based on thedata. Fact: Patient is crying. (You obsereve that directly) Inference: Patient is anxious. (You cannot observe anxiety, but you know taht crying and trembling mabesigns of anxiety) Forming a nursing diagnosis statement - answer - inference, etiology, characteristics.. evidence (clinicalmanifestitaions ) How many nursing diagnosis How many risks - answer - (3)(2) Actual Nursing Diagnosis - answer - Problem is present Risk Nursing Diagnosis - answer - Problem might occur Wellness (Health Promotion) Nursing Diagnosis - answer - No problem; client wants to be "more well"
C. Wellness Nursing Diagnosis
D. Medical Diagnosis - answer-B. Risk Nursing Diagnosis
Suppose that Todd tells you that he prays, participates in religious actvities, and trusts in God, but he would liek to feeel eve closer to God. He asks to meet with the minster from his church. You might make diagnosis of Readiness for Enchanched Spiritual Well-Being is what type of diagnosis?
A. Actual Nursing Diagnosis
B. Risk Nursing Diagnosis
C. Wellness Nursing Diagnosis
D. Medical Diagnosis - answer-C. Wellness NursingDiagnosis
Medical diagnosis - answer-describes a disease, illness,or injury Todd (Meet Your Patient) has two medical diagnosis :chronic renal failure and type 2 DM
A. Actual Nursing Diagnosis
B. Risk Nursing Diagnosis
C. Wellness Nursing Diagnosis
D. Medical Diagnosis - answer-D. Medical Diagnosis
Nursing Diagnosis - answer-Identifies client response tohealth problem Collaborative Problems - answer-Working on problemas a team (Nurse, PT, Doctor, NP)
Suppose that on Todd's transfer from the ED (Meet Your Patient), you made the follwoing nurisng diagnosisfor him. Using problem urgency as your criterion, assign each of these diagnosis a low medium, or high priority.
- Risk for Imbalanced Fluid Volume secondaty to renalfailure
- Risk for Falls releated to (r/t) decreased sensation andmobility in legs
- Deficient Knowledge (renal disease process) /t new diagnosis of renal invlovement secondary to type 2 DM
- answer-High, Medium, and LowShort term
goals- Long term goals- - answer-those you expect the patientto achieve within a few hours or days are changes in health status that you wish to achieveover a longer period of time What type of goal is this - describe pain as <3 on a 1 - 10 scale within 30 min after recieving analesic
A. Short
B. Long - answer-A. Short
What type of goal is this- Limits food intake to 1,500calories per day
A. Short
B. Long - answer-A. Short
every 6 hours for 24 hours. " She prepares and administers themedication
A. independent
B. dependent
C. interdependent - answer-B. Dependent
Interdependent - answer-one that is carried out incollaboration with other health team members (physcial therapists, physicians) Nurse C notes that a client newly diagnosed with diabetes has been seen by a dietitian, who taught andpro vided materials about a diabetic diet. The nurse observes the clients's menu chocies. She notes that theclient is eating candy brought by visitors. She explains to the client how concentrated sugar affects his diabetes; she also communicates her assessments and teaching to the dieitian.
A. independent
B. dependent
C. interdependent - answer-C. interdependent
Documentation - answer-the act of recording patientstatus and care Delegation - answer-transfer of responsibility NOTaccountability for outcome Occurrence report - answer-incident report, is a formalrecord of an unusual occurrence or accident.
Standard techniques for documentation
For TO order what must you do
A. clearly identify the patient
B. Record the order in real time
C. Repeat order back
D. Document read back
E. Question if needed
F. Document TO/VO
G. Two nurses f required
F. Order co-signed - answer-all the above What are the steps in a nursing process? - answer-Assess, Diagnose, Plan, Implement, Evaluate Once a nurse accesses a client's condition andidentifies appropriate nursing diagnosis, a A. Plan is developed for nursing care B. Physical assessment begins C. List of priorities is determined D. Review of assessment is conducted with other team members - answer- A. Plan is developed for nursing care Planning is a category of nursing behaviors in which:
A. The nurse determines the health care needed for theclient
B. The Physcian determines the plan of care for theclient
C. Client-centered goals and expected outcomes areestablished
D. The client determines the care needed - answer-C.Client-centered
goals and expected outcomes are established Priorities are establish to help the nurse anticipate andsequence nursing interventions when a client has multiple problesm or alterations. Priorities are determined by the clinet's:
A. Physician
B. Non Emergent, non-life threatening needs
C. Future well-being
D. Urgency of problems - answer-D. Urgency ofproblems
A client centered goal is a specific and measurablebehavior or resposne that reflects a client's:
A. Desire for specifc helath care interventions
B. Highest possible level of wellness and independencein function
C. Physican's goal for the specific client
D. Response when compared to another client with alike problem -
answer-B. Highest possible level of wellness and independence in function Collaborative interventions are therapies that require:
A. Physician and nurse interventions
B. Nurse and client interventions
C. Client and Physician intervention
4. Ask the client if there is anything in particular he or she is anxious
about. - answer-4. Ask the client if thereis anything in particular he or she is anxious about. Which describes the correct way to state a nursingdiagnosis?
1. Medical diagnosis and problem list linked by aconnecting
phrase
2. Medical diagnosis and medical history linked byetiology
3. A problem and an etiology linked by a connectingphrase
4. A problem and a medical diagnosis linked by a connecting
phrase - answer-3. A problem and an etiology linked by a connecting phrase Which are examples of a direct-care nursingintervention? Select all that apply.
1. Giving a medication
2.Notifying the physician of a change in assessment
3. Obtaining vital signs
4. Giving a bedside bath
5. Consulting case management for home oxygen - answer-1, 3,
According to Maslow's Hierarchy of Needs, what is theappropriate order of priority of the client needs?
- Falls prevention 2.Support group
3. Adequate hydration
4. A vase of flowers
5. Medication teaching - answer-3,1,2,5,
When creating a care plan, which describes outcomesthat can be influenced by nursing interventions?
1. Discharge readiness goals
2. Nurse-sensitive outcomes
3. Diagnostic statements
4. Critical pathways - answer-2. Nurse-sensitiveoutcomes
Which nursing interventions are considered direct-careinterventions? Select All That Apply.
1. Physical care
4. Making a referral
5. Managing the environment - answer-1, 2, 3
The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursingplan?
1. Basic three-part statement
2. Two-part NANDA-I label
3. Collaborative problem
4. Complex etiology - answer-1. Basic three-partstatement
During an assessment, the nurse notes that the clienthas an elevated temperature. Which type of data is this?
1. Subjective
2. Objective
3. Secondary
4. Reported - answer-2. Objective
Which describes benefits of the comprehensive writtennursing care plan?
Select all that apply.
1. Provides continuity of care
2. Establishes the discharge diagnosis
3. Ensures that care is complete
4. Meets accreditation requirements
5. Promotes efficient use of nursing efforts - answer-1,3, 4, 5
Why is the diagnosis step critical to the nursingprocess?
1. It connects the assessment with planning,interventions,
and follow-up evaluation.
2. Without a complete nursing diagnosis, insurance willnot compensate
the hospital.
3. It provides the physician with necessary informationto make a medical
diagnosis.
