Nursing Process I - Final Exam

• Benner's stages of nursing proficiency

  1. Novice2. Advanced Beginner3. Competent

  4. Proficient

  5. Expert
• Primary Roles and Functions of the Nurse

  • care provider
  • educator
  • advocate
  • leader
  • change agent
  • manager
  • researcher
  • collaborator
  • delegator
• Benner's stages of nursing proficiency

  1. Novice2. Advanced Beginner3. Competent4. Proficient5. Expert
• autonomy


  Making independent decisions within the scope of practice and are responsible for the results and consequences of those decisions.
• altruism


  unselfish concern for the welfare of others. Motivation for public service over personal gain
• The nurse is delegating frequent blood pressure (BP) measurements for a patient admitted with a gunshot wound to a licensed practical nurse (LPN). When delegating, the nurse understands which fact?


  He/she retains ultimate responsibility for patient care and supervision is needed.
• The nurse manager is interviewing graduate nurses to fill existing staffing vacancies. When hiring graduate nurses, the nurse manager realizes that they will probably not be considered "competent" until they complete which task?

  They have worked 2 to 3 years.
• A group of nursing students are discussing the impact of non-nursing theories in clinical practice. The students would be correct if they chose which theory to prioritize patient care?


  Maslow's Hierarchy of Needs
• what is an example of autonomy in nursing?


  Nurses assess a patient's vitals upon admittance as part of the patient's care plan, but occasions may arise when nurses become concerned about a patient's status. An example of clinical autonomy is when a nurse acts on this concern and assesses the patient's vital signs and symptoms without being called to do so
• The nurse is caring for a patient admitted for the removal of an infected appendix. Which actions by the nurse would indicate an understanding of the National Patient Safety Goals

  • Places an identification band on the right arm
  • Marks the surgical site with a black-felt pen
  • Checks medications three times before administration
  • Washes hands between patients and/or when soiled
• A newly licensed registered nurse is curious about the scope of care that he or she has in caring for patient's undergoing conscious sedation. Which would be the best source of information for this nurse?


  ANA Standards of Professional Performance
• ANA standards for professional performance


  two parts standards of practice: six responsibilities for nursing process -- assessment, diagnosis, outcome identification, planning, implementation, evaluation. standards of professional performance: ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, quality of practice.
• Standards for documentation


  • Health care organization's policies and procedures
  • The Joint Commission's (TJC) standards and elements of performance
  • Principles
  • Centers for Medicare and Medicaid Services
  • American Nurses Association
  • Diagnostic-related groups (DRGs)
• Reimbursement requires accurate documentation
• Electronic health records


  • Electronic medical record (EMR)
  • Electronic health record (EHR)
  • Computerized provider order entry
  • Written medical records
• Guidelines for Quality Documentation


  • Factual
  • Accurate
  • Complete
  • Current
  • Organized
• Critical aspects of documentation


  • Standardized nursing terminologies
  • Do-Not-Use abbreviations
  • Documentation formats
  • Narrative charting
  • Formatted charting
  • PIE notes
  • APIE notes
  • SOAP notes
  • DAR notes
  • Charting by Exception (CBE)
• Narrative


  Story-like format
• SOAP


  Subjective, Objective, Assessment, Plan
• PIE


  Problem, Intervention, Evaluation
• Focus charting - DAR


  Data, Action, Response
• CBE


  Charting by Exception
• Other Common Record-Keeping Forms


  • Admission Nursing History Form
  • Flow Sheet/Graphic Record
  • Discharge Summary Form
• Handoff


  Passing patient-specific information from one caregiver to another
• Handoff Reports


  • SBAR
  • ISBAR
  • EHR integration
  • Intra-hospital transport
• Handoff Reports


  • May be oral, written, or recorded
  • Promotes continuity of care
  • Provides opportunity for collaborative problem solving
• You must safeguard any information that is printed from the record or extracted for report purposes
• De-identify all patient data
• Nurses are legally and ethically obligated to keep all patient information confidential
• Nurses are responsible for protecting records from all unauthorized readers
• HIPAA requires that disclosure or requests regarding health information be limited to the minimum necessary
• Incident report


  • Generated when unusual and unexpected event involving a patient, visitor, or staff member occurs
  • Purpose: To document the details of the incident immediately to ensure accuracy
  • It is not part of the medical record and the fact that an incident report was completed is not recorded in the patient's medical record
• Data collection


  • Patient information used for patient care
  • Point of care technology
  • Reduces the potential for errors
  • Supports improved assessment
  • Improves data communication
• Technology in the information age


  • Bedside computers
  • Workstations on wheels
  • Smartphones
  • Tablets
  • Telehealth/telemedicine
  • Telehealth nursing
• Benefits of Informatics


  • Patient safety
  • Diagnostic test results are available sooner
  • Bar-code medication administration (BCMA) system reduces errors
  • Decision support systems (DSSs) and computerized provider order entry (CPOE) improve care
  • Research access
  • Computerization and storage of health care data
  • Data management programs
• Key areas of ethical conflict


  • Creation and retention of documentation
  • Ownership of software
  • Ownership and integrity of data
  • Preservation of privacy and confidentiality
  • Prevention of computer fraud and misuse
• Guidelines that help avoid social media problems


  • No transmission of any patient's image
  • No posting of any patient information including names
  • No disparaging comments about any patients or staff
  • No contact with patients outside of the work setting
• If you did not write it down, you did not do it
• If you did not do it, you were negligent
• Safety for every patient encounter


  1. Hand Hygiene

  2. Introduce Yourself

  3. 2 Patient Identifiers

  4. Explain Procedure

  5. Provide Privacy