Nursing Process

Notes

Introduction
  • The term Nursing Process was first used/ mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation.
  • Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step process (ADOPIE) Assessment, Diagnosis, Outcome, Identification, Planning, Implementaton and Evaluation.
Definition
  • Is a systematic, organized method of planning, and providing quality and individualized nursing care.
  • It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result.
  • It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.

Nursing Process

  • Goal-oriented – nurse make her objective based on client’s health needs.
  • Remember: Goals and plan of care should be base according to clients problems/needs NOT according to your own problem as the nurse.
  • Organized/Systematic – the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence.
Humanistic care
  • Plan to care is developed and implemented taking into consideration the unique needs of the individual client.
  • plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness)
  • in providing care, it involves respect of human dignity
  • Efficient – plan of case is relevant/ related to the needs of the client thereby promoting client satisfaction and progress.
  • Effective – in planning care, utilized resources wisely (staff, time, money/cost)
Aside from GOSH, other characteristic of Nursing Process:
  • Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status.
  • Involves skill in Decision-making – nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.
  • Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-ordinary situations where decisions must be made using critical thinking.

Nursing Pro

Purpose of Nursing Process:
  1. To identify a client’s health status; his Actual/Present and potential/possible health problems or needs.
  2. To establish a plan of care to meet identified needs.
  3. To provide nursing interventions to meet those needs.
  4. To provide an individualized, holistic, effective and efficient nursing care.
Steps/Phases of the Nursing Process:
  1. Assessment
  2. Diagnosis
  3. Outcome Identification
  4. Planning
  5. Implementation
  6. Evaluation

 

 

 


Reference: NCM (Mrs. Cubon, RN, MAN)

Exam

Welcome to your NCLEX-RN Practice Exam for Nursing Process! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 25 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

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1. Nurse Williams is diligently monitoring a client's wound that seems to be deteriorating despite the current treatment plan. Concerned with the client's wellbeing and knowing the importance of following the proper channels, Nurse Williams first thinks about an essential step to address the situation. What is the nurse's first consideration?

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2. The registered nurse (RN) has been assigned her patients for the day-shift. After completing initial rounds and assessing the patients, for which patient would the RN need to create a care plan first?

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3. While creating a nursing care plan for a patient with a fractured right tibia, the nurse incorporates independent nursing interventions in the care plan, such as:

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4. Upon identifying a nursing diagnosis of acute pain, the nurse establishes the following suitable patient-focused goal:

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5. The nurse is examining the critical paths for patients in the nursing unit. When conducting a variance analysis, which of the following situations would necessitate further action and investigation?

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6. Appropriately developed, patient-focused objectives ought to:

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7. The individual who first coined the term "NURSING PROCESS" and introduced its three steps - Observation, Ministration, and Validation - is:

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8. When reaching out to a nursing consultant regarding a challenging patient-centered issue, the primary nurse ensures to communicate the following:

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9. When composing an expected outcome statement in quantifiable terms, a nurse might write something like:

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10. The nursing care plan serves as:

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11. Upon evaluating the patient, the nurse identifies the following diagnoses. Arrange them in order of priority, with the most critical (categorized as high) appearing first.

  1. Constipation
  2. Expected grieving
  3. Inadequate airway clearance
  4. Insufficient tissue perfusion

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12. In the process of setting achievable goals, what should a nurse consider?

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13. Collaborative interventions necessitate the involvement of:

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14. In the planning phase of nursing actions, the following occurs:

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15. The process of prioritizing assists nurses in anticipating and organizing nursing interventions for patients with multiple issues or alterations. These priorities are determined based on the patient's:

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16. The primary nurse has sought advice from a clinical nurse specialist (CNS) regarding a complex nursing issue. The primary nurse is responsible for:

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17. In order to effectively implement an intervention, a nurse needs proficiency in three domains, such as:

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18. In the planning phase of the nursing process, which activities are involved?

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19. A patient-centered goal represents a precise and quantifiable behavior or response that demonstrates a patient's:

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20. Upon evaluating a patient's condition and determining suitable nursing diagnoses, a nurse should:

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21. While formulating goals, outcomes, and interventions, the nurse must:

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22. Which of the following nursing interventions are appropriately written?

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23. To actively engage in goal setting, patients should:

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24. The statements provided in a nursing care plan for a patient following a mastectomy – "Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile" – serve as examples of:

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25. The statement given in the nursing care plan for an immunosuppressed patient – "The client will remain free from infection throughout hospitalization" – exemplifies a: