Fundamentals of Nursing
Nurse practice act – Answer defines legal scope of practice, excludes untrained or unlicensed people
from practicing, establishes education and licensing criteria, creates a state board of nursing, makes and
enforces rules and regulations
percussion tones – Answer flat-soft muscle
dull-medium-liver(solid organs
resonance-loud-lung (air)
Hyperresonance-very loud-emphysema (more air pockets)
tympany-loud-gastric (air bubble)
physical assessment – Answer collect objective data about the patient, explain the exam to the pt and
perform in warm, quiet, private environment
preparing for the physical exam – Answer consider the needs of the patient, explain the process, ask pt
to change into a gown and empty bladder, answer questions directly and honestly, gather necessary
supplies, provide privacy, and a warm quiet room with adequate lighting
preventing illness – Answer reduce the risk of illness by avoiding or achieving early detection of illness or
to maintain function within the constraints of an illness. Teach by example, educational programs,
community programs, literature, and health assessments
professional nursing organizations – Answer to be considered a profession a professional organization
needs to be in place to set standards for practice and education. This sets education minimums, and
Nursing assessment – Answer looking for patient's response to health problems. Response to
medications ordered for HTN, Is BP at a normal reading, Information relayed to physician if patient is not
responding to tx
nursing diagnosis – Answer actual and potential health problems that nursing intervention can prevent
or resolve. the goal of the nursing diagnosis is to focus on the patient's responses to health problems
(NANDA)
, nursing process – Answer assess, nursing diagnosis, identify expected outcomes, implement care,
evaluate results
objective data – Answer observable and measurable data that can be seen heard or felt by someone
other than the pt. vital signs- a number or a lab
opthalmoscope – Answer instrument used to visual eyes
orthopnea – Answer breathe easier in an upright position
otoscope – Answer instrument used to visual ears
palpation – Answer touching-assess temp with back of hand, turgor-pinch fold of skin, moisture, texture,
shape-masses/lumps
percussion – Answer striking one object against another to produce sound to determine location, shape,
size, and density of tissue
promoting health – Answer promoting good physical, mental and emotional health by identifying,
analyzing, and maximizing the patient's strengths as components of preventing illness, restoring health
and facilitating coping with disability or death
purpose of documentation – Answer if it isn't recorded, it didn't happen, to identify actual and potential
health problems, plan appropriate care, evaluate the pt's responses to tx,
restoring health – Answer performing assessments that detect an illness refering questions and findings
to other healthcare providers, providing direct care, collaborating, planning, teaching and carrying out
rehabilitation for illnesses, working in rehab programs
RN – Answer AS or BSN degree, completes all nursing skills, specialized training, BSN level looking into
evidence-based practice, papers focused on research