Module 4P.A.S.S. Program

• How to apply Nursing Process to exam questions

• Assessment: Gathering information– When do you stop?– When do you continue assessing?• Objective or subjective?

– Based on diagnosis, what do you expect?• “Normal” for this patient

You are caring for a 48-year old woman diagnosed with breast cancer. Which of the following would you expect to be a part of her health history?

A. Grandmother died of breast cancerB. Pt does not perform monthly breast self-examsC. Is a nulliparaD. Wears tight, restrictive bras

You are caring for a 48-year old woman diagnosed with breast cancer. Which of the following would you expect to be a part of her health history?

A. Grandmother died of breast cancerB. Pt does not perform monthly breast self-examsC.  Is a nulliparaD. Wears tight, restrictive bras

• Diagnose: Analyze assessment info– Won’t have all the information needed– Draw on your knowledge of “normal”

Your patient has been hospitalized with severe jaundice secondary to cirrhosis of the liver. Which of the following would be an appropriate nursing diagnosis?

A. Ineffective management of therapeutic Regimen r/t alcoholismB. Risk for impaired skin integrity r/t pruritisC. Itching r/t jaundiceD. Imbalanced nutrition: less than body requirements r/t poor dietary habits

Your patient has been hospitalized with severe jaundice secondary to cirrhosis of the liver. Which of the following would be an appropriate nursing diagnosis?

A. Ineffective management of therapeutic Regimen r/t alcoholismB.  Risk for impaired skin integrity r/t      pruritisC. Itching r/t jaundiceD. Imbalanced nutrition: less than body requirements r/t poor dietary habits

• Plan: Goal, Actions, Rationales– Set patient goals– ID desired outcomes (NOC)• Measuring success!

– Prioritizing– Documenting care plan– ID nursing actions

• Nursing Diagnosis in question/answer DOES NOT EQUAL diagnosis-type question

You are caring for a patient that has just been admitted with a new diagnosis of diabetes insipidis. Which of the following would be a priority nursing diagnosis:

A. Deficient Fluid VolumeB. Ineffective Airway ClearanceC. Deficient KnowledgeD. Impaired Urinary Elimination

You are caring for a patient that has just been admitted with a new diagnosis of diabetes insipidis. Which of the following would be a priority nursing diagnosis:

A.  Deficient Fluid VolumeB. Ineffective Airway ClearanceC. Deficient KnowledgeD. Impaired Urinary Elimination

• Implementation: what you DO as the nurse– Teach– Provide hands-on care– Supervise– “How to”

You are supervising a new nurse who has just started working on your floor. She is assigned to a patient that requires the use of a transfer lift, but she states that she has never used one before. What would be the most appropriate action for you to take?

A. Explain in detail how to use it. B. Provide the nurse with the instruction manual for the transfer lift.C. Assign that patient to a more experienced nurse.D. Go with the nurse to assist her in using the transfer lift.

You are supervising a new nurse who has just started working on your floor. She is assigned to a patient that requires the use of a transfer lift, but she states that she has never used one before. What would be the most appropriate action for you to take?

A. Explain in detail how to use it. B. Provide the nurse with the instruction manual for the transfer lift.C. Assign that patient to a more experienced nurse.D.  Go with the nurse to assist her in using the       transfer lift.  

Which of the following, if observed being done by an LPN, would require intervention?

A. Putting on a mask, gown, and gloves before entering the room of a patient on contact precautions.B. Cleaning vaginal meatus with sterile water before inserting Foley catheter.C. Asking the patient to sip some water while inserting a nasogastric tube.D. Hanging a urinary collection bag from the side of a patient bed during transport.

Which of the following, if observed being done by an LPN, would require intervention?

A. Putting on a mask, gown, and gloves before entering the room of a patient on contact precautions.B.  Cleaning vaginal meatus with sterile water       before inserting Foley catheter.C. Asking the patient to sip some water while inserting a nasogastric tube.D. Hanging a urinary collection bag from the side of a patient bed during transport.

• Evaluation: How’s the patient doing?– Compare actual results to desired results• You will need to know desired results

– Best practice in measuring results

The patient is taking morphine for pain related to kidney stones. Which of the following, if observed, would best indicate that the patient's pain is being adequately controlled?

A. Blood pressure is 118/78, and heart rate is 76 beats per minute.B. Patient can demonstrate the use of appropriate relaxation techniques. C. The patient asks the nurse if the morphine can be given at regularly scheduled intervals.D. Patient says his pain is about 2/10.

The patient is taking morphine for pain related to kidney stones. Which of the following, if observed, would best indicate that the patient's pain is being adequately controlled?

A. Blood pressure is 118/78, and heart rate is 76 beats per minute.B. Patient can demonstrate the use of appropriate relaxation techniques. C. The patient asks the nurse if the morphine can be given at regularly scheduled intervals.D.  Patient says his pain is about 2/10.