Pnr 104 Exam #2

Steps of the nursing process in order {Ans: Assessment, nursing dx, planning, implementation, and evaluation}rhonchi {Ans: low pitched rattling sounds caused by secretions in the air passages}Assessment and nursing DX {Ans: RN's are responsible for this part of the nursing process}1 pt {Ans: 500 ml}focus charting {Ans: similar to POMR but it substitutes focus for the problem. 3 parts to this form of documentation are D - data A- action R- response (DAR) Advantage is that it keeps all relevant data to a problem in one place.}Documentation of the plan {Ans: Should be constructed right after the admission database is collected. Must be readily available to each nurse who is assigned to the patient. (Reviewed & updated once every 24 hrs.)}