Fundamentals of Nursing and the Nursing Process
This domain tests whether you can think in the ADPIE cycle - Assessment, Diagnosis, Planning, Implementation, Evaluation - and justify every action with a documented, patient-specific reason. Mongolian ward questions rarely ask for definitions alone; they give a scenario and ask what you do first, what you record, and how you know it worked.
Core rules
- Assess before acting, and reassess after anything that changes physiology: oxygen, analgesia, fluids, blood products.
- A nursing diagnosis describes a human response (ineffective airway clearance, acute pain), never a medical disease. Medical diagnoses do not belong in the nursing plan.
- Goals must be measurable and time-bound: 'Patient reports pain 3/10 or less within 60 minutes of analgesia', not 'patient comfortable'.
- Adult norms to know cold: temperature 36.5-37.5 C, pulse 60-100, respirations 12-20, SpO2 94% or above, hypertension from 140/90.
- Hand hygiene is the single most effective infection-prevention act; the WHO five moments apply at every contact.
- Document objectively, in real time, and never pre-chart an intervention.
Worked example
Day 2 after abdominal surgery: T 38.9 C, HR 108, RR 24, wound red, warm and draining pus. Reasoning: this data cluster is an actual problem, so the diagnosis is infection related to the surgical incision, not 'risk for infection'. Goal: temperature below 37.5 C within 24 hours. Implementation: culture the drainage before the next antibiotic dose, give the prescribed antibiotic on time, give the antipyretic, encourage fluids if not contraindicated, reassess vitals in one hour. Evaluation is written against the goal, not as 'patient stable'.
Traps
Mixing nursing and medical diagnoses; charting before doing; treating a 'risk for' problem as if it were actual; skipping reassessment after oxygen or analgesia; writing an evaluation that contains no data.