Clinical Judgement Sherpath Qs

For a patient scheduled for knee surgery, which statement identifies when the planning step of the nursing process begins? - After surgery is complete - When pt is admitted to hospital - Just before discharge from hospital - When the nurse contacts the pt to schedule surgery

*When the nurse contacts the patient to schedule surgery* Care planning begins when the patient and nurse first interact. Preadmission teaching is a significant planning responsibility for the office nurse who contacts the patient prior to surgery. After the surgery is complete Care planning must begin before surgery is complete. When the patient is admitted to the hospital Inpatient care planning begins when the patient and nurse first interact in the hospital. Just before being discharged from the hospital Discharge planning begins upon the patient's admission.

Which information would the nurse include in an evaluation statement?

- Level of goal attainment Evaluation statements include level of goal attainment (goal met, partially met, or unmet). - Revisions needed in the plan of care Evaluation statements include revisions needed in the plan of care. - Factors contributing to goal achievement Evaluation statements include evidence of factors contributing to the goal being met, partially met, or unmet.

According to The Joint Commission requirements, which time frame describes when the nurse would evaluate the plan of care? Daily Every shift Continuously Only if the patient's condition changes

Continuously The Joint Commission requires patient care plans to be evaluated on a continual basis. Making modifications to care plans as a patient's status changes is a necessary component of providing safe patient care.

Which characteristics describe pt goals developed during the fourth step of the CJMM?

Are either short term or long term goals Are supported by nursing interventions (when generating solutions to guide the development of the plan of care, the nurse applies knowledge of treatments and interventions that would most effectively move the pt toward goal achievement.) Describe anticipated changes in a pts condition (A goal is a broad statement describing anticipated changes in a patients condition or behavior that is the focus of nursing care)

When selecting interventions, the nurse considers:

Patient assessment findings and history, including prior responses to illness and life experiences Underlying etiology or related factors and interventions likely to have an impact on these factors Realistic patient outcomes based on current condition and available resources Evidence-based interventions found in scientific literature, policies and procedures, and standards of care Expertise and competency of the members of the health care team involved in the patient's care

Which action comprises the third step of the Clinical Judgment Measurement Model?

Prioritize hypotheses (Prioritizing hypotheses occurs during step three of the Clinical Judgment Measurement Model)

Which intervention category is likely to have the highest priority?

Problem oriented (b/c they deal with existing, and potentially immediate, issues)

Match the source of the nursing actions/interventions with the appropriate description.

Set of 3-5 evidence-based interventions that improve patient outcomes: Care bundles Preestablished set of health care provider prescriptions used to direct patient care: Standing orders Outlines the duties that all nurses should be able to perform competently: Scope of practice Recommendations facilitating the application of current evidence into practice: Clinical practice guidelines

Nursing Interventions

The treatments or actions that nurses implement (during step 5: take action) using clinical judgement and nursing knowledge to improve comfort and overall health of the patient, as well as to enhance patient outcomes

Match the corresponding step of the Clinical Judgment Measurement Model to the question the nurse asks during a patient situation.

What can improve the situation? Generate solutions What matters most? Recognize cues Where should efforts be focused? Prioritize hypotheses What does it mean? Analyze cues

Which rationale explains the importance of outcome identification to the achievement of patient goals?

indicates goal attainment Outcome identification sets specific measures used to evaluate effectiveness of meeting goals, indicating goal attainment.

Direct Care Interventions

Take place through contact w/ pt: reassessment, ADLs, physical care, informal counseling, and pt education

Steps of the CJMM focus on:

What matters most among the collected patient cues (step 1: recognize cues), what the collected pt cues could potentially mean (step 2: analyze cues), and where the nurse should focus efforts (step 3: prioritize hypotheses). The next step focuses on what the nurse can do to improve pts condition (step 4: generate solutions)

Once a patient meets a goal, which action would the nurse take?

Decide whether to continue or discontinue the goal. When a goal is met, the nurse decides whether the goal should be continued or discontinued, based on patient preference and the nurse's clinical judgment.

Which factor can influence the nurse's ability to recognize and categorize patient cues?

Experience with other patients (The nurse's experience with other patients can influence recognition and categorization of cues based on the progression of care for prior patients.)

Evaluation

Fifth and final step of nursing process, it involves use of critical thinking to determine whether a pt's short term or long term goals were met and whether the pt outcomes were achieved

The final component of the planning step is to create a plan of care for the patient. The plan of care summarizes the patient's condition, goals, and planned interventions. All comprehensive plans of care contain:

Key patient assessment data Prioritized nursing diagnoses and patient problems Measurable, patient-centered goals Interventions Evaluation of outcomes

Indirect Care Interventions

Performed on behalf of the pt, but they do not involve direct pt contact: Communication, referrals, research, advocacy, delegation

Nurses should do the following when determining how to take action to address prioritized needs (Potter et al., 2021):

Review all possible nursing interventions for the patient problem. Incorporate professional and organizational standards of clinical practice. Recognize which interventions are needed immediately. Consider all potential consequences associated with each possible nursing action. Determine the probability of potential consequences. Judge the value of the consequences to the individual patient. Collaborate with the interprofessional health care team. Consider which interventions can be delegated and to whom.

Implementation

fourth step of nursing process; occurs after the nurse develops the plan of care and consists of performing patient care interventions and documenting the interventions in the patients medical record (ex. the admin of prescribed meds and repositioning of pts to prevent the development of pressure lesions or injuries)

Interventions may be categorized in a variety of ways:

- By purpose (problem-based or prevention-based interventions) - By the person responsible for initiating and conducting them (independent, dependent, or collaborative interventions) - By whether the intervention involves direct patient contact (contact with the patient) - By whether the intervention involves indirect patient contact (no face-to-face contact with the patient)

Documentation promotes

- Continuity of patient care. - Effective communication among the interprofessional health care team. - A record of services rendered, which may be used by payors/insurance companies, accrediting bodies, and other groups. - An understanding of nursing's contribution to patient care outcomes. - The minimization of legal liabilities created by inadequate documentation. - Data collection for generating evidence through the use of information technology.

The nurse follows these steps to compare outcomes

1. Examine outcome criteria to determine expected outcomes. 2. Review evaluative measures of data collected before the nurse implements interventions. 3. Determine actual outcomes following nursing actions. 4. Compare actual outcomes with expected outcomes. 5. Consider the degree to which outcomes match expected outcomes and goals (met, partially met, unmet). 6. Determine the nurse's next action.

Step 4 of CJMM, generation of solutions includes two key elements:

1. Identification of goals and related outcomes 2. Selection of interventions

The nurse applies two foundational QI concepts during the evaluation step of the nursing process:

- Focus on patients: The nurse considers whether the patient's needs and expectations are met. - Use of data: The nurse uses data to identify how well interventions worked toward achievement of outcomes and to document progress toward goal attainment.

To effectively evaluate outcomes, the nurse must be able to:

Examine the results of care according to collected patient cues. Compare achieved outcomes with goals and expected outcomes. Recognize errors or omissions. Judgment error - treating patients with the same condition in the same way, resulting in potential unmet needs Omission error - realizing planned interventions were not doneIneffective treatment - recognizing the patient is not reacting to an intervention as expected Understand the patient's condition, reflect on the situation, and adjust the plan to correct errors.

With respect to evaluation, these standards define the expectation that nurses will evaluate patient progress toward goal and outcome achievement. The related competencies are:

Holistic, systematic, continual, and criterion-based evaluation Collaboration with the patient and other members of the health care team Utilization of ongoing assessment data to revise the plan of care Documentation of evaluation results

Match the priority concept the nurse uses to evaluate and rank hypotheses with the corresponding hypotheses and supporting data.

Hypertension, supporting data: BP 150/90 - Risk Inactivity, supporting data: fractured left ankle, pain upon movement - Likelihood Acute respiratory distress, supporting data: SaO2 89%, dyspnea - Urgency

Which statement summarizes how the scope of nursing practice influences interventions? It promotes evidence-based practice. It focuses on a specific clinical situation. It describes what actions a nurse can take. It outlines recommended interventions for a patient problem.

It describes what actions a nurse can take. The scope of practice describes the actions a licensed nurse should be qualified and competent to perform.

steps of the CJMM concentrated on the following:

Step 1: Recognizing cues, which meant identifying what was most important among the patient cues collected during the assessment. Step 2: Analyzing cues, which meant considering what those cues could potentially mean by identifying potential or actual patient problems, known as hypotheses. Step 3: Prioritizing hypotheses, which meant determining where the nurse should focus efforts by ranking the hypotheses so the most serious patient needs could be addressed first. Step 4: Generating solutions, which meant considering what the nurse could do by connecting patient needs to a plan of care, determining outcomes and possible interventions. Step 5: Take action, nurse will consider which actions are most appropriate and implement them Step 6: Evaluate outcomes, determine whether actions taken were effective and helped the pt (The nurse is not evaluating whether nursing interventions were completed.)

The nurse will then implement identified interventions in the fifth step of the CJMM:

Take action - must consider which actions to take and how to implement the solutions or interventions based on clinical judgement and nursing knowledge and by targeting the highest priority issues first. * Consider which intervention or combination of interventions is most pertinent for the patient and supports the achievement of established goals and outcomes. * Contemplate the best way to perform the interventions, considering the unique circumstances and conditions of the individual patient's scenario.

According to the American Nurses Association (ANA) scope of nursing practice, which statements describe an intervention the nurse should be qualified and competent to perform?

The facilitation of healing. The ANA scope of practice identifies facilitation of healing as a nursing action. The prevention of illness and injury According to the ANA scope of practice, the prevention of illness and injury determines nursing interventions. The advocacy of patients and families As outlined in the ANA scope of practice, advocacy in the care of individuals, families, groups, communities, and populations guide nursing interventions. The optimization of patient health and abilities According to the ANA scope of practice, nursing interventions enhance the protection, promotion, and optimization of health and abilities.

To effectively recognize patient cues, which concepts would the nurse need to understand?

The first few minutes of the patient encounter are critical. (It is easy to focus on tasks that need to be done when the nurse enters the patient's room. However, if the nurse leaps into task completion without taking time to listen to the patient and observe the patient's environment and nonverbal communication, the nurse can overlook key information and miss patient cues.) A nonjudgmental environment promotes communication. (The nurse needs to ensure a nonjudgmental environment to promote effective communication of subjective patient cues.) The nurse should adapt the physical assessment based on patient age. (Developmental level and age can influence a patient's ability to communicate cues during a patient interview.)

During the first three steps of the Clinical Judgment Measurement Model, the nurse ...

Completes a health history, clusters patient data, and prioritizes hypotheses.

Which questions would the nurse consider when prioritizing hypotheses?

What are the risks for other hypotheses? (Determining risks for rank ordering hypotheses supports the prioritization of hypotheses.) Which hypothesis is most important and should be managed first? (Consideration of which hypothesis is most important and should be managed first allows the nurse to prioritize hypotheses.)

Evaluate Outcomes

5th and final step of CJMM - outcomes are measurable changes the pt must achieve to attain a goal

Which statement describes the plan of care?

The plan of care summarizes the patient's condition, goals, and planned interventions. The nursing plan of care is a document that summarizes the patient's condition, goals, and planned interventions for the patient.

CJMM

1. Recognize cues: Identify what is most important among the patient cues collected during assessment. 2. Analyze cues: Consider what the cues could mean by identifying hypotheses, potential or actual patient problems. 3. Prioritize hypotheses: Determine where the nurse should concentrate efforts by ranking hypotheses by priority. 4. Generate solutions: Consider what the nurse can do by developing a plan of care, including outcomes and potential interventions. 5. Take actions: Decide which actions are the most appropriate to take, and implement them. 6. Evaluate outcomes: Determine whether actions taken were effective and helped the patient.

Which functions would the nurse complete when generating solutions in accordance with the CJMM?

Consider patient care options. To generate appropriate solutions for the individual patient, the nurse considers a variety of patient care options as part of the clinical decision-making process. Correct Connect needs to a course of action. The nurse connects previously identified and prioritized patient needs to potential courses of action (the plan of care) when generating solutions. Correct Identify appropriate nursing interventions. The nurse identifies nursing interventions that are appropriate for the individual patient's unique situation when generating solutions.

Which priority patient cues would the nurse promptly report to the health care provider when analyzing findings from a patient assessment?

Critical laboratory values (Critical laboratory values (those that can impact the pathophysiologic state and become life-threatening) should be rapidly reported to the health care provider.) Severe chest pain (Severe chest pain, which could indicate an urgent medical issue, should be quickly reported to the health care provider.) Respiratory distress (Respiratory distress, potentially indicating an urgent condition, should be quickly reported to the health care provider.) Extremely elevated temperature (Critically elevated vital signs, such as an extremely elevated temperature, should be rapidly reported to the health care provider.)

Which action describes the generation of solutions during the fourth step of the Clinical Judgment Measurement Model (CJMM)?

Identify expected outcomes based on priority hypotheses. To generate appropriate solutions for the individual patient (the fourth step of the CJMM), the nurse identifies expected outcomes and uses hypotheses, or patient problems, to define interventions for the expected outcomes.Identify expected outcomes based on priority hypotheses. To generate appropriate solutions for the individual patient (the fourth step of the CJMM), the nurse identifies expected outcomes and uses hypotheses, or patient problems, to define interventions for the expected outcomes.

Which nursing actions reflect critical thinking as the nurse evaluates outcomes during step 6 of the Clinical Judgment Measurement Model?

Reflect on the patient's condition. To evaluate outcomes effectively the nurse must apply critical thinking skills to understand the patient's condition, reflect on the situation, and adjust the plan of care to correct errors. Examine results of nursing care. Critical thinking skills allow the nurse to examine the results of care according to collected patient cues. Recognize ineffective treatments. The nurse uses critical thinking to recognize that the patient is not responding as expected to a treatment. Compare actual outcomes with expected outcomes. Comparison of actual outcomes with expected outcomes requires critical thinking skills.

Which patient cues would the nurse identify as priority and promptly report to the health care provider when analyzing findings from the assessment of a 30-year-old patient?

Severe chest pain (Severe chest pain, which could indicate an urgent medical issue, should be quickly reported to the health care provider.) Temperature of 104°F (40°C) (Extremely high vital signs, such as elevated temperature of 104°F (40°C), should be swiftly reported to the health care provider.) Heart rate of 140 BPM (Critically elevated vital signs, such as tachycardia, should be rapidly reported to the health care provider.) Oxygen saturation (SpO2) of 85% (Exceptionally low vital signs, such as a low oxygen saturation of 85%, should be quickly reported to the health care provider.)

Which questions would help the nurse generate solutions during the fourth step of the Clinical Judgment Measurement Model (CJMM)?

What are the desired outcomes for the patient? (Asking q's about desired outcomes related to the hypotheses or pt problems, helps the nurse to identify outcomes during the fourth step of the CJMM) What interventions can help achieve patient goals? (Asking q's about interventions that will help pts achieve goals or outcomes allows the nurse to select appropriate interventions during the fourth step of the CJMM)

Which activities related to evaluation did the American Nurses Association (ANA) identify as a standard competency for professional nursing practice? Select all that apply. Continual process Collaboration with the patient Resolution of patient problems Documentation of results Use of assessment data to revise plan

Continual process Holistic, systematic, continual, and criterion-based evaluation is a competency related to the standard of evaluation identified by the ANA. Collaboration with the patient The ANA evaluation-related competencies state that the nurse will collaborate with the patient and other members of the health care team. Documentation of results Documentation of results is an evaluation-related competency identified by the ANA standards. Use of assessment data to revise plan The ANA identified utilization of ongoing assessment data to revise the plan of care as a competency for the evaluation standard of nursing practice.

When providing care for a patient whose goal is to lose weight, which evaluative measure would the nurse utilize to evaluate the patient's expectations of care?

Conduct a patient interview to determine the patient's perspective related to care. Conducting a patient interview can provide information about the patient's expectations of care.

Which activities are independent nursing interventions?

Hand hygiene Hand hygiene is an independent nursing intervention. Nurses can initiate this intervention without a health care provider's prescription. Patient ambulation Ambulating the patient is an independent nursing intervention. Nurses can initiate this intervention without a health care provider's prescription. Teaching use of incentive spirometer Patient education regarding the use of an incentive spirometer is an independent nursing intervention. Nurses can initiate this intervention without a health care provider's prescription.

Which patient cue would the nurse categorize as "important" for a patient diagnosed with a femur fracture?

Temperature of 102.4°F (39°C) (Urgent patient cues demand immediate attention and generally relate to airway, breathing, circulation, or safety. An elevated temperature can be categorized as important since it is the most significant finding presented and indicates the potential of infection, but it will not necessarily influence airway, breathing, circulation, or safety.)

Which action would the nurse implement to promote patient success through goal attainment?

Ask what the patient would like to achieve. To be most effective in guiding care, goals must also include input from the patient and the patient's caregivers or family members.

Which factors would the nurse consider when establishing patient goals and outcomes during the "generate solutions" step of the Clinical Judgment Measurement Model?

Best available clinical evidence Nurses should consider the best available clinical evidence when developing goals and outcomes. Expertise of the health care team The expertise and competence of health care team members influences the achievability of goals and outcomes. Collaborative approaches to care Collaboration with the patient, family members, caregivers, and other members of the health care team is essential to the development of goals and outcomes. Patient Expectations Pt values and expectations are an important consideration when establishing patient-centered goals and outcomes

Patient Care planning

Preadmission planning: Preadmission teaching is an essential planning responsibility for the outpatient surgery or office nurse who contacts patients before testing or surgery. Inpatient Care Planning: Organized and effective inpatient plans of care are critical for maximizing the use of resources available in an inpatient setting to support patient recovery and promote patient wellness. Discharge planning: plays a role in the success of a patient's transition to the home after hospitalization. Discharge planning begins upon the patient's admission and continues until the patient is discharged. Home care planning focuses on patient care needs in the home. This planning must be flexible and continually adapt to the situation as the patient's condition improves or deteriorates due to advancing disease

Sequentially arrange the steps taken by nurses to implement the quality improvement process in nursing.

- Review data about nursing care. - Determine factors contributing to positive patient results. - Make changes in nursing practice Quality improvement is the process of making nursing care safer and better for patients. It is a formal way to look at patient and treatment outcomes and to determine what can be done differently to yield positive results in given situations.

Which statement describes the process used by the nurse to evaluate outcomes in step 6 of the Clinical Judgment Measurement Model (CJMM)? Nurses collect patient cues to determine problems or potential problems. The original assessment allows the nurse to focus on whether identified problems have changed. Reporting is not a component of the process nurses use to evaluate outcomes. The patient interview is one technique nurses use as an evaluative measure.

The patient interview is one technique nurses use as an evaluative measure. Evaluative measures include techniques such as observation, patient interview, review of measurements collected during physical examination, and implementation of different types of measurement scales (e.g., pain rating scale).

Based on urgency and risk, which hypothesis would the nurse rank as the priority? Risk for Activity Intolerance; supporting data: increased fatigue, difficulty breathing, dyspnea Self-Care Deficit; supporting data: inability to ambulate autonomously, inability to bathe independently Hypervolemia; supporting data: coarse crackles, dyspnea, 2+ edema, hypertension, heart failure diagnosis Urinary Tract Infection; supporting data: persistent urge to urinate, foul-smelling urine, burning sensation when urinating, low-grade fever

Hypervolemia; supporting data: coarse crackles, dyspnea, 2+ edema, hypertension, heart failure diagnosis (The supporting data for Hypervolemia suggests an immediate threat because of respiratory distress and the potential for additional complications if not corrected. Thus this is the highest priority hypothesis.)

When determining which actions to take during step 5 of the Clinical Judgment Measurement Model, which activities enable the nurse to validate the accuracy and appropriateness of the plan of care?

Reassessing the patient Accuracy and appropriateness of the plan of care provide the foundation for positive patient outcomes. Therefore, as the nurse determines which actions to take, the nurse should reassess the patient to validate the plan of care. Anticipating complications Anticipating complications for nursing actions helps the nurse to validate the plan of care. Identifying urgent interventions Labeling interventions as urgent or non-urgent allows the nurse to validate the plan of care and decide which actions to take. Revising the plan of care if needed While reassessing the patient to validate the accuracy and appropriateness of the plan of care, the nurse might revise the plan of care if conditions or circumstances have changed

Which statements describe the process utilized by nurses to evaluate patient outcomes?

Review of evaluative measures The nurse reviews evaluative measures of data collected before the nurse implements interventions and compares them to actual outcomes following nursing actions, or interventions. Determination of whether goals were met The nurse evaluates outcomes, comparing observed and expected outcomes to determine if goals were met and to what degree they were met (met, partially met, unmet). Decision regarding the nurse's next action After the nurse compares outcomes, the nurse determines the next appropriate action.

Conceptual care map (CCM)

A combination of both the plan of care and a concept map, creating a comprehensive overview of the patient status and plan Two major components include assessment data: Pertinent medical history, Provider orders/treatments, Medications/intravenous fluids, Laboratory test values/diagnostic test results, Physical assessment findings nursing plan of care: Nursing diagnoses/problem identification, Goals and expected outcomes, Nursing interventions, Criteria to evaluate outcomes

There are key questions based on the QI process that the nurse can ask to develop and evaluate the plan of care.

- What is the nurse trying to accomplish? (Aim: What is the goal?) - How will the nurse know that a change is an improvement? (Measures: What are the desired outcome measures?) - What changes can the nurse make that will result in improvement? (Change ideas: What interventions will generate positive patient outcomes?) - How will the nurse test the change? (PDSA improvement model) Plan: State the objective and develop a plan. Do: Implement intervention(s). Study: Review results. Act: Consider what is learned from the data (goal met/partially met/unmet), and revise the plan of care if needed.

Evaluate outcomes

6th and final step of CJMM. Outcomes are measurable changes the pt must achieve to attain a goal

Which examples are objective patient cues collected from the electronic health record?

Potassium level is 3.5 mmol/L. (The electronic health record includes a complete report of overall health, including laboratory test values.) Blood pressure is 118/70 mm Hg. (The electronic health record includes a comprehensive report of overall health, including vital signs.) Heart rate is 72 beats/min. (The electronic health record includes a thorough report of overall health, including vital signs.) Bowel sounds are heard in all quadrants. (The electronic health record includes a thorough report of overall health, including findings from the physical examination.)

Clinical practice guidelines (CPGs)

Promote the transfer of evidence-based practice into the clinical setting to improve pt care outcomes

Which process occurs when the nurse uses data and specific methods to systematically increase the quality of patient care? Planning Evaluation Nursing process Quality improvement

Quality improvement Quality improvement involves the use of data to monitor outcomes and improvement methods to implement change, with the ultimate goal of continuously improving the quality of patient care and health care systems.

The planning step involves:

Setting priorities based on patient problems and diagnoses Developing patient-centered goals and outcomes Making clinical decisions by selecting nursing interventions Creating a personalized patient plan of care

Which patient cue would the nurse categorize as "urgent" for a patient diagnosed with pneumonia?

Shortness of breath (Urgent patient cues demand immediate attention and generally relate to airway, breathing, circulation, or safety.)

SMART goals

Specific, Measurable, Attainable, Realistic, Timed

Match the term with the appropriate definition.

Statement describing anticipated changes in a patient's condition Outcomes Measurable change the patient must achieve Goals Identified patient problems Hypotheses Treatments nurses implement using clinical judgment and nursing knowledge Interventions

All comprehensive nursing care plans contain:

- Key patient assessment data - Prioritized nursing diagnoses - Measurable, patient-centered goals - Interventions - Evaluation of outcomes

Which statement about nursing interventions is accurate? Interventions are another term for health care provider orders. The nurse selects standardized interventions to promote safety. Interventions are activities that assist the patient in achieving goals. The nurse and the health care provider select the appropriate interventions for the patient.

Interventions are activities that assist the patient in achieving goals. Interventions are activities that assist the patient in achieving goals and improving health.

Which factors assist the nurse in creating patient-centered goals?

Patient condition The unique patient's condition is an important consideration when the nurse identifies patient-centered goals. Considering the patient's condition can assist the nurse in developing realistic goals (e.g., goals for a paralyzed patient will differ from those for an ambulatory patient). Available resources The resources available to the patient are an essential consideration when developing goals that will be realistic for the patient to achieve. Patient needs The patient's unique needs, such as cultural or religious beliefs, should be considered when creating patient-centered goals. Patient preferences Consideration of individual patient preferences allows the nurse to create patient-centered goals and may increase motivation to achieve goals.

Place the nursing actions associated with applying the Clinical Judgment Measurement Model to nursing practice in the order they should occur.

These nursing actions associated with the Clinical Judgment Measurement Model should occur in the following order: recognize cues, cluster cues, form hypotheses, evaluate hypotheses, rank hypotheses.

The answer to which question would help the nurse categorize patient cues according to the degree of concern?

Which cues demand immediate attention? (Data are categorized based on degree of concern or urgency if they demand immediate attention.)

Which actions would the nurse take when caring for a patient presenting to the emergency department with respiratory distress and a priority hypothesis of Hypervolemia?

Administer prescribed medications as needed. Medications promote diuresis and replace potential sodium and potassium deficits resulting from diuretics and fluid shift for patients experiencing hypervolemia. Notify the health care provider of concerning findings.Communication with the health care provider regarding critical or concerning patient findings is essential to ensuring timely, safe, and quality patient care. Validate the patient's values and beliefs about their plan of care. The nurse should incorporate the patient's values and beliefs into the individualized, patient-centered plan of care. Assess respiratory status every 2 hours and as needed. Changes in respiratory status and vital signs can indicate the development of complications, such as pulmonary edema. Increased pulmonary pressure causes fluid to move within the alveolar septum, resulting in auscultation of crackles. Frothy, pink-tinged sputum indicates the patient is developing pulmonary edema. In addition, diuretics reduce blood volume, resulting in lowered blood pressure.

Which aspects of patient care may influence the revision of the nurse's anticipated intervention priorities?

Changing patient conditions A change in the patient's condition or circumstances requires ongoing assessment and revision of priority interventions. Ongoing patient assessment Ongoing assessment of the patient may reveal changes in the patient situation, necessitating the revision of priority interventions. Potential patient complications As the nurse assesses and reassesses the patient, anticipating complications can influence the revision of priority interventions. Increased experience of the nurse As nurses gain patient care experience, they are able to more effectively anticipate clinical situations and priorities.

Which strategies would the nurse use to promote individualization of the identified nursing interventions?

Consider patient assessment findings. When selecting interventions, the nurse considers the patient assessment findings. Ensure interventions align with patient acceptance. The nurse works with the patient to identify the most reasonable and effective interventions. The nurse considers patient needs, priorities, and prior experiences to help ensure patient acceptance of interventions. Consult other professionals involved in the patient's care. The nurse consults with members of the health care team and considers their expertise and competency when selecting interventions. Consider the underlying etiology and related factors. The nurse considers underlying etiology and related factors to determine which interventions are likely to have an impact on these factors.

When determining which actions to take, which statement acknowledges the influence of attitudes on the nurse's decision-making process?

Considers patient preferences, values, and beliefs (Attitudes involve considering how patient preferences, values, and beliefs influence decision-making related to taking action.)

Which factors can hinder the nurse's ability to recognize patient cues?

The patient is 3 years old. (A patient's age and developmental level can create a barrier to effective communication) The patient is crying uncontrollably. (Stress, as evidenced by uncontrollable crying, can create feelings of frustration and anxiety, which can negatively affect communication.) The patient does not speak English as a first language. (Language can create a barrier when the nurse and patient do not understand each other. Translators should be used to promote effective communication.) The patient's culture discourages eye contact with strangers. (An individual's cultural background can influence the way someone communicates and the interpretation of verbal and nonverbal cues.)

Match each issue that negatively influences patient outcomes with a potential cause.

Treating patients with similar conditions with an identical plan of care: Judgment error Recognizing that planned interventions did not occur: Omission error Understanding the patient is not reacting as expected to an intervention: Ineffective treatment

The nurse should also consider the following questions when comparing observed outcomes with expected outcomes during the evaluative step of the CJMM:

Were the interventions effective? (Is the patient progressing as expected? Has the patient's condition improved?) Are there other potential interventions that might be effective or more effective for the patient? Which patient cues would indicate improving, declining, or unchanging patient status? Are there any follow-up data that would help the nurse evaluate outcomes? Are there any critical values that require immediate attention? Is the original priority hypothesis still the primary problem for the patient?