Nursing Fundamentals Exam 2-Clinical Decision Making
The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? "A nursing diagnosis is derived after the nurse develops the plan of care for the patient." "A nursing diagnosis is developed after the nurse evaluates the interventions provided." "A nursing diagnosis is determined by the medical diagnosis and current patient needs." "A nursing diagnosis is based on clinical judgment that is derived from assessment data."
"A nursing diagnosis is based on clinical judgment that is derived from assessment data."
The nurse is presenting how to differentiate between patient goals and outcomes. Which statement by the nurse is accurate? "Goals are established by the nurse and used to evaluate patient outcomes." "Goals include the subjective and objective data observed by the nurse." "Goals are patient responses, whereas outcomes are the patient's response to care." "Goals evaluate the patient's response to the plan of care developed by the nurse."
"Goals are patient responses, whereas outcomes are the patient's response to care."
The nurse is presenting how to differentiate between patient goals and outcomes. Which statement by the nurse is accurate? "Goals are established by the nurse and used to evaluate patient outcomes." "Goals evaluate the patient's response to the plan of care developed by the nurse." "Goals include the subjective and objective data observed by the nurse." "Goals are patient responses, whereas outcomes are the patient's response to care."
"Goals are patient responses, whereas outcomes are the patient's response to care." Goals are observable patient responses to the interventions provided by the nurse. Goals should be mutually established between the nurse and the patient; they are not specifically set by the nurse and are not used to evaluate patient outcomes. Difference Between Goal and Outcome: -Goals are observable patient responses. Such as: -What the nurse hopes to achieve through nursing actions -Mutually agreed upon between nurse and patient -Responses to nursing interventions -Identified during planning phase ------------------------------ Difference Between Goal and Outcome: -Outcomes are used to evaluate the patient's response to the plan of care. Such as: -Identified during planning phase -Specific, observable criteria used to evaluate whether goals have been met -Indicate effectiveness of nursing actions Assessment involves subjective and objective data. Outcomes, not goals, evaluate the patient's response to the plan of care.
The nurse made a medication error while caring for a patient. Which statement by the nurse indicates that the nurse is interpreting the situation using guided reflection? "I should have remembered to check the patient's wristband even though I've been taking care of this patient for several days." "I had to tell the patient and doctor that I gave the wrong medication. It was very embarrassing." "The medication didn't harm the patient, but I need to be more careful whenever I give medication." "I was so busy giving medication that I misread the order and gave the wrong one to the wrong patient."
"I should have remembered to check the patient's wristband even though I've been taking care of this patient for several days." Stating that the nurse should have remembered to check the wristband is an example of interpreting the situation and what went wrong. -------------------- The nurse is showing the process of observing after making the statement about being busy and misreading the order. Stating that it was embarrassing to make the mistake is an example of responding. Understanding the need to be more careful in the future is an example of reflecting.
A patient is hospitalized for the initiation of renal dialysis. The patient shares with the nurse that the patient likes to watch the morning news to start the day and would really like it if the dialysis did not interfere with that routine. Which statement would be the nurse's best response to this request? "Although I know your show is important to you, the need for dialysis is greater; when you get back home, you can watch your show." "I will request that the dialysis staff schedule you for after completion of your morning program if possible." "I am sorry, but it truly is not possible to accommodate this request. Maybe your family can record it for you." "I can try, but schedules are very tight, so it is not likely that it will happen."
"I will request that the dialysis staff schedule you for after completion of your morning program if possible." When possible, the nurse should incorporate patient preferences into their care. Because the morning show is very important to the patient, the nurse can request that dialysis be scheduled for after the program is over if possible.
A patient admitted for palliative care secondary to a recent diagnosis of pancreatic cancer asks the nurse for medication for pain because the pain is now a 9 on a 10-point scale. The family of the patient also asks if the nurse can make sure to fill the patient's water pitcher. Which response by the nurse would best help the family to understand the prioritization of the current needs? "The medications are not near the water station. Is it okay if I bring the water later?" "Right now, I'm just worried about getting the pain under control." "I'll see what I can do; I'll be back as soon as I can." "I'll get the pain medication first because the pain level is so high, and I'll get another staff member to refill the water pitcher."
"I'll get the pain medication first because the pain level is so high, and I'll get another staff member to refill the water pitcher."
The nurse educator is reviewing Tanner's clinical decision-making model and asks the students about the purpose of reflecting. Which response by a student is correct? A) "To sense what is happening in a situation" B) "To gain understanding about a situation" C) "To learn from actions in order to make adjustments to future practice" D) "To analyze a situation to choose an action"
"To learn from actions in order to make adjustments to future practice"
The emergency department nurse is triaging patients for the urgent or nonurgent track. Which patient should the nurse triage into the nonurgent track? A middle-aged adult complaining of sinus headache and possible sinus infection An infant with severe flu symptoms A school-aged child having an allergic response to a bee sting An older adult who fell at home and whose family is unsure if the patient experienced a head injury from the fall
A middle-aged adult complaining of sinus headache and possible sinus infection When triaging patients for care, nonurgent problems such as a sinus infection can be triaged into the nonurgent or minor track for care. These patients have issues that do not require prompt care. Due to age, an infant with severe flu symptoms should be seen fairly quickly on the acute care side of the emergency department. An older adult who fell and possibly has a head injury should also be evaluated as an urgent issue on the acute care side. A patient having an allergic reaction that could quickly progress to a life-threatening situation should be seen promptly. The three levels of triage care are as follows: Emergent or immediate Urgent or delayed Nonurgent or minor
The nurse is caring for several patients in the emergency department. Which patient should the nurse prioritize for care using the urgency factor? A patient with stroke symptoms A patient with sharp, continuous pain radiating from the kidney area A young child with a possible arm fracture A patient with a fractured femur
A patient with stroke symptoms
The nurse is caring for a patient who is scheduled to have a chest x-ray at 9:00 a.m. and will be off the unit. The patient is also due to have medication at 9:00 a.m. Which action by the nurse is most appropriate Administer the patient's medication at 8:45 a.m. Administer the patient's medication at the start of shift. Wait to administer the medication at the next dosage time. Administer the medication after the patient returns from x-ray.
Administer the patient's medication at 8:45 a.m. By administering the scheduled medication 15 minutes early, the nurse is using clinical decision making to ensure the patient receives all necessary care despite the apparent scheduling conflict. When making decisions, an experienced nurse uses many different types of actions or behaviors. They may include: -Choosing among alternatives. -Problem solving. -Using the nursing process. -Using a trial-and-error approach. -Relying on intuition. -Using the scientific method. -------------------- Because there is no way to tell how long the patient might be at x-ray, it might jeopardize the patient's dosing schedule to wait to administer the patient's medication. Administering medication at the start of shift may be inappropriate depending on the dosing schedule. Waiting until it is time for the next dose will result in the patient missing a dose, which is not an option.
After shift handoff, the nurse prioritizes care for the assigned patients. Which action is a common pitfall when prioritizing patient care? Administering medications based on vital signs taken during the previous shift Involving the patient during the care-planning process Completing tasks based on level of difficulty Being cognizant of time when completing tasks
Administering medications based on vital signs taken during the previous shift A common pitfall when prioritizing care is prioritizing care without completing an assessment. Administering medications based vital signs obtained during the previous shift is failing to assess the patient because the patient's condition may have changed since. Relying solely on another's assessment may negatively affect patient outcomes. Failing to do periodic reassessments can result in the inability to realign actions and timing of actions based on changes in a patient's condition, arrival of a new patient on the unit, and so on. Involving the patient during the care-planning process, completing tasks based on level of difficulty, and being cognizant of time when completing tasks are not pitfalls related to prioritizing care.
The nurse is caring for a 3-year-old and an 8-year-old patient who are sharing the same room. Which intervention is appropriate for the 8-year-old but not the toddler? Using play therapy and dolls and toys to explain treatments Allowing the child to help the care provider whenever possible Giving options when appropriate Providing age-appropriate explanations
Allowing the child to help the care provider whenever possible School-aged children benefit from hands-on exploration of equipment and materials and can help the care provider whenever possible, which can help to reduce anxiety. School-aged children need to explore equipment and materials and be involved in hands-on ways as much as possible. Getting kids in this age group involved helps to reduce anxiety and increase cooperation. -------------------- Both age groups can benefit from age-appropriate explanations and options when appropriate. Toddlers can use play therapy to better understand medical treatments, but this is not a good intervention for a school-aged child. Toddlers and preschoolers cannot reason about medical care, but they still need age-appropriate explanations. Play therapy can help them understand treatments or illnesses better. This age group is likely to benefit from being able to make simple decisions about their care.
The nurse is providing care to a patient who recently had back surgery. Which nursing action is a collaborative nursing activity? Arranging for physical therapy to ambulate the patient Assessing the patient's surgical wound site Assisting the patient with bathing Adjusting the head of the patient's bed for comfort
Arranging for physical therapy to ambulate the patient
The nurse manager notes that one of the nurses is 6 hours into the shift and has not had a break due to receiving two admissions. When the nurse manager asks the nurse how things are going, the nurse tersely responds, "Fine, just busy." Which action by the nurse manager would best address this situation? Telling the nurse to immediately take a break and finish up the admission paperwork after the break Providing reassurance that the nurse will not receive any further admissions so that the nurse can catch up Asking the nurse if any tasks can be delegated to others so that the nurse can take a break Asking the nurse to meet prior to the next assigned shift to discuss ways to better prioritize time management so that breaks can be taken
Asking the nurse if any tasks can be delegated to others so that the nurse can take a break
The emergency department (ED) is scheduled to receive an adult patient with a gunshot wound to the right upper abdomen. The patient has lost more than 1500 mL of blood. Which action should the nurse perform immediately upon the patient's arrival? Insert a Foley catheter. Obtain a complete medical history from those accompanying the patient. Assess pulse, respiratory rate, and blood pressure. Insert two large-bore intravenous (IV) catheters for fluid replacement.
Assess pulse, respiratory rate, and blood pressure. In this scenario, the patient has suffered a traumatic injury involving the loss of a great deal of blood. Upon arrival to the ED, the nurse would first assess airway, breathing, and circulation (ABC). An initial assessment of basic body functions necessary for sustaining life precludes a more definitive assessment or any patient intervention such as insertion of IV catheters or a Foley catheter or obtaining a medical history from those accompanying the patient. Assessment data that can help prioritize care include: -Observing for cues about pace and emotions of staff already working on the unit. -Conducting one's own assessment by making a quick safety check of patients after receiving the report. -Becoming aware of any patients who have an unstable status, who have a risk of change in their condition, or who require closer observation. -Asking if there are any complexities to patient problems. -Asking about any special safety concerns for the patients. -Making note of routine responsibilities and interventions that have time constraints. -Knowing how many and what level of nursing staff are available for delegation of tasks to help with patient care. -Noting the presence (and absence) of necessary resources on the unit. -Asking about patient preferences to take into consideration when providing care.
The nurse is caring for a patient with increased intracranial pressure. Which is a priority nursing intervention? Monitoring oxygenation status Spacing nursing care to allow for rest periods Assessing neurologic status frequently Checking for bowel and bladder distention
Assessing neurologic status frequently
The nurse on a medical-surgical unit has finished receiving the report on five assigned patients for the day. Which nursing intervention should the nurse consider an acute intervention when organizing the day? Sitting with a patient who is anxious about an upcoming procedure Teaching a patient and family how to care for an indwelling urinary catheter Assisting in the ambulation of a postoperative patient Completing an activity of daily living (ADL) assessment on a patient who is being transferred to a long-term care facility
Assisting in the ambulation of a postoperative patient
The nurse is caring for a patient with an electrolyte disturbance. The healthcare provider asks the nurse to draw an arterial blood gas (ABG), but the nurse has never performed the procedure and asks a more senior nurse to assist. Which critical thinking attitude is exemplified by the nurse's action? Awareness of self-limits Perseverance Approaching situations objectively Differentiating fact from fiction
Awareness of self-limits
The nurse educator is teaching student nurses about nursing judgment. Which statement by a student indicates effective learning? A) "Students must be skilled at using clinical judgment while in nursing school." B) "Both clinical decision making and critical thinking are important parts of nursing judgment." C) "Intuition is an important part of nursing judgment in the new nurse." D) "Clinical decision making is scarcely used in nursing judgment."
B) "Both clinical decision making and critical thinking are important parts of nursing judgment." Nursing judgment combines both critical thinking and clinical decision making when making decisions about patient care. -------------------- Student nurses are not expected to have excellent clinical judgment because it is honed and improved over time. Clinical nursing judgment is frequently used by nurses. As new nurses become more experienced, they will increasingly be able to use their intuition to help in decision making.
A nurse is changing a patient's dressing without indicating date and time because the dressing removed did not have this information. Which type of faulty reasoning is this? Bandwagon Cause-and-effect fallacy Circular reasoning Overgeneralizations
Bandwagon Doing something because everyone else is doing it
The nurse manager is looking at models of clinical judgment to use as an employee assessment tool. The nurse manager wishes to use a model that can evaluate clinical competence in the workplace. Which is best suited for the job? Guided reflection Lasater's clinical judgment rubric Benner's skill acquisition model Tanner's clinical judgment model
Benner's skill acquisition model
A home care nurse is scheduling the visit order for patients on the next day. Which nursing intervention would require priority based on a time constraint? Foley catheter change Blood draw for vancomycin trough Wound dressing change Admission assessment for new hospice patient
Blood draw for vancomycin trough When organizing the day, the home care nurse must consider which nursing interventions may be time constrained. In this case, a trough level for vancomycin must be drawn just prior to the next dose of the medication and is time constrained. The Foley catheter change, wound dressing change, and admission assessment would not necessarily be time constrained. Setting priorities for patient care requires advance planning to determine which direct- and indirect- care activities must be completed at expected times.
The trauma unit nurse is planning out the day before a holiday weekend based on the current patient assignments. Which action should the nurse perform to best support effective time management and address unexpected occurrences and changes in the condition of patients? A) Sharing the day's plan with the rest of the healthcare team so that they can easily provide assistance if something unanticipated occurs B) Prioritizing necessary activities so that unnecessary activities can be left for the next shift for follow-up if time becomes an issue C) Determining which tasks could be appropriately delegated to other personnel, allowing more flexibility for the nurse to adapt to any changes D) Building several open time frames into the day to allow for activities that may take more time than anticipated
C) Determining which tasks could be appropriately delegated to other personnel, allowing more flexibility for the nurse to adapt to any changes One way for nurses to manage time effectively is to appropriately delegate tasks to other healthcare team members, thus allowing the nurse more flexibility to adapt to changes or unexpected occurrences. Development of good time management requires the nurse to take into account: -Patient health preferences. -Changes in the patient's condition. -Unexpected occurrences. -Appropriate delegation of tasks. -------------------------------------- Although having some open time frames may be helpful, they may not align with when extra time is needed, so this is not the best approach. Sharing the day's plan with the rest of the healthcare team may be helpful but does not ensure that they can step in and help when needed. Leaving activities for the next shift to complete may sometimes be necessary, but it is not the best approach.
Thinking that the patient's nasogastric (NG) tube was draining fine until the nurse cleaned up the patient's bedside table; therefore, the nurse interfered with the NG tube drainage setup when cleaning up the bedside table. Which type of faulty reasoning is this? Circular reasoning Either-or fallacy Cause-and-effect fallacy Using emotions instead of words
Cause-and-effect fallacy Linking something that happens to something that occurs before it happens
Saying that a new dressing is very popular to use because a lot of nurses like using it. (The terms "popular" and "like using it" are saying the same thing.) Which type of faulty reasoning is this? Circular reasoning Using emotions instead of words Overgeneralizations Cause-and-effect fallacy
Circular reasoning Saying that a new dressing is very popular to use because a lot of nurses like using it. (The terms "popular" and "like using it" are saying the same thing.)
The nurse decides to suction and perform tracheostomy care on a patient before sending the patient to a scheduled procedure. Which process does the nurse's action define? Trial and error Intuition Choosing among alternatives Clinical decision making
Clinical decision making The nurse is relying on clinical judgment to perform respiratory care for the patient before sending the patient off the floor. This is to ensure that the patient does not need to be suctioned or cleaned up while at the procedure. When making decisions, an experienced nurse uses many different types of actions or behaviors. They may include: Choosing among alternatives.... Problem solving. Using the nursing process. Using a trial-and-error approach. Relying on intuition. Using the scientific method. -------------------- The nurse is not relying on intuition to make the decision, using trial and error, or choosing among alternatives.
The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met? Collect data related to patient-specific outcomes for accrediting bodies. Collect data related to the goal and make decisions about nursing care effectiveness. Collect data to develop new nursing diagnoses for the home health nurse to follow. Collect data to provide discharge instructions to follow when at home.
Collect data related to the goal and make decisions about nursing care effectiveness. Outcomes are evaluated to determine if the patient's goals have been met and for the effectiveness of the plan of care. Based on the evaluation, the plan of care is continued, modified, or terminated. The nurse will collect data at discharge to determine if the goals have been met and make decisions about nursing care effectiveness. Conclusions when evaluating goals include the following: -The goal was met; that is, the patient's response is the same as the desired outcome. -The goal was partially met; that is, either a short-term goal was achieved but the long-term goal was not or the desired outcome was only partially attained. -The goal was not met; that is, the patient did not achieve the goal within the time frame.
The nurse is sitting with the healthcare provider and a pregnant patient. The provider is explaining to the pregnant woman the various options for genetic testing that are currently available. The provider asks the patient which testing she would like to have done. The nurse understands that the provider is displaying which decision-making model? Mutualism Maternalism Paternalism Consumerism
Consumerism This is an example of the consumerism model, which is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision. -------------------- -Mutualism is a process of shared decision making between both the patient and the provider. -Paternalism is where the provider has the education and experience to make the best decision for the mom and baby. -There is no maternalism model of decision making.
The nurse is caring for a toddler who appears frightened by the nurse. To make the child more at ease, the nurse gives the toddler a disposable tape measure to play with. Which critical thinking concept is the nurse displaying? Creativity Independence Confidence Concreteness
Creativity
The nurse is planning to transfer a 76-year-old patient to a long-term care facility. The patient wants to live close to family; however, the facility that would best meet the patient's needs is a few miles farther away. Which action should the nurse implement? Tell the patient that the facility that is closer to family is not accepting admissions. Discuss the advantages of the facility that is a bit farther away. Tell the patient that being near family is not always a good idea. List other facilities so that the patient can make a better decision.
Discuss the advantages of the facility that is a bit farther away.
A recently hired graduate nurse is having difficulty establishing a workflow, which is affecting the quality of patient care provided. The nurse manager discusses setting priorities, managing time, and delegating to staff as strategies the new graduate can use. Which qualities that affect patient perception of nursing care are supported through use of these strategies? Accountability and responsibility Empathy and caring Adaptability and flexibility Effectiveness and efficiency
Effectiveness and efficiency Effectiveness and efficiency are two qualities that influence patient perception of care. Nurses employ effectiveness and efficiency by setting priorities, managing time, and delegating to staff. Accountability, responsibility, adaptability, flexibility, empathy, and caring are all other characteristics of successful nurses but are not necessarily developed through the use of these strategies. To support the qualities of effectiveness and efficiency, nurses need to limit distractions and interruptions as well as treat all patients with respect, dignity, and necessary attention.
Thinking that the only way to help a patient with a headache is either with medication or a cold cloth on the head. (This ignores other interventions that may be helpful, such as dimming the lights, decreasing noise, or giving the patient something to eat.) Which type of faulty reasoning is this? Circular reasoning Using emotions instead of words Overgeneralizations Either-or fallacy
Either-or fallacy Assuming that a problem has only two solutions
The nurse has developed a plan of care for a patient with a specific goal. The patient was unable to meet the goal by the stated time frame. Before revising the goal, which step must the nurse perform? Ask the healthcare provider for a more reasonable goal. Document noncompliance with the plan. Evaluate factors impeding goal attainment. Compare patient progress with that of other patients.
Evaluate factors impeding goal attainment.
Which statement describes the evaluation phase of the nursing process? Evaluation focuses on determining changes and preventing complications. Evaluation is performed throughout all phases of the nursing process. Evaluation is performed only after nursing interventions are performed. Evaluation is determined based on gathering subjective and objective data.
Evaluation is performed throughout all phases of the nursing process. Evaluation is performed throughout all phases of the nursing process. It is a constant, fluid process that is used to determine the effectiveness of planned interventions and includes reassessment of the patient. It is not only performed after nursing interventions. Purposes of data collection include the following: Purpose of Data Collection in Assessment Phase: -To develop a plan of care -To determine needs -To determine current abilities -To obtain a health history -To obtain baseline data Purpose of Data Collection in Evaluation Phase: -To determine if goals were met -To determine future needs -To revise the plan of care ----------------------------- Implementation focuses on determining changes and preventing complications. Assessment is based on gathering subjective and objective data.
The nurse is preparing to administer insulin coverage to an assigned patient who has just finished breakfast. It is now 0830, and the nurse is basing coverage on the blood sugar result provided in the report at 0600 during the change of shift. Which common pitfall is occurring in this situation that may result in a negative patient outcome? Incomplete assessment Poor time management Failure to do periodic reassessment Doing the easiest task first
Failure to do periodic reassessment In this situation, the nurse is basing the amount of insulin coverage on a blood sugar result received during the report. This blood sugar may have been taken 1-2 hours prior to the end of that shift. In this situation, prior to giving insulin, the nurse should reassess the blood sugar. The pitfalls of poor time management, doing the easiest task first, and incomplete assessment are not described in this scenario.
The nurse is conducting triage in a mental health facility. A family member brings in a patient for suspected overdose. The patient's breathing is very slow and shallow, and the patient is not responding to the nurse's questions. The nurse has several other patients awaiting triage. Which level of urgency in nursing intervention should the nurse prioritize? Imminent death Nonacute Acute Critical
Imminent death Imminent death is the highest urgency factor. In this situation, the patient could quickly deteriorate, and rapid intervention would be necessary to save the patient's life. Teaching points for the nurse prioritizing care include the following: Critical nursing interventions address high-priority physical and psychologic conditions such as difficulty breathing or bleeding secondary to a wound. Imminent-death interventions address life-threatening situations such as cardiac arrest, opioid overdose, and threatened suicide.
The nurse determines the following nursing diagnosis for a patient: Impaired Urinary Elimination related to retention secondary to enlarged prostate. Which portion represents Axis 3 in the nursing diagnosis? Enlarged prostate Urinary Retention Impaired
Impaired Axis 3 consists of the modifier that gives meaning to the nursing diagnosis. In this diagnosis, the term Impaired represents Axis 3. Urinary represents Axis 1 because it is the focus of the nursing diagnosis. "Enlarged prostate" would be Axis 7 because it is the current or actual health problem. "Retention" is Axis 4 because it describes the focus of the problem. (NANDA-I © 2014) 7 Axis of Nursing Diagnosis: 1-Focus of diagnosis 2-Subject 3-Modifier (give meaning, nursing judgement, describe foucs...ex-impaired, decreased, increased etc) 4-Location, Sytem or Function 5-Age 6-Time 7-Status
A patient who is recovering from a motor vehicle crash has been ordered complete bedrest for 3 months. The patient presents with skin breakdown. Which nursing diagnosis statement is correct? Impaired Skin Integrity related to skin breakdown Impaired Skin Integrity related to time in bed Impaired Skin Integrity related to immobility Impaired Skin Integrity related to motor vehicle crash
Impaired Skin Integrity related to immobility
During shift handoff, the outgoing nurse tells the incoming nurse that the assessments done on patients were a few hours ago due to a late admission. The nurse begins to plan out the day immediately after obtaining reports for the five assigned patients. Which pitfall is most likely to occur in this situation? Important interventions may be missed or may be inappropriate. Tasks may be inappropriately delegated to other healthcare team members. Easier tasks may be planned for completion prior to more complicated tasks. Important patient preferences may not be considered by the nurse.
Important interventions may be missed or may be inappropriate. In this situation, the outgoing nurse indicated that the information provided was several hours old. The incoming nurse, however, begins to plan the day without completing the nurse's own assessments, which can result in a pitfall. The outcomes include missing important interventions or providing interventions based on old data that may now be inappropriate. Lack of consideration of patient preferences, inappropriate delegation, and doing the easiest tasks first are other common pitfalls but do not best characterize this scenario. To avoid common pitfalls, nurses should: Follow ethical practices. Use available resources. Know the health concerns of their patients. Have a sense of patient priorities. Prioritize care appropriately. Use questions from clinical decision-making models.
While the nurse is caring for a patient who had a fall, a monitor alarm for an intravenous (IV) line goes off in the adjacent room. The nurse asks the unlicensed assistive personnel (UAP) to go to that room and slow the rate of the IV down until the current patient's care is finished. Which common pitfall has occurred based on the action taken? Failure to do periodic reassessments Poor time management Incomplete assessment Inappropriate delegation
Inappropriate delegation
The nurse is working on the oncology floor of the hospital and notes that many of the patients request internet access so that they can communicate with loved ones more easily. Using this information, the nurse obtains a grant to purchase several laptops for the patients to share. Which type of reasoning did the nurse use to develop this protocol? Inductive reasoning Deductive reasoning Clinical reasoning Careful reasoning
Inductive reasoning
The nurse is caring for a patient who is admitted with erosive gastritis. Blood pressure on admission was 136/68 mmHg with a heart rate of 94 beats/min. Currently, the patient's blood pressure is 74/52 mmHg with a heart rate of 138 beats/min. Which healthcare provider prescription should the nurse initiate first? Initiating gastric lavage Testing stool for occult blood Infusing intravenous fluids Infusing drugs to reduce gastric acidity
Infusing intravenous fluids In this situation, the blood pressure is very low; thus, according to the ABCs (airway, breathing, and circulation), the nurse would first infuse intravenous fluids to help increase blood pressure. Initiating gastric lavage, testing the stool for occult blood, and infusing drugs to reduce gastric acidity would have a lower priority.
The nurse is caring for a neonate who requires nasogastric (NG) tube feedings due to prematurity. The NG tube frequently slips out of position, and the nurse tries different approaches to prevent this from happening. Which critical thinking skill is the nurse demonstrating? Reasoning Inquiry Intellect Reflection
Inquiry
The nurse forgets to provide the patient with discharge papers. When speaking with a coworker, the nurse states, "I should have remembered to bring the papers into the patient's room, but I got distracted with another task." Which guided reflection task is the nurse demonstrating? Observing Interpreting Responding Reflecting
Interpreting The nurse is interpreting the situation after thinking about the background information needed to understand the situation and making pertinent observations (observing) about what happened. -------------------- -Responding describes the nursing response to the situation. -Reflecting describes an understanding of the "take-away" lesson from the experience or situation.
The nurse with 15 years of obstetric experience is caring for a patient in labor who is reporting extreme pain. The nurse knows that the patient is likely getting very close to delivery but asks the provider to come and evaluate the patient. Which decision-making process is reflected in this situation? A) The scientific method B) Intuition C) The nursing process D) Trial and error
Intuition
The nurse is caring for a patient who was admitted with abdominal pain. The patient's complete blood count (CBC) is normal, but the nurse is still concerned about the patient having a gastrointestinal bleed and monitors the patient closely. Which cognitive skill is the nurse displaying? Reflection Reasoning Inquiry Intuition
Intuition Intuition is the use of nursing knowledge and experience for understanding without the conscious use of reasoning. Steps in the process of intuition include the following: -Information is continuously received through senses, although it is not always recognized consciously. -Patterns and similarities of patterns are clustered and analyzed. -Comparisons are made between a current pattern and past patterns in a response to similar situations. -If the new pattern is recognized as being similar to an old pattern, this brings it to conscious awareness for the nurse to use. -------------------- Inquiry uses questions to find alternative approaches or solutions. Nurses use intellect to identify salient cues and group them into meaningful patterns. Clinical reasoning is the careful evaluation of information to improve patient care. Reflection is looking back at a situation to determine what worked, what did not work, or what could have been done better.
A nurse new to the emergency department is struggling with triaging patients and assigning priority for care because many of the individuals who present seem to have equally significant problems. Which ethical principles should the nurse use as guides when setting priorities? Fidelity and beneficence Integrity and respect Justice and fairness Autonomy and accountability
Justice and fairness The ethical principle of justice can be used to guide nurses in making decisions about setting priorities. Additionally, nurses should show fairness by treating individuals as equals. Integrity, respect, autonomy, accountability, fidelity, and beneficence are also important for nurses to consider in daily practice but do not relate as directly to prioritization as do justice and fairness. Safety is an aspect of justice; the nurse needs to protect patients and provide them with a safe environment. Additionally, nurses can demonstrate fairness by allocating time, attention, and skills to ensure patient safety.
The pediatric nurse is preparing to establish intravenous (IV) access for a toddler who is admitted with high fever and inconsolable crying. The toddler has been very uncooperative with admission procedures because the child's mother is not with the child. Which factor should the nurse take into consideration when planning the time needed for this procedure? More time may be needed to establish IV access. Toddlers can be difficult, but the time required to establish IV access is generally the same across this age group. Less time will be needed to obtain IV access because the toddler can easily be restrained by staff if needed. A sedative may be needed, so the nurse should allow time for the sedative to take effect.
More time may be needed to establish IV access.
The nurse is sitting with a laboring patient who is requesting intermittent fetal monitoring. The nurse is explaining the risks, benefits, and evidence to support the different types of monitoring. Which type of decision making is the nurse demonstrating? Mutualism Paternalism Consumerism Maternalism
Mutualism This is an example of mutualism, which is a process of shared decision making between both the patient and the provider. -------------------- -Paternalism is where the provider has the education and experience to make the best decision for the mom and baby. -Consumerism model is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision.
The nurse auscultates a patient's breath sounds after the patient receives an albuterol nebulizer treatment secondary to wheezing. The nurse finds that the patient is still wheezing despite the therapy. Which aspect of Tanner's clinical judgment model is the nurse displaying? Reflecting Responding Interpreting Noticing
Noticing
A recently graduated nurse asks a mentor for guidance concerning how to determine priorities when working with patients. Which process codified by the American Nurses Association (ANA) should the mentor refer to as a useful framework? Quality-improvement process Nursing process Evidence-based process Clinical decision-making process
Nursing process The nursing process was codified by the ANA in 1973; the steps of the nursing process are used as a framework to determine priorities when working with patients. The National Council of State Boards of Nursing (NCSBN) provides a model for states to use when revising their nurse practice acts and nursing administrative rules. Sections covering the scope and standards of nursing practice list the steps of the nursing process used to develop a nursing plan of care and also support accountability for the following: Clinical judgments Decision making Critical thinking Competence of interventions in the course of nursing practice, including: Prioritizing care. Performing interventions. The clinical decision-making process is used to help determine priorities but was not codified by the ANA. Evidence-based and quality-improvement processes are used to support implementation of safe, effective, high-quality care and may help inform prioritization of patient care but were not codified by the ANA as a framework.
A 64-year-old patient is receiving chemotherapy for breast cancer. After the morning report, the nurse finds the patient nauseated, vomiting light green emesis, and crying because her hair is falling out in clumps. The pulse is 110 beats/min and thready, and the blood pressure is 96/50 mmHg. Which intervention should the nurse make a priority for this patient? Teaching the patient some deep-breathing exercises to help her calm down Cleansing the skin and applying a clean hospital gown Obtaining an order for intravenous fluids at 100 mL/hr Premedicating for nausea before the next chemotherapy dose
Obtaining an order for intravenous fluids at 100 mL/hr If the nurse uses Maslow's hierarchy of needs, the priority of care would be the patient's thready pulse and low blood pressure. Contacting the provider and obtaining an order to administer intravenous fluids to counter her fluid loss due to vomiting would be the priority. Providing premedication for nausea before the next chemotherapy dose will be helpful later but will not help restore her fluid balance now. Cleansing the skin and applying a clean hospital gown is not a priority. This comfort and hygiene intervention can be done once the nurse has intervened to restore the patient to homeostasis. Teaching deep-breathing exercises as a calming measure may help the patient through the course of her treatment, but this intervention to meet her psychologic needs is of lesser priority than restoring her to physical homeostasis.
Concluding that a postoperative patient eats all of his meals based on the observation that he ate 100% of his last meal. Which type of faulty reasoning is this? Circular reasoning Assumption Either-or fallacy Overgeneralizations
Overgeneralizations Coming to a conclusion when there is not enough evidence to do so
A pregnant patient presents with rising blood pressure and protein in her urine. After testing, the provider diagnoses the patient with preeclampsia and informs her that they are taking her to the operating room to deliver the baby through cesarean delivery immediately. Which decision-making model is displayed? Maternalism Paternalism Consumerism Mutualism
Paternalism This is an example of paternalism, where the provider has the education and experience to make the best decision for the mom and baby. -------------------- -Consumerism model is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision. -Mutualism is a process of shared decision making between both the patient and the provider. There is no maternalism model of decision making.
The nurse is examining the following nursing diagnosis statement: Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. The use of "secondary to" in this diagnosis reflects which component? Subjective data obtained Primary identifiable nursing problem Pathophysiological disease process Axis 2 of the nursing diagnosis
Pathophysiological disease process Because Diabetes is a medical diagnosis and hence it is a pathophysiological disease process. The diabetes dx secondary to the nursing diagnosis is not subjective data. Primary identifiable nursing problem is the first clause "Impaired skin integrity". Axis 2 is the subject. In this instance, the secondary clause reflects the pathophysiological disease process that caused the problem. The nursing diagnosis is the primary nursing problem. Axis 2 represents the patient or subject of the diagnosis. Subjective data lead the nurse to develop the nursing diagnosis. (NANDA-I © 2014)
The nurse is performing an admission assessment for hospice for a patient who has significant declines in health and cognitive capabilities. The patient's spouse and three children are present. Which factor will most likely impact the amount of time needed to complete this admission? Inability to complete certain patient-specific aspects of the assessment process Regulations of insurance providers and home care agency concerning amount of assessment information required Patient cognitive status and presence of several family members Inability to ask the patient directly about preferences related to care
Patient cognitive status and presence of several family members
The nurse is performing an admission assessment for hospice for a patient who has significant declines in health and cognitive capabilities. The patient's spouse and three children are present. Which factor will most likely impact the amount of time needed to complete this admission? Inability to complete certain patient-specific aspects of the assessment process Regulations of insurance providers and home care agency concerning amount of assessment information required Patient cognitive status and presence of several family members Inability to ask the patient directly about preferences related to care
Patient cognitive status and presence of several family members The presence of cognitive decline will make it more difficult for the nurse to obtain the required admission information. Additionally, the presence of several family members may require more time for input and questions. When working with children and older adults, the nurse needs to remember that more time may be needed for discussion, answering questions, and teaching based on the patient's developmental stage and cognitive ability.
The nurse is looking at ways to help infants in the healthcare process. Which intervention is appropriate for this age group? Provide simple options when appropriate. Encourage the use of play therapy and toys in the treatment rooms. Place cots for parents to stay over in all patient rooms. Allow for hands-on exploration of all equipment.
Place cots for parents to stay over in all patient rooms. Infants are not able to be involved in decision making but must be comforted and made to feel secure throughout the entire healthcare process. Placing cots in patient rooms to allow parents to sleep over helps infants feel more comfortable. -------------------- Infants are not able to participate in play therapy, choose between options, or explore all equipment with their hands.
The nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. Which phase of the nursing process will the nurse use to develop interventions? Planning Nursing diagnosis Implementation Assessment
Planning Nursing interventions are selected and written during the planning phase of the nursing process. The purpose of the planning phase is to develop an individualized plan of care that specifies patient goals/desired outcomes and related priority nursing interventions. The activities that are a part of the planning phase are as follows: -Set priorities and goals/outcomes in collaboration with patient. -Write goals/desired outcomes. -Select nursing strategies/interventions. -Consult other health professionals. -Write nursing interventions and nursing plan of care. -Communicate plan of care to relevant healthcare providers. ------------------------------ The nursing process begins with assessment, which involves the collection, organization, and validation of data. These data are used to formulate a nursing diagnosis. During the implementation phase, interventions are prioritized and carried out.
A patient is admitted for dehydration. During morning care, the patient becomes upset when the breakfast tray features items that the patient does not eat. The patient tells a family member that the staff must not think the patient is important. Which should be the immediate nursing intervention to improve patient care? Planning to talk with the patient about the patient's care needs, priorities, and preferences Discussing the importance of other patients' treatments being of greater priority Explaining to the patient that the patient's care issues are not life-threatening and can be delayed Identifying the easiest task to complete for the patient and doing this first
Planning to talk with the patient about the patient's care needs, priorities, and preferences A common pitfall when prioritizing care is not involving the patient in the care. The patient obviously was not consulted because the meal tray contained items that were not on the patient's preference list. The nurse should plan time to discuss the patient's needs, priorities, and preferences. Explaining to the patient that care issues can be delayed does not take the patient's preferences into consideration. Discussing other patients' care needs as taking priority over this patient minimizes the needs and would be inappropriate for the nurse to do. Performing the easiest tasks first is not a good use of the nurse's time and should be avoided. Patients have preferences, including how they do things, when they want things to happen, and what they want to do. These may be a result of: -Culture. -Family influences. -Spirituality. -Heritage.
An unlicensed assistive personnel (UAP) has asked the nurse for assistance ambulating an 87-year-old patient who is on postoperative day 3 following a knee replacement. As which level of priority should the nurse classify this request when organizing the activities of the day? Priority 1: Must do Priority 2: Should do Priority 3: Nice to do Priority 1: Vital to do
Priority 2: Should do Setting priorities can be done by thinking about nursing interventions as "must do," "should do," and "nice to do." It is important to ambulate a patient and assist the UAP in this activity upon request; this is a priority 2 activity. This activity should be done after priority 1 ("vital to do" and/or "must do") activities are completed. This intervention would not be considered a priority 3 ("nice to do") activity.
The nurse is caring for a patient with a history of diabetes mellitus. The nurse notices an upward trend to the patient's daily fasting serum blood glucose and notifies the patient's healthcare provider. Which level best describes this nurse according to Benner's skill acquisition model? A) Advanced beginner B) Proficient C) Competent D) Novice
Proficient
The nurse is developing a plan of care for a patient with the nursing diagnosis Impaired Physical Mobility related to inactivity secondary to arthritis. The nurse and patient develop a goal of ambulating the hall three times a day with a wheeled walker. Which purpose should this goal help achieve? Provide direction for nursing interventions. Identify a time frame for an action to occur. Evaluate the patient's response to the plan of care. Measure the end result of nursing action.
Provide direction for nursing interventions. Goals provide direction when selecting nursing interventions. Therefore, the nurse and patient develop the goal of ambulating the hallways three times a day to help provide guidance for improving mobility. Goal setting and the nurse-patient relationship include: -Providing direction for selecting nursing interventions. -Serving as criteria for evaluating patient progress. -Enabling closure of nursing diagnosis when goals are met. -Helping to motivate the patient by providing a sense of achievement. -Supporting a therapeutic nurse-patient relationship. ---------------------------- Outcomes are used to evaluate the patient's response to the plan of care and to measure the end result of the nursing action. Identifying a time frame for an action to occur is part of the goal statement; however, it is not the purpose of a goal. (NANDA-I © 2014)
A new nurse is speaking with a mentor about a mistake made the day before. The mentor encourages the nurse to review the situation and make a mental note to respond differently the next time the situation occurs. Which process is the mentor encouraging? Noticing Reflecting Interpreting Responding
Reflecting
The nurse is reviewing assessment data collected from a patient with pneumonia. Which data should the nurse identify as subjective? Presence of cough Observation of yellow sputum Report of difficulty breathing Rapid breathing
Report of difficulty breathing
The nurse decides to take vital signs and draw morning blood work before the patient's family comes to visit. Which type of decision does the nurse's action reflect? Priority decision Time-management decision Value decision Scheduling decision
Scheduling decision
The nurse is caring for a patient who has difficulty breathing. Which nursing action would be considered independent? Sitting the patient up in bed Prescribing oxygen therapy Administering medication to relax breathing Ordering chest physiotherapy
Sitting the patient up in bed Everything else requires a doctors order.
Which clinical situation best exemplifies the nurse who is choosing between alternatives when making a clinical decision? The nurse has a "gut reaction" to the patient's pain and calls the patient's physician. The nurse changes the patient's position numerous times until the patient appears in less pain. The nurse determines that the patient's nursing diagnosis is Pain, Acute. The nurse administers an intravenous (IV) narcotic instead of an oral narcotic.
The nurse administers an intravenous (IV) narcotic instead of an oral narcotic.
The nurse is caring for a teenager who requires surgery to repair a broken femur after a motor vehicle crash. Which statement about patient consent is correct? The parents must provide consent. The teenager must sign the consent form. The teenager must sign the consent form, and the parents must also provide assent. The parents must provide consent, and the teen must sign an assent form.
The parents must provide consent. Even though teenagers should be involved in healthcare decisions whenever possible, the parents must provide consent. Whenever possible, the teenager should also assent to the procedure, although no formal form is required. Unless the teenager was given autonomous and legal decision-making power, the teen does not sign the consent form.
The nurse notices changes in the condition of the patient who is second-day postoperative after a coronary artery bypass graph. Which changes should receive priority by the nurse for immediate sharing with other members of the healthcare team? The patient reports mild dyspnea, diaphoresis, and restlessness. The patient verbalizes feelings of hopelessness in relation to cardiac status. The patient's total serum cholesterol level is 376 mg/dL. The patient desires to prepare advance directives.
The patient reports mild dyspnea, diaphoresis, and restlessness. Changes that require immediate reporting include those that need early intervention to prevent further deterioration, such as difficulty breathing, diaphoresis, and restlessness.
A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis. Which goal includes all elements of a goal statement? The patient will demonstrate correct use of the incentive spirometer after the teaching session. The patient will be given supplemental oxygen to use via nasal cannula. The patient will be instructed in use of the incentive spirometer every hour. The patient will be given bronchodilators as prescribed.
The patient will demonstrate correct use of the incentive spirometer after the teaching session. An appropriate goal for a patient with any nursing diagnosis includes a subject and verb and is both measurable and patient centered. The statement of the patient demonstrating the correct use of incentive spirometry after a teaching session meets these requirements. It is also realistic and relevant. Appropriate verbs for writing goals include the following: Apply Discuss Select Change Drink Sit Demonstrate Explain State Describe Inject Verbalize Differentiate Prepare Walk -------------------------- Providing supplemental oxygen, administering bronchodilators, and instructing on the incentive spirometer are all nursing interventions, not goals. (NANDA-I © 2014)
Which short-term goal should the nurse view as appropriate for a patient with the nursing diagnosis Deficient Knowledge related to disease process secondary to diabetes? The patient will maintain blood sugars between 80 and 120 mg/dL within 1 month. The patient will identify ways to prevent complications from diabetes within 2 months. The patient will follow a diabetic diet with 90% compliance within 3 months. The patient will verbalize understanding of how insulin affects blood sugar by the end of the day.
The patient will verbalize understanding of how insulin affects blood sugar by the end of the day.
The nurse who is working in the emergency department receives multiple patients. Which patient requires priority nursing care? The patient with a laceration to the lower extremity requiring sutures The patient with a distended bladder and accompanying pain requiring catheterization Unselected The patient with atelectasis requiring thoracentesis The patient with difficulty breathing requiring oxygenation
The patient with difficulty breathing requiring oxygenation
The school nurse is looking at the effects that increasing recess and recreation time has in the classroom. The nurse plans to assign some classes within the school an additional hour of recess each day, and the remaining classes will stay on the current schedule. Which concept of problem solving and critical thinking should be most useful in this situation? The nursing process Intuition Trial and error The scientific method
The scientific method The scientific method is a formalized and systematic approach to solving problems and is best used in this situation. The scientific method is best used when working in a controlled, investigative situation. When used in the clinical situation, the scientific method must be modified in order to accommodate patient variables. -------------------- Intuition is relying on subconscious clues and previous experience to find patterns in patient behaviors. The nursing process uses five defined steps (assessment, diagnosis, planning, implementation, and evaluation) to solve a problem. Trial and error is the process of trying different options to see what works and what does not, such as trying different positions to find one that is comfortable for the patient.
The nurse is caring for a patient who is 8 weeks pregnant, reports never having been pregnant before, and does not know what to expect. The nurse instructs the patient to keep all scheduled prenatal clinical visits and states, "These classes will help you and your baby to stay healthy." Which is the reason for the nurse to make this statement? To develop a nursing diagnosis of Knowledge, Deficient for the patient To provide the patient a list of reasons why attending classes is important. To educate the patient on the importance of attending the classes To motivate the patient by associating a personal meaning with the goal
To motivate the patient by associating a personal meaning with the goal
The nurse is caring for a patient who is having back discomfort. The nurse helps the patient change position several times until comfortable. Which process is defined by this action? Intuition Trial and error The nursing process Clinical decision making
Trial and error Trial and error is the process of trying different options to see what works and what does not, such as trying different positions to find one that is comfortable for the patient. Trial and error can be useful only when time and safety allow for multiple opportunities to find the right answer. Examples include: Patient comfort. Preference. It is not appropriate when an option or error can cause harm to the patient. -------------------- Intuition is relying on subconscious clues and previous experience to find patterns in patient behavior. The nursing process uses five defined steps (assessment, diagnosis, planning, implementation, and evaluation) to solve a problem. Clinical decision making uses the nurse's skills, experience, and knowledge to make a decision.
The nurse is planning interventions for a patient with a nursing diagnosis of Activity Intolerance related to weakness, as evidenced by inability to walk two steps. Which part of the nursing diagnosis statement is used as the framework for planning nursing interventions? Weakness Activity Intolerance Previous health history Inability to walk two steps
Weakness The framework for selecting nursing interventions is created when the correct problem is identified during the assessment and nursing diagnosis phases. In this instance, it is the weakness. The diagnostic label, Activity Intolerance, may have several etiologies, such as pain or sedentary lifestyle, so it is important to define the cause of the problem so that interventions are appropriate. --------------------------- A patient's previous health history is not used as the framework for identifying nursing interventions. A sign of not being able to walk two steps helps explain how a problem is affecting a patient. (NANDA-I © 2014)