ATI CLINICAL DECISION MAKING: Clinical Judgement Process, Managing Client Care, priority-setting framework

A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching?

"I should try to escape or put a barrier between myself and the client." The nurse should always try to escape a dangerous situation. If escape is not possible, creating a barrier where the client cannot reach them until help arrives is the next acceptable action.

A nurse is precepting a newly licensed nurse and suggests using the IDEAL method to structure the client's discharge planning. The client's caregiver is also in the room. Which of the following statements made by the newly licensed nurse demonstrates the correct the use of the IDEAL method?

"I will include the client and caregivers in the discharge discussion." "I" stands for "include" in this model. The nurse should include the client and caregivers to review the discharge instructions. Research shows including caregivers in the discharge instructions with the client leads to a safer transition.

A nurse is caring for a client who has been wheezing. The nurse asked an assistive personnel do use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts?

Delegation of the wrong task

A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR?

The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues. The nurse is providing relevant and needed information for SBAR reporting: situation, background, assessment, and recommendation.

a nurse at a provider's office is reviewing the records of several clients. which of the following clients should the nurse recommend as the priority for treatment

a client who report new chest pain

a nurse is providing education on priority setting frameworks to a group of newly licensed nurses. which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework?

this framework assigns the highest priority to the situation that poses a threat to the client's physical well-bing

A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching?

"I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level." This response indicates the client understands and is using the SMART goal method: creating goals that are specific (S), measurable (M), attainable (A), realistic (R), and timely (T).

a nurse is caring for a client who is experiencing unexpected manifestations with several body systems. which of the following priority setting frameworks should the nurse use the prioritize client assessment

ABCDE

A nurse and urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?

Assessment

In what order should an RN perform the steps of the nursing process?

Assessment, analysis, planning, implementation, evaluation

A charge nurse is planning to discuss factors that can influence the clinical decision making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include?

Available resources, awareness of client status, support from other staff

A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN model that can assist the nurse is critical thinking and decision making?

Clinical judgment

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reason when it is complicated by which of the following factors?

Complex clinical situations, ongoing client and family concerns

A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk?

Continuity of care The nurse should understand that continuity of care can cause a safety risk of a client when there are numerous hand-off reports completed during a transfer to another unit. The nurse should wait until the other nurse is available for report.

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make?

Critical thinking is the foundation for clinical decision making

A nurse asked the client to write the current level of pain using a scale of 0 to 10 after administering a pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

Evaluation

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion?

Inference, creativity, inductive reasoning

A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use?

Make a list and prioritize a plan. Managing multiple clients can be difficult for a new nurse. Making a list of all tasks to accomplish and then prioritizing a plan can help the nurse stay organized and efficient.

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process?

Planning

A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety?

Right task The charge nurse should delegate an assignment or task that is safe for a health care worker to carry out. Safety includes right training, competency, or within the health care worker's scope of practice.

A nurse is speaking with a client who is non-compliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make?

What is preventing your consistency with your daily blood glucose checks?" The nurse is using an open-ended question to encourage the client to talk more about what is hindering them from the process for daily blood glucose testing.

a nurse is assisting with client triage at the scene of a mass casualty event. which of the following clients should the nurse recommend for transport first.

a client who has an abdominal wound that is actively bleeding

a nurse has received change-of-shift report on four clients. which of the following clients should the nurse plan to see first

a client who has audible wheezing during respiration

a nurse has received change-of-shift report for a group of clients. which of the following clients should the nurse plan to see first

a client who is receiving a blood transfusion and reports urticaria

a nurse is reviewing the medical records of four clients. which of the following clients should the nurse identify as the priority for care

a client who received digoxin and has a heart rate of 48/min

a nurse is assessing a client using the ABCDE approach. the nurse has already assessed the client's airway and breathing status. which of the following assessments should the nurse perform next

blood pressure

a nurse is caring for a client who is confused and trying to remove their peripheral IV. using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take first

cover the IV site with an elastic bandage

a nurse is assessing a client using the ABCDE priority-setting approach. which of the following actions should the nurse take when completing the exposure component of this priority setting method

observe the client's lower extremities for indications of deep vein thrombosis measure the client's temperature check the client for bruising

a nurse is admitting a client who has hypertension. using the nursing process, which of the following actions should the nurse take first

perform a physical assessment

a nurse is caring for a client who reports feeling inferior and states that they are not good enough. the nurse should recognize that these feeling fall under which of the following categories of Maslow's Hierarch of needs

self-esteem

a nurse is performing an admission assessment on a client. using the safety and risk reduction priority setting framework, which of the following finding should the nurse identify as the priority

the client reports dizziness when standing

a nurse is caring for a client who reports new onset of abdominal pain. the nurse should assign the client's condition to which of the following categories when prioritizing care

urgent

A charge nurse is teaching a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Nurses will pair together to care for an assigned group of clients." Team nursing is the concept of nursing that pairs two or more nurses together to provide care for a group of clients. Team nursing provides support for novice nurses and others that are not as skilled in performing more complex tasks. A positive outcome of team nursing is the team works together. No one is expected to perform tasks that they are uncomfortable with or not competent to perform.