ATI- Clinical Judgment Process

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 with critical thinking and decision making?

Clinical judgment (The Clinical Judgment Model was developed to assist nurses in using evidence-based practice to think critically and make decisions.)

Some Things Cannot Be Delegated!

Clinical reasoning and clinical judgment cannot be delegated to unlicensed staff.

The PN plans to return to the client's bedside and explain that promethazine is usually effective in relieving nausea, and that this medication is administered rectally. The PN enters the client's room and asks the client, "Have you ever received a suppository before?"; the PN then explains the procedure before its administration. The PN assists the client to a comfortable position. The client asks for a cool towel to place on the forehead to assist in relieving nausea, saying this has helped in the past. Write the steps of the PN nursing process used and explain how the PN addressed each one in this scenario. (Submit your response to compare it to an expert response.)

Collect data: The PN asks if the client has previously had a suppository. Plan: The PN plans to reinforce teaching on the medication usage and administration. Implement: The PN explains the suppository procedure, assists the client into a comfortable position, and provides a cool towel per the client's request.

In what order should a licensed practical nurse (LPN) perform the steps of the nursing process?

Data collection, Planning, Implementation, and Evaluation.

Subjective data

Data that is based upon the client's feelings, perception and assumptions.

A nurse is caring for a client who has been wheezing. The nurse asks an assistive personnel (AP) to use a stethoscope and listen to the client's lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts?

Delegation of the wrong task (Using a stethoscope and listening to lung sounds is not within the range of function of an AP. The circumstances of this assignment involves assessment or data collection, which require clinical reasoning and should be delegated to a nurse.)

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

Evaluation (The nurse is using the evaluation step of the nursing process by collecting subjective data from the client using an established pain scale to compare the client's current pain level to their original level of pain.)

4. Implementation

Involves the nurse's ability to apply nursing knowledge to implement interventions to assist a client to promote, maintain, or restore health

A nurse is assisting with 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 (In the planning step of the nursing process, the nurse develops interventions to treat or manage the client's identified problems. The plan of care guides the treatment of the client and should be modified as the client's condition changes. In this scenario, the nurse is making goals for the client regarding ambulation.)

In an urgent care setting, the PN is caring for a client who reports nausea. When collecting data, which of the following questions should the PN ask the client regarding the nausea?

The PN should collect data relating to nausea. When did the nausea begin? What did you have to eat or drink, if anything, before the nausea began? Has the nausea been constant or intermittent? Have you done anything or taken any medication for your nausea? Did it help? Have you vomited? If so, how many times? When did the vomiting begin?

1. Assessment

The application of nursing knowledge to the collection, organization, validation and documentation of data about a client's health status. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information.

In what order should a licensed nurse (RN) perform the steps of the nursing process?

The nursing process for RNs consists of five steps that are performed in the following order: Assessment, Analysis, Planning, Implementation, and Evaluation.

Sort the following into tasks that can be delegated to an AP and tasks that cannot be delegated to an AP.

Wound care for a new wound: Wound care is a skill that requires judgment both in assessment and data collection and in choice of treatment. This would not be appropriate to delegate to an AP. The RN must assess and make decisions about treatment. Measurement of vital signs, including pulse, can be delegated to the AP. Measurement of urine can be delegated to the AP. Assessment of the respiratory system should be completed by the RN. Collection of a stool sample can be delegated to the AP. Assessment of urine should be completed by the RN. Ambulation to the bathroom may be assisted by the AP. Medication administration, including eye drops, must be performed by a licensed person—an RN or PN, or a licensed medication technician in some facilities.

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? (Select all that apply.) Appropriate delegation Cost of client care Available resources Awareness of client status Support from other staff

Available resources (Resources are factors that can influence the decision-making process, which is used as the framework for developing the plan of care.) Awareness of client status (The nurse's awareness of the client's status is a factor that can influence the decision-making process, which is used as the framework for developing the plan of care.) Support from other staff (The availability of support from other staff is a factor that can influence the decision-making process, which is used as the framework for developing the plan of care.)

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? (Select all that apply.)

Inference (Inference is a skill that is associated with critical thinking that the nurse can use as part of higher-level thinking.) Creativity (Creativity is a skill that is associated with critical thinking. The nurse can use creativity as a part of higher-level thinking to critically analyze problems and develop solutions.) Inductive reasoning (Inductive reasoning is a skill that is associated with critical thinking that the nurse can use as a part of higher-level thinking.)

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the client's care requires clinical reasoning when it is complicated by which of the following factors? (Select all that apply.) Complex clinical situations Ongoing client and family concerns Cost of health care Decreased need for advanced health care practitioner intervention Availability of computerized medical records

Complex clinical situations Ongoing client and family concerns

A PN is contributing to the plan of care for a client who has nausea. After collaborating with the RN, a plan is developed that calls for administering a prescribed promethazine suppository for the client's nausea. What might an appropriate client-centered goal for this plan include?

The goal is that the client will report a decreased nausea level and the absence of vomiting within an hour of administration of the promethazine suppository.

Delegation

Assigning a nursing task or procedure to another person who has the training appropriate for that task or procedure.

Objective data

Data that can be observed by the nurse through the senses.

critical thinking

Thought process that is systematic and logical in reviewing information and data, that is open to reflection, inquiry and exploration in order to make informed decisions.

5. Evaluation

review patient goals and determine if expected outcomes were met, document degree of goal attainment, terminate, continue, or revise plan of care

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." (Critical thinking is considered a higher order of thinking that is the foundation for clinical decision making. It is a critical component of nursing care and is used in each step of the nursing process to enhance client care.)

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2. Analysis

RN only happens after nurse collects data second step of nursing process for RNs lays foundation for making decisions about client's plan of care takes priority over planning, implementation, and evaluation

Clinical Judgment in Nursing Practice

1. Recognize Cues (Assessment) Filter information from different sources (e.g., signs, symjptoms, health history, environment). 2. Analyze Cues (Analysis) Link recognized cues to a client's clinical presentation and establish probable client needs, concerns, or problems. 3. Prioritize Hypotheses (Analysis) Establish priorities of care based on the client's health problems (e.g., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values). 4. Generate Solutions (Planning) Identify expected outcomes and related nursing interventions to ensure clients' needs are met. 5. Take Actions (Implementation) Implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client's health. 6. Evaluate Outcomes (Evaluation) Evaluate a client's response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met.

A nurse at an 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 (The nurse should identify auscultating a client's lungs as being part of the assessment step of the nursing process because the nurse is collecting data from the client. Auscultating the client's lung sounds is part of a physical assessment.)

Nursing Process

Assess and identify expected and unexpected findings. Analyze assessment data and prioritize needs. Plan nursing interventions. Implement interventions to address client needs. Evaluate the effectiveness of interventions.