Nursing Process
Which statement by a nurse best indicates an accurate understanding of the different types of assessments? "It is up to the nurse to decide which assessment to perform." "How much time the nurse has and how the client is feeling determine which type of assessment to perform." "The purpose for the assessment offers guidance for which type and how much data to collect." "The physician informs the nurse of which type of assessment to perform for each client."
"The purpose for the assessment offers guidance for which type and how much data to collect."
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? "My leg hurts so bad. I can't stand it." "Appears anxious and frightened." "I am so sick; I am about to throw up." "Unable to palpate femoral pulse in left leg."
"Unable to palpate femoral pulse in left leg."
These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Impaired Swallowing Risk for Impaired Skin Integrity Altered Body Image Fluid Volume Deficit
1. Impaired Swallowing 2. Fluid Volume Deficit 3. Risk for Impaired Skin Integrity 4. Altered Body Image
The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious A 68-year-old woman with bruises across the chest and lower abdomen who is observed rubbing the bruised area on the lower abdomen and moaning A 4-year-old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly An 18-year-old woman sitting up in bed with an egg-size hematoma and a 5-cm laceration on the forehead who is talking rapidly on a cell phone
A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious
Analysis should always arise from
A cluster of clues as opposed to one single clue
Actual or Potential: Higher priority
Actual
A client has been diagnosed with pneumonia and is experiencing chest pain when taking a deep breath. What are the priority nursing diagnoses? Select all that apply. Acute Pain Feeding Self-Care Deficit Risk for Infection Anxiety Ineffective Airway Clearance
Acute Pain Ineffective Airway Clearance
A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply. Developing a nursing care plan Administering an oral antibiotic Auscultating breath sounds Performing an admission assessment Obtaining pulse oximetry
Administering an oral antibiotic Auscultating breath sounds Obtaining pulse oximetry
Assess...
Assess Intervention
What part of the Nursing Process is being carried out? Clustering Data & Identifying Patterns
Assessment
What part of the Nursing Process is being carried out? Collect patient data
Assessment
What part of the Nursing Process is being carried out? Ongoing monitoring
Assessment
What part of the Nursing Process is being carried out? Validating Data
Assessment
Planning Nursing Intervention
Assessment Cares Teaching Treatment
The Nursing Process: Order or Sequence of Events
Assessment Determining Problems (Diagnoses) Planning Implementation Evaluation
Objective or subjective finding: Weakness
Both Subjective or Objective
Monitor or Provide
Care Intervention
A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective? Client will use chin tuck and double swallow for each bite. Client will avoid straws and drink thickened liquids. Client will sit in chair for all meals and snacks. Client will chew food well and use a tongue sweep.
Client will use chin tuck and double swallow for each bite.
Determining what's relevant and forming initial impressions
Clustering Data & Identifying Patterns
Requires combination of nurse-driven and provider-driven interventions
Collaborative Problems
Which parts of the nurse's decision about care occur after evaluating the client's responses to the plan of care? Select all that apply. Continue the plan of care Terminate the plan of care Begin the plan of care Communicate the plan of care Modify the plan of care
Continue the plan of care Terminate the plan of care Modify the plan of care
Upon evaluation, determine whether the plan of care should be
Continued, modified, or terminated
A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking." What is the priority nursing diagnosis? Impaired Walking Activity Intolerance Deficient Diversional Activity Disturbed Body Image
Deficient Diversional Activity
A client has just given birth to the client's first baby. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. Which is the priority nursing diagnosis for the nurse to address prior to discharge of this client? Fear Deficient Knowledge Alteration in Family Processes Stress Overload Ineffective Coping Mechanisms
Deficient Knowledge
Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply. Delegate tasks that are within the UAP's scope of practice. Provide appropriate supervision when delegating tasks. Delegate tasks that involve minimal risk. Provide feedback to the UAP after the task is completed. Delegate correctly to avoid the UAP asking questions about the task.
Delegate tasks that are within the UAP's scope of practice. Provide appropriate supervision when delegating tasks. Delegate tasks that involve minimal risk. Provide feedback to the UAP after the task is completed.
What part of the Nursing Process is being carried out? Analysis
Determining Problems (Diagnoses)
What part of the Nursing Process is being carried out? Collaborative Problems
Determining Problems (Diagnoses)
What part of the Nursing Process is being carried out? Considerations
Determining Problems (Diagnoses)
Bedside shit report
Direct intervention
Deescalating patient
Direct intervention
Giving Subcutaneous injection of Heparin every 12 hours per provider order
Direct intervention
Giving patient Albuterol breathing treatment per provider order
Direct intervention
Patient is getting chest physiotherapy (CPT)
Direct intervention
Turning patient
Direct intervention
Treatment performed through interaction with patient (both physiological and psychosocial cares)
Direct treatment
The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? Outcome identification Assessment Evaluation Implementation
Evaluation
What part of the Nursing Process is being carried out? Evaluate the effectiveness of plan of care
Evaluation
What part of the Nursing Process is being carried out? Identifying factors that positively or negatively impacted outcome
Evaluation
What part of the Nursing Process is being carried out? Include patient/support system
Evaluation
The nurse is caring for a patient with an IV infusion and notes an elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention. Based on the assessment, the nurse suspects: fluid overload air embolism acute myocardial infarction imminent stroke dehydration
Fluid overload
What part of the Nursing Process is being carried out? Direct or Indirect Treatment
Implementation
What part of the Nursing Process is being carried out? Execute the plan of care to promote wellness, prevent disease, restore health, facilitate coping.
Implementation
Treatment performed away from patient but on their behalf
Indirect Treatment
Cardiac Monitor Tech
Indirect intervention
Documentation
Indirect intervention
Getting report from another nurse over the phone
Indirect intervention
Determining Problems (Diagnoses): Considerations
Is it an actual or potential problem? What is the patient's readiness for health improvement efforts or education? What is the patient's response to their actual or potential problem?
> 48 hours
Long-Term
Objective or subjective finding: Accessory Muscle Use
Objective
Objective or subjective finding: BP
Objective
Objective or subjective finding: Bags under eyes
Objective
Objective or subjective finding: Cyanosis
Objective
Objective or subjective finding: Diaphoretic
Objective
Objective or subjective finding: Dyspnea
Objective
Objective or subjective finding: Ecchymosis
Objective
Objective or subjective finding: Erythema
Objective
Objective or subjective finding: Full active ROM
Objective
Objective or subjective finding: HR
Objective
Objective or subjective finding: Vomiting
Objective
Objective or subjective finding: X-ray shows pneumonia
Objective
To detect changes in patient condition or cues to revise plan of care
Ongoing monitoring
Planning Prioritization
Physiological and Psychological Safety Pt. preference Anticipation of future problems
Planning considerations
Plan individualized care that specifies desired patient goals and related outcomes that prevent, reduce, or resolve identified problems
What part of the Nursing Process is being carried out? Evidence-based, nurse-initiated interventions
Planning
What part of the Nursing Process is being carried out? Identify nursing interventions that will aid in meeting those outcomes
Planning
What part of the Nursing Process is being carried out? Plan individualized care that specifies desired patient goals and related outcomes that prevent, reduce, or resolve identified problems
Planning
What part of the Nursing Process is being carried out? Prioritization
Planning
What part of the Nursing Process is being carried out? Short-Term or Long-Term
Planning
What part of the Nursing Process is being carried out? Utilize patient strengths to achieve outcomes, involve support system as able
Planning
Actual or Potential: RISK
Potential
A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition? Risk for Activity Intolerance Risk for Ineffective Coping Risk for Infection Risk for Imbalanced Nutrition
Risk for Infection
< 48 hours
Short-Term
What part of the Nursing Process is being carried out? SMART outcome
Specific Measurable Achievable Realistic Timely
Objective or subjective finding: Anxiety
Subjective
Objective or subjective finding: Blurry Vision
Subjective
Objective or subjective finding: Headache
Subjective
Objective or subjective finding: Nausea
Subjective
Objective or subjective finding: Patient report of fever
Subjective
Objective or subjective finding: Tired
Subjective
Objective or subjective finding: Urgency with urination
Subjective
Collection of patient data includes
Subjective Objective History Physical Exam Support System/Family
Objective or subjective finding: Panic attack
Subjective (HR increase with observed panic attack-Objective)
Objective or subjective finding: SOB
Subjective (Increase in RR with SOB-Objective)
Objective or subjective finding: Frequency with urination
Subjective (Observe patient getting up frequently to urinate-Objective)
A client presents to the clinic for a routine postoperative visit. The nurse assesses the site of the incision and determines that the edges of the incision are approximated, sutures have been removed, and there is no redness or edema at the site. The incision appears to be well healed. The nurse reviews the plan of care and notes that one nursing diagnosis is related to potential infection related to impaired skin integrity. The nurse determines that this is no longer an issue for the client. Which change should the nurse make to the plan of care? Terminate the plan of care. Continue the plan of care. Modify the plan of care related to infection. Terminate the plan of care as it relates to infection.
Terminate the plan of care as it relates to infection.
Independent diagnosis and treatment based on nursing scope of practice and emphasizing a holistic approach to care and comfort
The Nursing Process
Which client outcome is a physiologic outcome? Select all that apply. The client self-administers insulin subcutaneously. The client rates their pain rating as 6. The client's HA1c is 7.4%. The client describes manifestations of wound infection. The client's blood pressure is 118/74.
The client rates their pain rating as 6. The client's HA1c is 7.4%. The client's blood pressure is 118/74.
Which of the following is a correctly written client goal? Select all that apply. The client will eat at least 75% of all meals by May 5. The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. The client will know the signs and symptoms of infection. The client will understand the side effects of digoxin (Lanoxin). The client will identify five low-sodium foods by October 9.
The client will eat at least 75% of all meals by May 5. The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. The client will identify five low-sodium foods by October 9.
The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. Which goal written by the nurse requires revision? The client will understand the effects of smoking related to heart disease. By 08/02/18, the client will state three therapeutic methods of reducing stress. By 8/02/18, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. By 8/02/18, the client will state when to notify the health care provider after discharge.
The client will understand the effects of smoking-related to heart disease.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client who needs vital signs taken following infusion of packed red blood cells. The client who requires assistance dressing in preparation for discharge. The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who is pleasantly confused and requires assistance to the bathroom.
The client with continuous pulse oximetry who requires pharyngeal suctioning.
Which items reflect the assessment phase of the nursing process? Select all that apply. The client's abdomen is firm and distended with hypoactive bowel sounds. The nurse and the client determine a tolerable pain level. The nurse asks the client, "How would you rate your pain?" The nurse assists the client with coughing and deep breathing every hour. The client states, "I rarely sleep more than 6 hours."
The client's abdomen is firm and distended with hypoactive bowel sounds. The nurse asks the client, "How would you rate your pain?" The client states, "I rarely sleep more than 6 hours."
Which nursing actions reflect the evaluation stage of the nursing process? Select all that apply. The nurse performs tracheostomy care using sterile technique. The nurse documents the client's response to suctioning. The nurse identifies that a client's pain is not being adequately treated. The nurse determines the client did not lose the expected 2 lb (0.90 kg). The nurse sets an anxiety level of 3 or less with the client.
The nurse documents the client's response to suctioning. The nurse identifies that a client's pain is not being adequately treated. The nurse determines the client did not lose the expected 2 lb (0.90 kg).
The nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made? The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. The nurse delegated tasks to the UAP that are outside the scope of that person's preparation. The nurse failed to validate the UAP's knowledge and skill to perform the tasks. The nurse delegated too many tasks to the unlicensed assistive personnel.
The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure.
Movement through the nursing process requires
Thorough completion of each previous step (fluid and constantly changing)
The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply. To help clients feel that something is being done for them To reveal changes from previously collected data To monitor clients' responses to treatment To help establish a diagnosis To confirm previously collected data
To reveal changes from previously collected data To monitor clients' responses to treatment To help establish a diagnosis To confirm previously collected data
The Nursing Process
Using clinical judgment to identify actual or potential health problems
Increases accuracy of care plan (done when there are discrepancies or data lacks objectivity)
Validating Data
A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first? an asthma client who reports shortness of breath with a respiratory rate of 26 bpm a client who has had a hysterectomy and reports bleeding from the surgical site a newly diagnosed client with diabetes who is crying and states "I do not understand how to give my insulin." a client who has had an appendectomy and has a temperature of 39.1 degrees C
an asthma client who reports shortness of breath with a respiratory rate of 26 bpm
The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? "Let me know if the client's blood pressure becomes elevated." "I need to know if the client's blood pressure changes from his normal baseline." "Notify me right away if the client's systolic blood pressure is 170 or greater." "If the client's blood pressure falls outside normal limits, come get me."
"Notify me right away if the client's systolic blood pressure is 170 or greater."
The charge nurse identifies the need for further education when a new nurse makes which statement? "Physical assessment is the examination of the client for objective data." "Physical assessment is the examination of the client for subjective data." "Physical assessment is ongoing to detect changes in the client's condition." "Physical assessment should be documented in a timely manner."
"Physical assessment is the examination of the client for subjective data."
