Clinical judgement-Adaptive Assessments (Nursing Concepts Online for RN 2.0, 2nd Edition)

Which action of the leader signifies the implementation phase of the nursing process to teaching?

Sequencing different tasks

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as examples of the feedback component? Select all that apply.

1 -"The nurse notices that the client's pain has decreased after giving a back massage." 2 -"The caregiver says that the client's body temperature has decreased after administering the prescribed medication." 5 -"The nurse finds that the client has developed breathing issues after the medication is administered through the central venous access device."

A nursing student is learning about the nursing process, which consists of four components. Which scenarios should the nursing student consider as content components? Select all that apply.

2 -"The nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli." 4 -The nurse understands that many clients buy prescribed medications from multiple medical stores; this is known as polypharmacy." 5 -"The nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent the spread of pathogens." The content component involves information about the nursing interventions for clients with specific health care problems. When the nurse-in-charge asks the nurse to check the intravenous tubing for air bubbles to prevent air emboli, this action is an example of the content component. When the nurse understands that many clients practice polypharmacy by purchasing prescribed medications from multiple stores, this understanding is an example of the content component. When the nurse knows that clients with airborne diseases should be placed in an airborne infection isolation room (AIIR) to prevent spread of pathogens, this knowledge is an example of the content component. When the nurse assessing a client's medical records before surgery finds that the client is allergic to latex, this discovery is an example of the input component. When the nurse checks the medical records of the client for blood transfusion reaction before administering a blood transfusion, this action is an example of the input component.

A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake?

Assessment

The nurse interviews a client about a current health problem. The nurse then obtains and documents the client's temperature, blood pressure, and heart rate. Which step of the nursing process is involved in this situation?

Assessment

The nurse is verbally interviewing and taking a history of a client who was admitted to the hospital. Which phase of the nursing process is being used in this situation?

Assessment

With reference to the nursing process as a system, what is content?

Content is the product and information obtained from the system.

A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied?

Evaluation

Which nursing process includes tasks that can be delegated?

Implementation

Which nursing process involves delegation and verbal discussion with the healthcare team?

Implementation

Which step in the nursing process would involve promoting a safe environment for the client?

Implementation

While assessing a client, the nurse finds that the client has swelling and skin discoloration in the lower limbs. Which component of nursing process does this information indicate?

Input