General Survey 3.0 Test , Test: Skills Module 3.0: Infection Control Pretest, ATI vital post test, Intro to Health Assessment, ATI: Clinical Judgement Process

A nurse is caring for a client who is experiencing severe pain. Which of the following client statements indicates that the client is experiencing chronic pain? Select all that apply.

"The pain has been off and on for about a year now." "I have had this pain for 9 months." "The pain has been off and on for about a year now"

A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey? Select all that apply.

- Height and weight - Behavior and mood - Use of assistive devices

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? Select all that apply.

- Obesity - Diuretic medication - Time of day - Smoking

Survival Potential

-Use this framework for situations in which health resources are extremely limited (mass casualty, disaster triage) -give priority to clients who have a reasonable chance of survival with prompt intervention. **Clients who have a limited likelihood of survival even with intense intervention are assigned the lowest priority.

5 steps of the Nursing Process

1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation AAPIE *Blueprint for Nursing

A nurse is preparing to measure a clients vital signs. The nurse should identify that which of the following factors will affect the methods that are used?

1. BMI of 35 2. Stuffy nose 3. irregular hearth rate 4. mastectomy 2 years ago

A nurse is planning to obtain orthostatic blood pressures from a client who has syncope. In what order should the nurse complete the steps?

1. Place the client in a supine position and allow them to rest 2. Take the client's blood pressure in the supine position 3. Keep the cuff in place and assist the client to a seated position 4. Take the client's blood pressure in a seated position 5. Assist the client to stand and then obtain their blood pressure

Inspection

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment?

Request assistance from an interpreter during the assessment

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process?

Autonomy

A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." Which of the following ethical principles is the client using?

Assessment

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first?

Implementation

A nurse is assisting with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing?

Put themselves in the client's situation to understand the client's anxiety

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client?

Record the client's most recent assessment results.

A nurse is completing documentation in a client's medical record. Which of the following actions should the nurse take?

Palpate the tender areas of the abdomen last.

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?

Maintain a fair distance between self and client.

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?

Subjective

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which of the following is the type of data the nurse is collecting?

Stethoscope

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment?

Correct answers: Penlight Tape measure Tongue depressor

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (SATA)

Correct terms: -Goggles -Gown -Gloves

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of PPE should the nurse wear while performing this task? (SATA)

Do not expose any more of the client's body than required at a time.

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy?

Skin temperature, moisture, and abnormalities

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?

iterative process

A process based on repetition of steps and procedures. Doing it again and again RNs knowledge to observe and assess presenting situations, identify prioritized client concern, generate best possible evidence-based solutions in order to deliver safe client care

Factors that influence RN decision making in Acute care setting

Awareness of client setting Goals/outcomes Options to meet goals Routines Education Nursing Roles Teamwork Resources Support from other staff Patient education

critical thinking

Critical Component The foundation of decision making-independently and collaboratively (inference, creativity, and inductive reasoning) Includes logic and reasoning to identify areas of needs while considering alternative approaches and solutions

utilizing the nursing process and clinical judgement functions in order for RN to make sound clinical decisions involves:

Critical thinking Clinical reasoning -Cannot be delegated and Clinical Judgement -Cannot be delegated

4 Steps of the PN process (NOT RN)

Data Collection Planning Implementation Evaluation

black (expectant) lowest priority

Deceased or will not survive

To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry?

Drying provides the full antiseptic effect.

A nurse is assessing a client's respiration. Which of the following actions should the nurse take?

Elevate the head of the clients bed 45 degree to 60 degree.

A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39 celsius (102 degrees f). Which of the following other vital signs should the nurse expect?

Elevated pulse rate A fever increases metabolic rate and peripheral vasodilation resulting in an increased pulse rate

A nurse is preparing to conduct a general survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take?

Engage in active listening with the client and allow the client to express concerns early in the assessment process.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take?

Ensure the client's feet are in contact with the wall or measuring pole.

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). What is the priority? Top-down

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. Was goal met? Partially met? Goal not met? Reassess or continue with care plan

PN evaluation

Evaluating outcome of interventions

Hypothesis is formed based on

Evidence

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement?

Fasciculation

Analysis-Analyzing cues & prioritize hypothesis

Formulates a plan of care *Ability to analyze assessment data to identify health problems and risks of a client for health intervention *Identifies trends and patterns-compares to expected data ranges and draws conclusions to direct nursing care

When conducting a general survey of a client, the nurse should assess ________, ________, and ________.

Gait, Speech, and Level of Consciousness

After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately?

Gloves

Generate Solutions (Planning)

Identify expected outcomes and related nursing interventions to ensure clients' needs are met. Develop evidence-based goals and desired outcomes-BE SPECIFIC

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. *Less invasive first or right away

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?

Infectious disease

A nurse is taking an adult client's temperature rectally. Which of of the following actions should the nurse take?

Insert the prob about 2.5 cm (1 to 1.5 in) into the client's anus

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?

It might not follow with the fitfh Korotkoff sound.

Which of the following is an advantage of using alcohol-based gel?

It takes less time to use than washing with soap and water.

Analyze Cues (Analysis)

Link recognized cues to a client's clinical presentation and establish probable client needs, concerns, or problems. This involves making clinical judgement regarding potential health conditions or needs

Safety Issues

Medication errors Surgical complications device and equipment malfunctions healthcare associated infections falls pressure injuries environmental factors (wet floor ect)

Assessment -Recognizing Cues

New and unstable clients Identify expected and unexpected findings *Applying nursing knowledge to the collection, validation, and documentation of client data *Focus on client responses to specific health problems, health beliefs and practices (Cultural) *Critically performing a comprehensive assessment of subjective and objective information *Excellent communication and assessment skills to plan care

Planning-Generate Solutions

Nursing Interventions-Less invasive 1st *Formulates individualized interventions and goals *Rn has the ability to make decisions and problem-solve *RN uses client assessment data to develop measurable goals, outcomes, and interventions to assist the client to meet goals *Attainable-Short term and long-term goals that are measurable, realistic time frame, and acceptable to the client

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?

Observe the clients chest movements while appearing to assess their pulse.

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration.

Observe the degree of the chest-wall movement during inspiration and expiration.

A nurse is preparing to auscultate a client's apical pulse a the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?

Over the fifth intercostal space at the left midclaviclular line.

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record?

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula

Which of the following products can affect the permeability of latex gloves?

Petroleum Based hand lotion

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?

Place the probe in the posterior lingual pocket lateral to there midline. The heat produces by superficial blood vessels in the right and the left posterior

A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client?

Protect their eyes.

A nurse is preparing to use a tympanic thermometer to acquire a clients temperature. Which of the following actions actions should the nurse take to ensure an accurate reading?

Pull the pinna back and upward gently

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting?

Pulse pressure

Clinical Judgement can be carried out by

RN NOT PN

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors as possibly interfering with obtaining a pulse oximetry reading?

Recent scan with contrast dye

A nurse is caring for an adult client who is comatose. Which of the following routes should the nurse use to obtain the most accurate core body temperature of the client?

Rectal

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?

Respirations 30/min

PN data collection

Stable Patients only

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings?

Tachycardia

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings?

Tachypnea

Implementation-Take Actions

Take action outlined in the care plan *RN has the ability to apply knowledge to implement client interventions to promote, maintain, or restore health *RN's ability to delegate and supervise care and document care and client's response to care

While conducting a general survey on a client who is being admitted to a long-term care facility, a nurse is assessing the client's emotional state. Which of the following findings should the nurse record as an unexpected finding?

The client reports they feel sad and lonely most of the time.

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can decrease a client's respiratory rate?

The client takes a narcotic pain medication for chronic pain.

Recognizing cues (assessment)

The nurse collects, organizes, and filters information from different sources and focuses on clients' responses to actual/potential health problems. (Relevance and data collection) (i.e.: signs, symptoms, health history, environment) Use Holistic approach

A nurse is admitting a client who is 162.6 cm (64 in) tall and weighs 68.2 kg (150 lb). Using the BMI table shown below, what should the nurse record as the client's BMI? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

The nurse should record the client's BMI as 25.

Clinical Judgement

The observed outcome of critical thinking and decision making

A nurse is preparing to obtain a clients blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?

Use a cuff of the appropriate size for the client

A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take which of the following actions?

Wash for atleast 20 seconds

A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?

When the semilunar valves close

clinical reasoning

a specific term usually referring to ways of thinking about patient care issues (determining, preventing, and managing patient problems Assessing and compiling data Selecting and discarding info based off of relevance Client care decision making based on knowledge Mental process of analyzing clinical situation data

Safety & Risk Reduction

assigns priority to the factor or situation posing the greatest: safety risk to the client, greatest risk to the client's physical or psychological well-being Maslows Hierarchy of Needs ABCDE

Spiritual well-being holistic approach to a client

assist client to observe a religious practice by providing time for meditation, praying, etc...

PN Planning

assisting and collaborating with the RN -NOT assuming full responsibility for the care plan

Interdependent interventions

carried out in collaboration with other health team members such as physical therapists social workers dieticians and physicians

PN implementation

collaborate with the RN and only within scope of practice

Critical Thinking

creative action based on professional knowledge and experience involving sound judgement applied with high ethical standards and integrity Problem-thinking-solution

NCSBN (National Council of State Boards of Nursing)

developed CJAM-Clinical judgement action model

What should the nurse do to maintain standard precautions?

disinfect hands immediately after removing gloves

A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear?

face shield

Nursing Process

five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating that requires critical thinking and clinical decisions using both experience and evidence-based practices

Plan of care

goals, interventions, desired outcomes, and criteria for discharge It is accessed, utilized, and modified by ALL members of the interprofessional healthcare team

holistic process

holistic client centered care that considers entire person: Includes physical, spiritual, and mental well-being

interprofessional healthcare team

includes professionals (RN, NP, PA, PT/OT/RT, social worker, etc) and nonprofessionals (those integral to healthcare but don't have license)

Individual factors of Clinical Judgement

knowledge and skills attitudes prior experience level of experience cognitive load demands stresses problem-solving memory

Red/Emergent/Immediate

life threatening-high potential for survival Need transport from scene immediately

green (nonurgent)

minor injuries

Physical well-being holistic approach to a client

nutrition-diet promoting physical activity educate on recommended health screening

Solutions are based on a hypothesis that is

prioritized (refined)

Clinical Judgement Model

recognize cues(assessment), analyze cues (Analysis), prioritize hypotheses (Analysis), generate solutions(Planning), take action (Implementation), evaluate outcomes (Evaluation)

4 categories of survival potential

red-emergent yellow-urgent or delayed green-non-emergent black-expectant

Clinical Judgement

refers to the result (outcome) of critical thinking or clinical reasoning; the conclusion, decision, or opinion a nurse makes to deliver safe and effective care to clients in all clinical settings

Dependant interventions

require instruction, written orders, or supervision of another health care provider with prescriptive authority

A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI?

salmonella

Yellow (urgent/delayed)

serious injury-not life threatening require treatment in 30min -2 hrs

Environmental factors of Clinical Judgement

setting and situation safety equipment surroundings staffing supplies health records time pressure cultural considerations task complexity risk assessment

Mental well-being holistic approach to a client

teaching relaxation techniques outdoor walks assist in maintaining relationships with support

Evaluation-Evaluate Outcomes

the effectiveness of the interventions *RN's ability to identify the need for further intervention or alter the plan of care- to evaluate the need to continue, discontinue, or modify the care plan based on the client's intervention response to reach a nurse's judgment regarding the client's extent of meeting goals and outcomes. *RN to assess client/staff understanding of instruction and effectiveness of interventions *RN to asses clients adherence to the plan Goal Met Partial Goal Met-reassess (is it moving in the right direction?) Goal Not Met-reassess

After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take?

washing hands with soap and water

independant interventions

what the nurse can do (w/o Dr order)