ATI Clinical Judgment Process

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? A. Evaluation B. Implementation C. Analysis D. Assessment

D. 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. A. Evaluation is incorrect. In the evaluation step of the nursing process, the nurse evaluates the effectiveness of interventions provided for the client. B. Implementation is incorrect. In the implementation step of the nursing process, the nurse carries out the interventions in the client's plan of care. C. Analysis is incorrect. In the analysis step of the nursing process, the nurse reviews the client's assessment findings to determine what problems the client might have in order to formulate a plan of care.

In what order should an RN perform the steps of the nursing process? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps). Analysis Assessment Planning Evaluation Implementation

Assessment Analysis Planning Implementation Evaluation The nursing process for RNs consists of five steps that are performed in the following order: Assessment, Analysis, Planning, Implementation, and 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? (Select all that apply). Inspection Implementation Inference Creativity Inductive reasoning

Inference, creativity, and inductive reasoning. Inspection is incorrect. Inspection is part of the assessment step of the RN nursing process in which the nurse observes the client for expected and unexpected findings. Implementation is incorrect. Implementation is the fourth step of the nursing process that involves taking action to provide nursing care as outlined in the client's plan of care.

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? A. Clinical judgment B. Critical thinking C. Clinical reasoning D. SMART goal

A. Clinical judgment. The Clinical Judgment Model was developed to assist nurses in using evidence-based practice to think critically and make decisions. B. Critical thinking is incorrect. Critical thinking is the skill of learning to analyze and interpret data and is an element of the NCSBN's Clinical Judgment Model for nurses. C. Clinical reasoning is incorrect. Clinical reasoning is a constant and repeated action that nurses use in practice. Clinical reasoning influences the NCSBN's Clinical Judgment Model for nurses. D. SMART goal is incorrect. The acronym SMART represents a goal-setting framework (specific, measurable, attainable, relevant, time-based). While it is helpful in goal setting, it is not specific to using evidence-based practice to make clinical judgments used in the NCSBN's Clinical Judgment Model for nurses.

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? A."Critical thinking is the foundation for clinical decision making." B. "Critical thinking takes into consideration nursing, scientific, and technological knowledge in client situations." C. "Critical thinking is the visible or observed outcome while using evidence-based practice." D. "Critical thinking is necessary for the nurse to collect objective client data."

A."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. B. "Critical thinking takes into consideration nursing, scientific, and technological knowledge in client situations." is incorrect. Clinical reasoning, rather than critical thinking, takes into consideration nursing, scientific, and technological knowledge in client situations. C. "Critical thinking is the visible or observed outcome while using evidence-based practice." is incorrect. Clinical judgment is defined by the NCSBN® as the visible or observed outcome of the elements of critical thinking and decision making that considers nursing knowledge, client situations, prioritization of client problems and concerns, while using evidence-based practice. D. "Critical thinking is necessary for the nurse to collect objective client data." is incorrect. Objective client data is data that can be observed by the nurses through the senses (sight, hearing, smelling, touching). It does not involve the element of critical thinking to collect this type of data.

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? A. Delegation of the right circumstance B. Delegation of the wrong task C. Delegation to the right person D. Delegation of the wrong time

B. Delegation of the wrong task. Delegating an AP to use a stethoscope and listen to lung sounds is inappropriate as it is not within the range of function of an AP. This action involves clinical reasoning and should be delegated to a nurse. A. Delegation of the right circumstance is incorrect. 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. C. Delegation to the right person is incorrect. Using a stethoscope and listening to lung sounds is not within the range of function of an AP. This action involves clinical reasoning and should be delegated to a nurse. D. Delegation of the wrong time is incorrect. The nurse does need to have this task completed at this time. However, this assignment is not within the range of function of an AP and should be delegated to a nurse.

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 Cost of health care is incorrect. In some cases, the benefits of the health care interventions can be much less than the cost of those interventions. For example, a client who has terminal cancer might not benefit from medication or surgery and, by receiving either form of care, the client would incur further costs without receiving a benefit. Decreased need for advanced health care practitioner intervention is incorrect. A decreased need for advanced health care practitioner intervention would not complicate the client's care and could help to simplify it. The need for fewer interventions would not require clinical reasoning because the health care decisions would be less complex. Availability of computerized medical records is incorrect. Computerized medical records can assist nurses by providing quick access to client information and clinical resources which can streamline, rather than complicate, clinical reasoning.

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? A. Evaluation B. Implementation C. Analysis D. Planning

D. 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. A. Evaluation is incorrect. The evaluation step of the nursing process occurs when the nurse assesses the effectiveness of interventions used to help the client achieve a goal, such as ambulating. Reviewing if the client ambulated with assistance is an example of the evaluation step of the nursing process. B. Implementation is incorrect. The implementation step of the nursing process occurs when the nurse carries out the interventions planned for the client. Assisting the client to ambulate is an example of implementation. C. Analysis is incorrect. In the analysis step of the nursing process, the nurse uses objective and subjective data to determine what problems the client is experiencing. For this client, the nurse could use nonverbal cues (such as shaking of the head), verbal reports of an inability to ambulate alone, and reluctance to ambulate as indications that the client's situation requires intervention.

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? A. Evaluation B. Implementation C. Analysis D. Planning

A. 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. B. Implementation is incorrect. In the implementation step of the nursing process, the nurse carries out interventions that were planned for the client. An example of the implementation step would be the administration of pain medication to the client. C. Analysis is incorrect. In the analysis step of the nursing process, the nurse reviews client findings and determines the client's problems in order to develop the client's plan of care. D. Planning is incorrect. In the planning step of the nursing process, the nurse develops interventions to treat or manage the client's identified problems.

A charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly license 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 Awareness of client status Support from other staff Appropriate delegation is incorrect. Although appropriate delegation is a necessary part of daily nursing practice, it is not a factor that can influence the clinical decision-making process, which is used as the framework for developing the plan of care. Cost of client care is incorrect. Cost is not considered a factor that can influence the decision-making process, which is used as the framework for developing the plan of care.