Nursing Process & Clinical Judgement
This initial step of the nursing process involves collecting, organizing, validating, and documenting client health data
What is Assessment OR Data Collection for Practical Nurses?
This physical assessment technique uses the stethoscope’s diaphragm or bell to listen to heart, lung, and bowel sounds
What is Auscultation?
Standardized handoff communication technique that includes Introduction, Situation, Background, Assessment, Recommendation, and Read-back[20]
What is I-SBAR-R (or ISBARR)?
This core ethical principle directs health care providers to "do no harm" to the client
What is Nonmaleficence?
Guidelines established by the NCSBN that include Right Task, Right Circumstance, Right Person, Right Direction/Communication, and Right Supervision/Evaluation
What are the Five Rights of Delegation?
In the NCSBN Clinical Judgment Measurement Model, this cognitive function directly corresponds to the Assessment phase
What is Recognizing Cues?
This acronym documents normal pupil findings during a cranial nerve/neurological examination
What is PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation)?
A therapeutic communication technique where the nurse repeats or rephrases the client's message to verify understanding
What is Restating (or Paraphrasing / Summarizing)?
Federal law prohibiting emergency departments from turning away clients based on insurance or inability to pay
What is EMTALA (Emergency Medical Treatment and Labor Act)?
Tasks such as obtaining vital signs, measuring I&O, and assisting with basic ADLs are delegated to this care team member
Who is Assistive Personnel (AP) or Certified Nursing Assistant (CNA)?
This type of health data is derived directly from the client's self-reported feelings, symptoms, or statements
What is Subjective Data?
An adult heart rate that falls below 60 beats per minute is documented using this term
What is Bradycardia?
The Joint Commission recommends hospitals establish this policy regarding workplace incivility, bullying, and lateral violence
What is a Zero-Tolerance policy?
A mandatory safety pause conducted by the entire operating team prior to surgery to confirm client, site, and procedure
What is a Time-out?
State-level legislation defining the legal boundaries and scope of practice for licensed nurses
What is the Nurse Practice Act (NPA)?
During the planning phase, client goals must possess these specific characteristics to ensure effective evaluation
What are realistic, measurable, and time-oriented goals?
Located between the great toe and second toe, this peripheral pulse site evaluates perfusion to the foot
What is the Dorsalis Pedis pulse?
Asking a client "Why did you do that?" is considered this type of nontherapeutic inquiry because it induces defensiveness
What is a "Why" question (or challenging/dismissive statement)?
An unexpected healthcare incident resulting in severe physical/psychological injury or death
What is a Sentinel Event?
A reimbursement structure where facilities receive a fixed payment based on client admission categories regardless of actual length of stay
What are Diagnosis-Related Groups (DRGs)?
Unlike basic routine tasks, these cognitive responsibilities can never be delegated to unlicensed assistive personnel (AP)
What are clinical reasoning and clinical judgment?
This condition occurs when a client experiences a drop in systolic BP of at least 20 mm Hg or diastolic BP of at least 10 mm Hg upon standing
What is Orthostatic Hypotension?
In Motivational Interviewing, the acronym OARS stands for these four fundamental techniques
What are Open-ended questions, Affirmations, Reflective listening, and Summarizing?
A civil wrong or failure to perform a duty that causes legally cognizable injury or harm to a person or property
What is a Tort?
Recognized as the single most effective action health care workers can perform to prevent hospital-acquired infections (HAIs)
What is Hand Hygiene?