Patient Problems
A client who recently lost a spouse cries frequently, shares memories of their partner, and says, "I miss them every day."
What is the Patient problem: Grieving?
Before delegating a task, the nurse should consider the right task, right circumstance, right person, right direction, and right __________.
What is supervision?
Measurable goals and nursing interventions are developed during this step.
What is planning?
This professional behavior is demonstrated when a nurse uses evidence-based practice, follows the Code of Ethics, and consistently puts the patient's welfare first.
What is professionalism?
These 2 pieces of information must be verified by the nurse every time a medication is administered.
What are name and DOB?
This assessment is the nurse's highest priority before administering IV morphine to a postoperative patient.
What is the respiratory rate?
This assessment technique uses the sense of touch to gather information.
What is palpation?
This IV complication is characterized by cool, pale, swollen tissue at the insertion site.
What is infiltration?
A client awaiting biopsy results cannot sit still, reports nausea, has difficulty concentrating, and says, "I just don't know what's going to happen."
What is the Patient problem: Anxiety?
This team member may reinforce teaching but should not provide the initial patient education.
Who is the LVN?
A patient reports chest pain. Before calling the provider, the nurse obtains vital signs, assesses the pain, and applies oxygen.
Which step of the nursing process is this? What is assessment?
A nursing student realizes they administered a medication one hour late, immediately notifies the instructor, assesses the patient, and completes the required documentation.
What is accountability?
This is the 6th right of medication administration.
What is Right Documentation?
This medication reverses life-threatening respiratory depression caused by opioid medications.
What is naloxone (Narcan)?
Listening to heart, lung, and bowel sounds is called this assessment technique.
What is auscultation?
This IV complication occurs when a vesicant medication leaks into surrounding tissue.
What is extravasation?
The client has diminished pedal pulses, cool pale feet, delayed capillary refill, and reports calf pain when walking.
What is the patient problem: Decreased Perfusion?
This hierarchy helps nurses prioritize physiologic needs before psychosocial needs.
What is Maslow’s hierarchy?
In this step of the nursing process, the nurse determines that the patient's pain decreased from 8/10 to 2/10 after medication.
What is evaluation?
A patient refuses a blood transfusion due to religious beliefs. Although the nurse personally disagrees, the nurse respects the decision, ensures the patient understands the risks, and communicates the patient's wishes to the healthcare team.
What is patient advocacy?
A medication order for 2.0 mg is an example of this, which should be avoided due to risk for error.
What is a trailing zero?
The nurse must closely monitor this electrolyte in patient’s taking loop diuretics.
What is potassium?
This assessment finding suggests decreased peripheral perfusion.
What is delayed capillary refill and weak/thready peripheral pulses?
Redness, warmth, tenderness, and a palpable cord are signs of this IV complication.
What is phlebitis?
The client has gained 6 lb in one week, has bilateral pitting edema, jugular vein distention, crackles, and increasing shortness of breath.
What is the patient problem: Excess Fluid Volume?
Transferring the authority to a competent individual to perform a selected task in a selected situation.
What is delegation?
A nurse identifies impaired gas exchange after reviewing assessment findings. This nursing process step is being completed.
What is analysis?
A nursing student copies portions of a classmate's care plan into their own assignment without giving credit and submits it as original work.
What is plagiarism or academic dishonesty?
This is the internationally recognized list of dangerous abbreviations.
What is the Do Not Use list?
Before administering metoprolol (Lopressor), the nurse should assess this vital sign because the medication may significantly decrease it.
What is the heart rate?
This is the correct order of abdominal assessment techniques. What is Inspect, auscultate, percuss, and palpate?
What is inspect, auscultate, percuss, and palpate?
This is the nurse's first action when extravasation is suspected.
What is stop the infusion?
The client has redness over the coccyx, limited mobility, poor nutrition, and urinary incontinence.
What is the patient problem: Impaired Skin Integrity?
Even after delegating a task, this team member remains accountable for the patient's care.
Who is the registered nurse?
Vital signs, laboratory values, and physical assessment findings are examples of this type of data.
What is objective data?
When there is disagreement between the healthcare team and the patient's family about withdrawing life support, this hospital resource can help guide ethical decision-making.
What is the ethics committee?
When measuring liquid medication in a medicine cup, the nurse reads the volume at the bottom of this curve.
What is the meniscus?
When teaching a patient about nifedipine (Procardia XL), the nurse explains that this type of tablet should not be crushed or chewed.
What is an extended-release tablet?
The assessment find of >30 ml/hr indicates adequate kidney perfusion in an adult.
What is urine output?
This assessment finding is expected with phlebitis but not infiltration.
What is warmth?
A client diagnosed with alopecia refuses visitors, avoids looking in the mirror, and says, "People won't recognize me anymore."
What is the patient problem: Altered Self-Concept?
The nurse uses this framework to determine which patient should be cared for first.
What is ABCDs?
When planning nursing care, the nurse should address the__________ before risk for problems.
What is actual problems?
This document legally determines limitations and allowances regarding what a registered nurse (RN) or licensed practical nurse (LPN) is legally permitted to do.
What is the scope of practice?
Creating this environment in the medication room is an evidence-based method designed to prevent interruptions and reduce medication errors.
What is a Quiet Zone?
This laboratory value must be monitored regularly in a patient taking warfarin (Coumadin) to ensure the medication is therapeutic while minimizing the risk of bleeding.
What is INR?
This assessment finding may indicate poor oxygenation when observed around the lips and nail beds.
What is cyanosis?
This is the standard amount of time you should scrub a needleless IV hub with a chlorhexidine or alcohol swab before accessing it.
What is 15 seconds?