Assessment
Identify one key difference between subjective and objective data.
Subjective = patient-reported; Objective = measurable/observable.
What are the three parts of an actual NANDA-I nursing diagnosis?
Problem, related factors, and defining characteristics.
What does SMART stand for in goal setting?
Specific, Measurable, Achievable, Relevant, Time-bound.
Define the implementation phase of the nursing process.
Putting the care plan into action through interventions.
What is the primary goal of evaluation in the nursing process?
To determine if patient outcomes were met.
What is the first step in the NCSBN Clinical Judgment Measurement Model?
Recognize cues.
Differentiate between risk and health promotion diagnoses.
Risk = potential problem; Health promotion = desire to enhance wellness.
Create a short-term goal for “Impaired Skin Integrity.”
Short-term: wound edges remain well approximated during hospital stay.
Differentiate independent, dependent, and collaborative interventions.
Independent: nurse-initiated; Dependent: require order; Collaborative: shared responsibility.
Differentiate between ongoing and summative evaluation.
Ongoing = during care; Summative = after interventions completed.
Name two priority assessments for a postoperative patient receiving opioids.
Respiratory rate and level of consciousness.
Formulate a nursing diagnosis for a patient with SOB and O₂ sat of 88% on room air.
Impaired gas exchange related to alveolar-capillary changes as evidenced by low O₂ saturation and dyspnea.
Which patient should the nurse see first: pain 8/10, new onset of confusion, or fever 100.8°F?
New onset confusion—possible acute change in neuro status.
Before giving a PRN pain med, what assessments are required?
Pain level, vital signs, and time since last dose.
Give an example of a revised care plan after a goal was not met.
Change intervention frequency or update outcome timeframe.
A patient reports dizziness when standing. What focused assessment should you perform next?
Orthostatic vital signs.
How does data validation prevent diagnostic error?
Confirms accuracy by comparing subjective and objective data.
How do Maslow’s hierarchy and ABC priorities guide planning?
They help identify life-threatening and basic needs first.
Describe how delegation fits within implementation.
Assigning tasks within scope and supervision ensures safe care.
Why is accurate documentation vital during evaluation?
Provides legal record and supports care continuity.
Explain how clustering data supports accurate nursing diagnoses.
It helps identify patterns that point to underlying problems.
Give an example of a collaborative problem requiring interprofessional management.
Risk for respiratory failure requiring medical and nursing interventions.
Identify one measurable expected outcome for “Ineffective Airway Clearance.”
Patient will maintain clear lung sounds and O₂ ≥ 92% within 24 hours.
What should a nurse do if a prescribed intervention conflicts with current evidence-based practice?
Clarify with the provider before implementation.
How can EHR technology support evaluation?
Dashboards and trend reports show progress toward goals.