Nursing Process
What are the steps of the nursing process?
Assess, Diagnosis, Plan, Implementation, Evaluation
Assessment- data collection
Diagnosis- identify patient's problem
Plan- setting priorities and patient goals
Implementation: carrying out nursing care
Evaluation: determine if goals are met or well-being has improved
After assessment and administration of pain medication, what is the nurse's next priority?
A. Add additional pain therapy to the plan of care
B. Direct the nursing assistive personnel to reassess pain
C. Reassess patients pain in 30 minutes
D. Notify the physician
C. Reassess the patient's pain in 30 minutes.
The nurse’s priority action for this patient is to evaluate whether the nursing intervention of administering acetaminophen was effective.
While discharging a patient that had undergone hip surgery, what is needed for the nurse to discontinue the patient's plan of care?
A. Make sure the patient is prescribed pain medication
B. Set up transportation to get the patient home safely
C. Evaluate whether the patient goals and outcomes have been met
D. Set up a follow-up appointment for the patient
C. Evaluate whether the patient goals and outcomes have been met
You evaluate whether the results of care match the expected outcomes and goals set for a patient before discontinuing a patient’s plan of care.
Which of the following is an example of a nursing intervention?
A. The patient will get up to the chair every 4 hours
B. Impaired physical mobility related to hip fracture
C. Provide assistance while the patient walks with crutches twice during the shift
D. The patient is unable to use right arm to eat
C. Provide assistance while the patient walks with crutches twice during the shift
Providing assistance to a patient who is ambulating is a nursing intervention.
Demonstrating a psychomotor skill such as self-injection to a patient is an example of?
A. Wellness
B. Health behavior
C. Psychological self-control
D. Health service utilization
B. Health behavior
Health behavior involves demonstrating a psychomotor skill such as self-injection. The skill is psychomotor, not psychological self-control. Health service utilization is readmission within 30 days or emergency department use.
Reassessing the patient is the initial phase of which step in the nursing process?
A. Implementation
B. Planning
C. Evaluation
D. Diagnosis
A. Implementation
When a patient is complaining of chest pain what is the first action step for the nurse?
Reassess the patient
Preparation for implementation ensures efficient, safe, and effective nursing care; the first activity is reassessment. The cause of the patient’s chest pain is unknown, so the patient needs to be reassessed before pain medication is administered or a chest x-ray is obtained. The nurse then notifies the patient’s health care provider of the patient’s current condition in anticipation of receiving further orders. The patient’s chest pain could be due to muscular injury or a pulmonary issue. The nurse needs to reassess first.
How would you evaluate that patient's turning schedule and skin routine is effectively preventing skin breakdown?
Absence of skin breakdown. Absence of redness on bony prominences, ie. coccyx, heels
What would be the highest priority nursing diagnosis for a patient with a spinal cord injury?
A. Risk for impaired skin integrity
B. Risk for infection
C. Impaired mobility
D. Reflex urinary incontinence
D. Reflex urinary incontinence
Reflex urinary incontinence is highest priority. If a patient’s incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases but not in this situation. Impaired mobility is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case.
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 2days with an expected outcome of having no secretions present in the lungs in 24 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
A. No sputum present in 3 days
B. Congestion present throughout all lung fields in 24 hours
C. 30 breaths per minute in 24 hours
D. Lungs sounds present in all fields following use of inhaler
D. Lungs sounds present in all fields following use of inhaler
In this case, the patient’s goal is to not experience shortness of breath with activity in 3 days. If the lung sounds are clear following use of inhaler, the nurse can determine that the patient is making progress toward achieving the expected outcome. One way for the nurse to evaluate the expected outcome is to assess the patient’s lung sounds. Goals are broad statements that describe changes in a patient’s condition or behavior. Expected outcomes are measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. The time frame of 3 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Congestion indicates fluid in the lungs, and a respiratory rate of 30 breaths per minute is elevated/abnormal. This indicates that the patient is still probably experiencing shortness of breath and secretions in the lungs.
When reviewing health history the patient reveals they are allergic to sulfa-antibiotics. What is the next step to be performed by the nurse?
A. Review of patient's medication list
B. Ask the patient to describe their reaction
C. Move on to the next phase in the health history
D. Document sulfa-antibiotic allergy on the patient's allergy list
B. Ask the patient to describe their reaction
health care personnel need to be aware of what type of response the patient suffered.
While conducting a nursing health history which components will the nurse include?
A. Nursing concerns
B. Patient expectations
C. Physician orders
D. Nursing goals
B. Patient expectations
Some components of a nursing health history include chief concern, patient expectations, spiritual health, and review of systems.
A patient that is recovering from a hip fracture is complaining of pain 7/10 and is unable to walk due to the pain. What nursing intervention is the priority?
A. Notify the physician
B. Get a walker for the patient
C. Consult physical therapy
D. Administer ordered pain medication
D. Administer ordered pain medication
The patient’s pain is a 7, indicating the priority is pain relief (administer pain medication). Acute pain is the priority because the nurse can address the problem of immobility after the patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker will not address the pain the patient is experiencing.
Please give examples of subjective data.
Patient describing excitement about discharge
Patient's expression of fear regarding the upcoming surgery
Subjective data include patient’s feelings, perceptions, and reported symptoms
When performing a dressing change what is the first step the nurse should take?
Always be sure a patient is physically and psychologically ready for any interventions or procedures. After determining the patient’s readiness for the dressing change, the nurse gathers needed supplies.
Please give an example of a patient outcome using the SMART approach.
The patient will feed self during all mealtimes without the presence of choking.
An expected outcome should be patient-centered; should address one patient response; should be specific, measurable, attainable, realistic, and timed (SMART approach).
Give an example of a nurse utilizing interpretation as a critical thinking skill.
Asking the patient if they have a history of heart problems after vitals signs show a low pulse.
Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data.
While caring for a patient with a spinal cord injury, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take?
A. Postpone insertion until urologist can see the patient
B. Adapt the positioning technique to the situation
C. Notify the provider
D. Continue with the procedure with contraindicated position
B. Adapt the positioning technique to the situation
The nurse must use critical thinking skills in this situation to adapt positioning techniques. In practice, patient procedures are not always presented as in a textbook, but they are individualized.
What does it mean to use critical thinking in nursing?
A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients.
Example: Taking immediate action when the patient condition worsens
The first component of the critical thinking model is a nurse’s specific knowledge base. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. Clinical learning experiences are necessary to acquire clinical decision-making skills. The nursing process competency is the third component of the critical thinking model. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem.
How can a nurse utilize data validation when making a clinical decision? Give an example.
Deciding to change the patient's dressing because the nurse notices old new drainage and the patient states the dressing is old and needs to be changed.
This validates a patient’s report with a nurse’s observation is changing the wound dressing. The nurse validates what the patient says by observing the dressing.
What are interdependent interventions, Physician-initiated interventions, Independent nursing interventions?
Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Physician interventions are dependent nursing interventions or actions that require an order from the HCP. Independent nursing interventions, or actions that a nurse initiates without supervision or direction from others.
Give examples of nursing interventions for a patient with poor wound healing due to diabetes.
Perform dressing changes as ordered
Educate patient on s/s of infection
Instruct family members how to perform dressing changes
Administer medications to control diabetes
Name findings the nurse may recognize as responses to stress when making clinical decisions.
Tense muscles, reactive responses, trouble concentrating, feeling tired
Define clinical practice guideline or protocol.
Protocols or clinical practice guidelines assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.
Nursing practice includes cognitive, interpersonal, and psychomotor skills. Please give an example of each.
. Psychomotor skill requires the integration of cognitive and motor abilities. The nurse in this example displayed the psychomotor skill of inserting an intravenous catheter while following standards of care and integrating knowledge of anatomy and physiology. Cognitive involve the application of critical thinking and the use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly.