Nursing Process
This is the first step of the nursing process, where the nurse gathers subjective and objective data.
ASSESSMENT
A nurse keeps a patient's HIV status private despite pressure from neighbors. Which ethical principle is demonstrated?
Confidentiality
A nurse explains the purpose and side effects of a newly prescribed medication before discharge.
EDUCATOR
Which situation BEST demonstrates nursing as a science?
A. Comforting a grieving family
B. Applying evidence-based wound care
C. Holding a patient's hand
D. Listening to a patient's fears
B. Applying evidence-based wound care
Which documentation system organizes information according to the healthcare discipline (e.g., nursing notes, physician's notes, laboratory reports)?
Source-Oriented Record (SOR)
A nurse writes:
Which of these is subjective data?
"I can't catch my breath."
A nurse accidentally administers the wrong medication after failing to verify the patient's identity. Is this negligence or malpractice?
Malpractice
A nurse assigns a nursing assistant to obtain vital signs while another nurse administers medications to ensure timely patient care.
MANAGER
A nurse defines health as the ability to fulfill work, family, and community responsibilities despite having arthritis.
ROLE PERFORMANCE MODEL
A patient suddenly develops shortness of breath. The nurse raises the head of the bed, administers oxygen, notifies the physician, and reassesses the patient's oxygen saturation.
Which nursing note is BEST?
A. "Patient appeared anxious. Oxygen given. Physician informed."
B. "Patient experienced respiratory distress. Oxygen was administered."
C. "0830: Patient complained of difficulty breathing. RR 32 breaths/min, SpO₂ 86% on room air. Head of bed elevated, oxygen initiated at 2 L/min via nasal cannula. Physician notified. 0845: SpO₂ improved to 94%; patient reported easier breathing."
D. "Patient stabilized after appropriate nursing care."
C. "0830: Patient complained of difficulty breathing. RR 32 breaths/min, SpO₂ 86% on room air. Head of bed elevated, oxygen initiated at 2 L/min via nasal cannula. Physician notified. 0845: SpO₂ improved to 94%; patient reported easier breathing."
After assessing a postoperative patient, the nurse identifies the following problems:
Which nursing diagnosis should be prioritized?
Ineffective Breathing Pattern
A postoperative patient is awake, alert, and oriented. The physician recommends blood transfusion because the patient's hemoglobin is critically low. The patient refuses after receiving complete information about the risks. The family insists the nurse should proceed because "he doesn't know what's best for himself."Which ethical principle should guide the nurse's action?
Autonomy
A nurse reviews current evidence showing that chlorhexidine is more effective than povidone-iodine for preventing central line infections and recommends changing unit practice.
RESEARCHER
A nurse evaluates a patient's blood pressure, blood glucose, and cholesterol to determine health status.
Which model is primarily being used?
CLINICAL MODEL
A nurse accidentally writes the wrong blood pressure in the patient's chart.
What is the CORRECT action?
Draw a single line through the error, write the correct information, and initial/sign according to institutional policy.
A nurse assesses a patient with diabetes and records:
The nurse immediately gives oral glucose before documenting the assessment.
Which principle of the nursing process best explains the nurse's action?
The nursing process is dynamic (or cyclical), not strictly linear
A nurse threatens to apply restraints if a patient refuses medication, even though no restraints are actually applied.
Assault
A nurse notices that several patients have developed pressure injuries over the past month. The nurse analyzes the data, develops a prevention program, educates the staff, and monitors outcomes.
CHANGE AGENT
A patient has hypertension but continues to achieve personal goals, maintain healthy relationships, and express satisfaction with life.
Which model best explains this view of health?
EUDAIMONISTIC MODEL
A hospital uses Charting by Exception (CBE).
Which patient requires documentation?
A. Temperature 36.8°C
B. Patient sleeping comfortably
C. Surgical dressing dry and intact
D. New onset confusion and disorientation
C. Surgical dressing dry and intact
A patient is admitted with the following assessment findings:
Possible nursing diagnoses include:
Which diagnosis should the nurse prioritize?
Ineffective Airway Clearance
A patient scheduled for surgery says,
"I signed the consent because my family pressured me, but I really don't want the operation."
What is the nurse's BEST action?
Notify the physician and postpone the procedure until the patient's decision is clarified.
A nurse is caring for a patient who refuses chemotherapy despite understanding the consequences. The physician insists that treatment should proceed because it offers the best chance of survival. The patient's family agrees with the physician.
PATIENT ADVOCATE
A patient develops leptospirosis after walking through floodwater contaminated with rat urine. Identify the Agent, Host, and Environment.
A physician failed to remove a surgical sponge after surgery. The sponge was discovered weeks later.
Res Ipsa Loquitur