Nursing process/scope
What does ADPIE stand for?
Assessment, Diagnosis, Planning, Implementation, Evaluation
When a patient's clinical status becomes unstable, accountability for care shifts strictly to whom?
The registered nurse
Clear, watery plasma drainage is known by this clinical term.
Serous drainage
According to nursing standards, a nurse must completely remove a physical restraint to assess skin integrity and range of motion at least this often.
Every 2 hours
This 5-letter acronym outlines a standardized communication framework used among healthcare team members to improve patient safety during handoffs or critical updates.
ISBARR
Information gathered directly from the patient’s own words.
Subjective Data
While the LPN cannot perform initial teaching, they are legally permitted to do this to help the patient learn.
This is the clinical term for turning a pale skin area red by pressing on it, which tests for microvascular integrity in light skin tones.
Blanching
This is the single most accurate and reliable daily nursing assessment tool used to monitor a patient's overall fluid volume changes.
Daily weight
This position involves placing the patient flat on their back with the head of the bed elevated between 45 and 60 degrees.
Fowler's position
The legal document that defines the scope of nursing practice in each state.
Nurse Practice Act
True or False: An AP can adjust a patient’s oxygen wall flow meter if the patient complains of shortness of breath.
False
This phase of wound healing involves tissue growth, collagen production, and wound contraction.
Proliferation phase
To document bowel sounds as completely absent, a nurse must listen continuously to each quadrant for this specific amount of time.
4-5 minutes
This macronutrient is essential for tissue repair, wound healing, and maintaining oncotic pressure in the vascular system.
Protein
Comparing actual patient outcomes to expected outcomes occurs in this final phase.
Evaluation
Of a patient with chronic stable asthma, a patient with a newly fractured wrist, and a patient suddenly reporting a tight throat and stridor, the nurse must assess this patient first.
Tight throat and stridor
This clinical term describes painful or difficult urination, often felt as a burning sensation
Dsyuria
A positive Chvostek's sign (facial twitching when tapping the facial nerve) is a hallmark clinical indicator for this electrolyte deficiency
Hypocalcemia
These three non-restrictive nursing interventions should always be tried and documented before resorting to physical or chemical restraints.
Reorientation, bed/chair alarms, and 1-on-1 observation, diversional activities, moving the patient closer to the nurse's station
What must the nurse do if a UAP is found performing a task outside their training?
Intervene
When an immobile patient suddenly develops severe dyspnea, this is the very first, non-invasive action the nurse should take before gathering oxygen equipment or calling the doctor.
Raise the HOB
This cardiovascular complication occurs when a patient experiences a drop in blood pressure of 20 mmHg or more upon sitting or standing up from bed.
Orthostatic hypotension
This term describes an late sign of chronic hypoxia characterized by an increased focal angle between the fingernail bed and the proximal nail fold, making the fingertips look bulbous.
Clubbing
This progressive, irreversible structural brain disorder causes a gradual decline in memory, cognition, and functional abilities over several years.