Nursing Process
The nurse collects data about a client's symptoms and medical history
What is Assessment?
A client reports mild nausea after a new medication. Which action is best first?
What is assess the client's vital signs and medication history?
A client requests water, another has mild pain, and a third has sudden shortness of breath. Who should the nurse see first?
What is the client with sudden shortness of breath ?
A client refuses a blood transfusion. Which action respects their rights?
What is honor the clients decision and provide education?
The nurse should wash hands for at least 20 seconds to prevent transmission of infections. This is an example of?
What is Standard Precautions?
Setting a goal that the client will ambulate 50ft by the end of the day falls under this step?
What is Planning ?
Four clients need care. One has mild anxiety, one has a scheduled dressing change, one has sudden confusion, and one is asking for water. Who should the nurse see first?
What is the client with sudden confusion?
The nurse notices a client's IV site is slightly red and swollen but the client has no pain. What is the best next action?
What is notify the provider and monitor closely?
Delegating an AP (assitive personnel) without proper training violates which principle?
What is safe delegation / scope of practice?
A client with suspected airborne infection should be placed in which type of room?
What is a negative pressure room?
Choosing an intervention based on multiple pieces of client data before evaluating outcomes demonstrates this.
What is Clinical Judgement ?
A client's pain is 7/10, but vital signs are within normal limits. Which action demonstrates good clinical judgement?
What is offer pain relief while monitoring for underlying causes?
A client refuses a medication for fear of side effects. Which is the best first action?
What is explore the client's reason and provide education?
The nurse witnesses a colleague falsifying documentation. What is the best first action?
What is report according to facility policy?
Which action is least effective for preventing the spread of infection in the hospital?
What is wearing gloves but not performing hand hygiene?
Which nursing process step involves comparing the client's responses to expected outcomes?
What is Evaluation?
Which of the following interventions is least restrictive for preventing falls in a confused client?
What is placing the client near the nurses station and using a bed alarm?
Four clients; one has fever, one is postoperative day 1, one has mild anxiety, one needs routine vitals. Which is highest priority?
What is the client with fever (potential infection or sepsis)?
Administering medication without a provider's prescription is an example of what?
What is malpractice / legal violation?
A nurse notices a frayed electrical cord in a client's room. Which is the first action?
What is remove the equipment to prevent injury?
A client's complaint of dizziness and palpitations leads the nurse to identify a problem for risk of falls. This step of the nursing process is called ?
What is Analysis?
The nurse must decide quickly whether to notify the provider, implement an intervention, or wait for more data. Which type of thinking is this?
What is Clinical Judgement/Prioritization?
A client's blood pressure drops suddenly while another needs routine dressing change. What guides the nurses decision?
What is ABCs/ client safety/ prioritize unstable over stable?
A client asks the nurse to withhold a terminal diagnosis from them. Which ethical principle is being challenged?
What is beneficence?
Which action demonstrates proper safety and infection control when removing PPE?
What is gloves first, goggles, gown , mask , then hand hygiene?