Physical Assessment
When auscultating bowel sounds, should you use the bell or diaphragm of the stethoscope?
Diaphragm
A patient points to where his pain is but does not verbalize anything. Which form of communication is this?
Nonverbal
When caring for a patient with an open wound and evaluating healing progress, this is the nurse’s priority action.
What is measuring the wound and observing for redness, swelling, or drainage?
This action shows a registered nurse is taking responsibility for clinical decision-making.
What is taking immediate action when a patient’s condition worsens?
A nurse who values freedom of choice and responsibility for those choices is demonstrating this element of shared decision-making.
What is autonomy?
Your patient weighed 275 lbs on admission (yesterday) and today you note that the weight is 285 lbs. Which condition will you assess for this patient?
Fluid retention
Which characteristic tends to make a nurse the best communicators with patients?
Developed critical thinking skills
When creating a nursing care plan, this statement would be used as an outcome for a goal of care.
What is “The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift”?
This is the action a nurse should take when applying critical thinking to clinical decisions.
What is considering what is important in any given situation?
A patient is one day post-hip fracture repair. This assessment requires immediate nursing intervention.
What is reporting severe pain 30 minutes after receiving pain medication?
You are called to assess a student who has injured their leg. The student is crying, is in severe pain, and has an obvious deformity. Which proper sequence will the nurse follow to perform the initial assessment?
Inspection and light palpation
What is the term that describes the belief that the nurse-patient relationship is a partnership, and both are equal participants?
Mutuality
This information about a goal shows that a nurse has a good understanding of its purpose.
What is recognizing it as a broad statement describing a desired change in a patient’s behavior?
Your postop patient continues to rate their pain 9/10 despite being given pain medication. Their next dose of pain medication isn't due for another hour. What should you do?
Explore other options for pain relief.
A nurse with a transformational leader as a manager can expect this outcome.
What is an increased level of patient satisfaction?
During a routine physical examination of a 80-year-old patient, a blowing sound is heard over the carotid artery. Which assessment finding will the nurse report to the health care provider?
Bruit
What critical thinking standards should the nurse use when communication with patients?
Humility, self-confidence, and demonstrating an independent attitude
A nurse demonstrates use of critical thinking skills in the first phase of the nursing process with this action.
What is completing a comprehensive database?
This is the rationale when a nurse applies professional standards to guide clinical decisions
What is using critical thinking to ensure the highest level of quality nursing care?
When prioritizing care for four patients, this patient should be seen first.
Who is the patient with difficulty breathing?
You are the ER nurse caring for a patient who has been brought in after a motor vehicle accident. You note the patient’s level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. What is the patient’s Glasgow Coma Scale score?
9
What is the purpose of SBAR?
To standardize communication
After setting a goal for a patient with pneumonia to maintain oxygen saturation above 92%, the nurse places the patient in semi-Fowler’s position, encourages coughing and deep breathing, and administers prescribed nebulizer treatments. Which phase of the nursing process is the nurse demonstrating?
What is implementation?
When a nurse uses the critical thinking skill of evaluation, this is the action they are performing.
What is reviewing the effectiveness of nursing actions?
When following the accepted “rights” of delegation, a nurse ensures these elements are included.
What are the right task, right person, right direction/communication, right supervision, and right circumstances?