Prioritization
A patient with a Foley catheter complains of lower abdominal pain and the nurse notes no urine output in 4 hours. What should the nurse do first?
What is assess the catheter for kinks or blockage?
A patient suddenly reports right flank pain.
What would be a logical next step to gather more information?
what is "Assess urine output, appearance, and vital signs to evaluate for infection or kidney issues."
What is the correct term for actions a nurse takes to help the patient achieve their goals as a part of ADPIE?
What are "nursing interventions"
What's worse?
A) Emptying a catheter bag without gloves
B) Leaving a catheter in for 10 days without reassessment
B) Leaving a catheter in for 10 days without reassessment
---Prolonged use is a leading cause of CAUTI.
Name one standard precaution nurses must always follow to prevent the spread of infection?
what is "hand hygiene"
Which wound requires immediate attention?
A) A Stage 1 pressure injury on the sacrum
B) A surgical incision with slight serosanguinous drainage
C) A reddened wound with green drainage and a foul odor
D) A wound covered with a transparent dressing
What is C) A reddened wound with green drainage and a foul odor?
During an assessment, you note a capillary refill time of 4 seconds.
Is this normal or abnormal, and what does it suggest?
what is :Abnormal"
--it suggests poor peripheral perfusion and may require further assessment.
The patient has a nursing diagnosis of "Impaired skin integrity related to immobility."
Which of the following is an appropriate intervention?
A) Encourage high-protein diet
B) Administer pain medication
C) Check vital signs every 4 hours
D) Instruct patient on fall prevention
A) Encourage high-protein diet
A) A respiratory rate of 10
B) A heart rate of 112
A) A respiratory rate of 10
---Slow breathing can indicate respiratory depression and is more immediately concerning than mild tachycardia
What type of question should a nurse avoid because it suggests the desired answer?
What is "a leading question"
A nurse is assessing four patients. Who should be assessed first?
A) A patient with 3+ edema in both legs
B) A patient with crackles in bilateral lung bases and O2 sat of 88%
C) A patient with bruising on both arms
D) A patient reporting 2/10 pain
B) A patient with crackles and O2 sat of 88%
A nurse is assessing a patient's peripheral circulation. Which finding indicates arterial insufficiency of the patient's legs?
Dependent Rubor, pale when elevated
---Arterial insufficiency leads to poor blood flow, causing the legs to appear pale when elevated and reddish (dependent rubor) when lowered
What type of data is the following: “The patient reports feeling short of breath when walking to the bathroom, has been complaining of pain and also feeling tired”?
What is subjective data?
A) A confused patient left alone in a room with all four side rails up
B) A call light left out of reach
A) A confused patient left alone with all four side rails up
---This increases fall risk and may be considered a restraint.
What key piece of information should NEVER be excluded when delivering an SBAR?
what is "Vital signs"
You are caring for a patient who is out of bed for the first time following surgery. During your assessment, you note the following:
Blood pressure: 140/86 mmHg
Heart rate: 97 bpm
Respiratory rate: 18 breaths per minute
Oxygen saturation: 90% on room air
The patient says, “I feel a little dizzy when I sit up.”
What is your next nursing action?
Help the patient lie back down and reassess vital signs
You are caring for an elderly patient admitted with pneumonia. During your routine check, you observe that the patient is more confused than earlier in the shift and is having difficulty answering simple questions. Their oxygen saturation has dropped from 96% to 88% on room air, and HR increased to 101.
What action do you perform next?
Apply oxygen and reassess the patient
Which of the following is a correctly written NANDA-I approved nursing diagnosis?
A. Trouble breathing related to low oxygen.
B. Impaired Gas Exchange related to alveolar-capillary membrane changes.
C. Patient has pneumonia and should be monitored closely.
D. Oxygen levels are low due to lung infection.
B. Impaired Gas Exchange related to alveolar-capillary membrane changes.
What's worse?
A) Not performing perineal care daily for a patient with a Foley
B) Hanging the Foley drainage bag on the side rail
Answer: B) Hanging the Foley drainage bag on the side rail
---This can cause backflow and increase infection risk.
You observe clubbing of the patient’s fingernails during an assessment.
What does this finding commonly indicate?
what is "Chronic hypoxia or long-term lung disease".
Which of these patients do you go see first?
Mr. Johnson, post-op day 1 from abdominal surgery, reports pain at a level of 7/10 and requests immediate pain medication.
Ms. Lee, with a history of diabetes, has a blood glucose level of 56 mg/dL and is conscious but confused.
Mr. Patel, admitted for pneumonia, has a temperature of 101.8°F and is due for antibiotics.
Mrs. Smith, 82 years old, is scheduled for discharge today and is waiting for her instructions.
Ms. Lee
--Ms. Lee is showing signs of hypoglycemia (blood glucose 56 mg/dL with confusion), which can quickly become life-threatening if not treated immediately. Critical thinking involves prioritizing care based on urgency, potential harm, and patient stability. While the other patients also need care, Ms. Lee's condition is the most emergent.
During abdominal assessment, you find the abdomen is distended and hard with absent bowel sounds.
What serious condition might this indicate, and what should you do?
It may indicate an intestinal obstruction or paralytic ileus; notify the provider immediately and withhold oral intake.
Which is the correct format for a nursing diagnosis?
A) Problem – Treatment – Cause
B) Medical Diagnosis – Goal – Plan
C) Problem – Related to – Evidence
D) Goal – Assessment – Evaluation
What is C) Problem – Related to – Evidence?
What's worse?
A) Breath sounds absent in the left lower lobe
B) Respirations are slightly irregular
A) Breath sounds absent in the left lower lobe
---Could indicate a collapsed lung or fluid buildup.
What are the 5 rights in the delegation process?
what is "Task, Circumstance, Person, Directions, Supervision"
"The Cool Penguins Dance Smoothly"
Right Task
Is this a task that can be safely delegated for this specific patient?
Must be within the delegatee’s scope and competency.
Right Circumstance
Is the patient’s situation stable?
Are the right resources and supervision available?
Right Person
Is the delegatee trained and competent to perform the task?
Does the person have the legal authority to perform it?
Right Direction/Communication
Were clear instructions and expectations given?
Did the nurse communicate what to do, how to do it, and when to report back?
Right Supervision/Evaluation
Is the nurse providing appropriate monitoring, feedback, and follow-up?
Has the outcome been evaluated?