Tanner's Clinical Judgment Model
The nurse assesses that the patient is grimacing and breathing is shallow.
What is noticing?
The nurse is auscultating breath sounds of a patient who has come to the ER with complaints of worsening asthma. What lung sounds does the nurse expect to hear?
What is wheezing?
The community center is hosting a flu shot clinic this weekend. The nurse recognize this as what level or prevention?
What is primary prevention?
The patient is not able to turn themselves in bed and needs assistance to get out of bed. What is a priority nursing diagnosis.
What is
Risk for Skin Breakdown
Impaired Mobility
Credit for Mobility or Skin Breakdown
The tool used to screen for risky or harmful drinking patterns?
What is the AUDIT screening tool?
The nurse gives the PRN medication for high blood pressure after reviewing the vital signs.
What is responding?
What is less than 2 seconds?
Credit: Brisk
The nurse enters the patient's room to give 0900 medications. What first action taken by the nurse shows a commitment to patient safety.
What is confirm patient identity with two identifiers?
Credit: check the wrist band
The provider orders 650mg of Tylenol PO Q6 hours PRN Pain. The Pyxis stocks 325mg tablets, how many tablets do you administer?
What is 2 tablets
The tool that is used to assess nutrition.
What is the Mini Nutritional Assessment?
The nurse thinks about how the near miss medication error could be prevented.
What is reflection?
The nurse is completed an exam on a 2 week old newborn. What would be an abnormal finding of a newborn's fontanel?
What is firm or bulging?
What is sunken?
The nurse ask the pediatric patient to hold their arms out to thier sides and then says "now show me your muscles" while demonstrating by lifting their forearm to a 90 degree angle. What two range of motion components is the nurse assessing?
What are extension and flexion?
A patient is post operative status with a new oxygen requirement. What is a nursing intervention to help this concern?
What is incentive spirometry?
Credit for: Turn, cough, deep breathe
The tool used to assess and describe the level of impaired consciousness for medical and trauma patients.
What is the Glasgow Coma Scale?
What are the 4 parts of Tanner's Clinical Judgement Model
The nurse asks the patient to smile, frown, and show their teeth. The nurse is observing for ____?
What is observing for symmetrical face movement?
Credit: Symmetry
Identity vs. Role Confusion and Integrity vs. Despair are part of what theoretical framework?
Erik Erickson's Stages of Psychosocial Development.
The patient is ordered to have insulin per sliding scale. The glucose level is 50. What is the priority nursing intervention.
Give juice and a snack with protein for hypoglycemia.
The scale used for predicting pressure score risk.
What is the Braden Scale?
Noticing is similar to what part of the nursing process/
What is assessment?
The patient has been imobile for the last 72 hours. On assessment the patient complains of calf pain and tenderness. The nurse notices the right calf is larger than the left. The nurse is concerned for what diagnosis.
What is DVT?
Credit: Blood clot
Physical safety/security, love, and belonging are part of what theoretical model that can be used to prioritize a nurses plan of care.
What is Maslow's Hierarchy of needs?
The patient has order to receive 400 mg of tylenol per NG tube x 1 now. The concentration is 500mg per 1 mL. How many mL will the nurse administer?
What is 0.8mL
A mother comes to her 6 week postpartum visit and states " I thought I just had the blues, but this is lasting a long time." The nurse pulls a copy of what screening form for the mother to fill out?
What is The Edinburgh Postnatal Depression Scale (EPDS)?