Nursing Process
What are the 5 steps involved in the nursing process?
Assess
Diagnose
Plan
Implement/intervene
Evaluate
What does S.W.I.P.E stand for?
Scan pt environment for safety and states name and title.
Washes hands before touching the pt
Identifies client using full name, DOB and allergies by looking, and touching the wrist band
provides privacy
explains procedure and asks permission
Which patient is at greatest risk for infection?
A. A 25-year-old with a sprained ankle
B. A 55-year-old with well-controlled diabetes
C. A 72-year-old post-operative patient with a urinary catheter
D. A 40-year-old with seasonal allergies
C. A 72-year-old post-operative patient with a urinary catheter
Rationale: Older adults and those with invasive devices (catheters) are at highest risk for healthcare-associated infections (HAIs).
RACE
PASS
Rescue, Alarm, Contain, Extinguish
Pull, Aim, Squeeze, Sweep
Which of the following best describes clinical judgment?
A. Memorizing textbook symptoms
B. Applying evidence-based practice only
C. Interpreting patient data and making decisions
D. Delegating tasks to other providers
C. Interpreting patient data and making decisions
Rationale: Clinical judgment involves interpretation, reasoning, and decision-making.
A nurse collects data from a newly admitted patient. Which action represents the first step of the nursing process?
A. Formulating nursing diagnoses
B. Recognizing cues and gathering assessment data
C. Planning patient-centered goals
D. Implementing nursing intervention
B. Recognizing cues and gathering assessment data
Rationale: Assessment (Recognize Cues) is always the first step in ADPIE/AAPIE
An emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. the client reports a medical history of hypertension, gout, and migraine headaches. which piece of the assessment should the nurse obtain first in the comprehensive assessment?
A. Vitals
B. Medical history
C. Focused assessment
D. Psychosocial assessment
A. Vitals
Which link in the chain of infection does hand hygiene primarily break?
A. Susceptible host
B. Portal of entry
C. Mode of transmission
D. Reservoir
C. Mode of transmission
Rationale: Hand hygiene prevents the transfer of pathogens—breaking the mode of transmission.
A physician prescribes a new medication, but the nurse suspects it’s the wrong dose. What should the nurse do?
A. Administer it as ordered
B. Refuse to give it and document refusal only
C. Verify with the physician before administration
D. Ask another nurse to confirm
C. Verify with the physician before administration
Which of the following is a high-priority problem according to the ABCs?
A. Constipation
B. Risk for social isolation
C. Airway obstruction
D. Impaired skin integrity
C. Airway obstruction
Which of the following best describes clinical judgment?
A. Memorizing textbook symptoms
B. Applying evidence-based practice only
C. Interpreting patient data and making decisions
D. Delegating tasks to other providers
C. Interpreting patient data and making decisions
Rationale: Clinical judgment involves interpretation, reasoning, and decision-making.
A nurse is preforming a gastrointestinal assessment on a patient who has abdominal pain with a fever. After the nurse palpates the abdomen, they listen and notice hyperactive bowel sounds in all four quadrants and notes it in the patient's chart. Is there anything about this assessment that you would do differently?
The nurse would need to auscultate bowel sounds before palpating in order to have an accurate assessment
Which best describes the prodromal stage of infection?
A. Period between infection and first symptoms
B. Interval from nonspecific to specific symptoms
C. Stage of maximum symptom intensity
D. Period of recovery
B. Interval from nonspecific to specific symptoms
During morning rounds, a nurse notes a patient’s oxygen saturation dropped to 84%. What is the priority action?
A. Notify the physician
B. Reassess using a different pulse oximeter
C. Apply oxygen as ordered and reassess
D. Document the finding
C. Apply oxygen as ordered and reassess
Rationale: Apply oxygen (Act Now!) — implement immediate safety-focused care.
Which of the following represents the Six Rights of medication administration?
A. Patient, doctor, medication, route, time, storage
B. Patient, medication, dose, route, time, documentation
C. Patient, drug, expiration, storage, route, evaluation
D. Patient, medication, site, dose, frequency, report
B. Patient, medication, dose, route, time, documentation
Which statement best summarizes the nursing process?
A. A linear checklist used once per shift
B. A cyclical, dynamic process focused on patient-centered outcomes
C. A physician-driven method of care delivery
D. A documentation-only process
B. A cyclical, dynamic process focused on patient-centered outcomes
During a respiratory assessment, the nurse hears crackles in both lower lobes. What is the most appropriate nursing action?
A. Encourage the patient to cough and deep breathe
B. Document the finding and continue the exam
C. Ask the patient to lie flat to listen better
D. Immediately administer oxygen
A. Encourage the patient to cough and deep breathe
Rationale: Crackles suggest fluid in the lungs; deep breathing may help clear secretions.
The term “shift to the left” refers to:
A. Decrease in neutrophils
B. Increase in immature white blood cells
C. Decrease in RBCs
D. Increase in lymphocytes only
B. Increase in immature white blood cells
The nurse is preparing to administer medications. What is the first action to ensure patient safety?
A. Scan the medication barcode
B. Verify the medication with the MAR
C. Identify the patient using two identifiers
D. Ask another nurse to confirm the order
C. Identify the patient using two identifiers
Which of the following are sources of assessment data? (Select all that apply.)
A. The patient’s spouse
B. Lab results
C. Nursing textbook
D. Physical exam findings
E. Internet resources
A. The patient’s spouse
B. Lab results
D. Physical exam findings
The nurse notes the patient’s BP dropped from 130/80 to 90/60 and urine output decreased. What is the next best step?
A. Document findings and continue care
B. Give antihypertensive medication
C. Notify the provider of possible hypovolemia
D. Ask another nurse to recheck BP later
C. Notify the provider of possible hypovolemia
Rationale: Prioritize safety—recognize cues and take immediate action.
While assessing peripheral pulses, the nurse is unable to palpate the dorsalis pedis pulse on the right foot. What should the nurse do next?
A. Document “absent” pulse and notify provider
B. Use a Doppler to attempt to locate the pulse
C. Reassess in 1 hour
D. Palpate the radial pulse instead
B. Use a Doppler to attempt to locate the pulse
Rationale: A Doppler should be used to confirm pulse presence before concluding it is absent.
1a.The mnemonic “SPIDERMAN” helps recall which isolation type?
A. Airborne
B. Contact
C. Droplet
D. Protective environment
2a.What does the mnemonic stand for?
1a. C. Droplet
2a. S-sepsis, S-scarlet fever, S- Streptococcal pharyngitis, P-Parvovirus B19, P- Pneumonia, P- Pertussis, I-Influenza, D- Diphtheria, E- Epiglottitis, R- Rubella
The nurse identifies “Risk for Falls.” What is the priority action?
A. Implement safety interventions
B. Call the provider
C. Document the diagnosis
D. Wait until a fall occurs
A. Implement safety interventions
What is the nurse’s first step before delegating a task?
A. Ask the UAP to do it immediately
B. Assess the situation and patient stability
C. Notify the charge nurse
D. Explain why delegation is needed
B. Assess the situation and patient stability
Rationale: Delegation requires assessing “right circumstance” first.