Nursing Process
What are the 5 steps of the nursing process in order?
Assess, Diagnose, Plan, Implement, Evaluate.
Which PPE do you remove last?
Mask/respirator.
Normal range for adult respirations per minute?
12–20
A nurse is preparing to administer a scheduled dose of digoxin 0.25 mg to a client with atrial fibrillation. The client’s vital signs are:
HR: 52 bpm
BP: 110/68 mmHg
RR: 18/min
O₂ sat: 96%
Which action should the nurse take?
Hold the medication and notify the provider
What are the 3 priority frameworks for patient care?
ABCs, Maslow’s, Safety
A patient is short of breath. Which action comes first: calling the doctor, applying oxygen, or documenting?
Apply oxygen (immediate intervention).
What type of precaution is required for TB?
Airborne precautions (N95, negative pressure room).
A patient with COPD is placed on 4 L O₂ nasal cannula. What’s the concern?
Too much O₂ can decrease their drive to breathe
Convert 0.5 g to mg.
500 mg.
Which is a modifiable risk factor for cardiovascular disease: age, family history, or smoking?
Smoking.
Writing “Patient will ambulate 50 feet with walker by end of shift” is an example of which part of the nursing process?
Planning (goal setting)
A nurse is caring for 4 patients. Which patient do you see first: a fall risk with family present, a patient on contact precautions, a patient with chest pain, or a post-op patient requesting pain meds?
Patient with chest pain.
What’s the earliest sign of hypoxia?
Restlessness/anxiety.
A patient is ordered 2 mg morphine IV. The vial reads 10 mg/mL. How many mL do you give?
0.2 mL.
What’s the difference between type 1 and type 2 diabetes?
Type 1 = no insulin production; Type 2 = insulin resistance/deficiency.
A patient has crackles in the lungs and O2 sat 86%. Which is the priority nursing diagnosis?
Impaired gas exchange.
Name 2 correct identifiers for ensuring patient safety before a procedure or medication.
Name & date of birth (compared with armband/EMR).
A patient’s BP is 88/40, HR 128, RR 30. What is the priority?
Notify provider/rapid response — signs of shock.
Which medication should be held if the apical pulse is <60 bpm?
Digoxin
You are the nurse caring for 4 patients. Which one do you see first?
A post-op patient with pain rated 8/10.
A diabetic patient with blood sugar 62 mg/dL.
A patient with COPD who needs help ambulating.
A patient waiting for discharge instructions.
The diabetic patient with blood sugar 62 (risk of hypoglycemia → life-threatening).
A nurse rechecks a patient’s pain level after giving morphine. This is which step of the nursing process?
Evaluation
The nurse finds a patient on the floor after a fall. What is the first action?
Assess the patient for injury.
The nurse hears wheezing during assessment. This indicates?
Narrowed airways/bronchoconstriction (asthma, obstruction).
A patient is prescribed Lasix (furosemide). What electrolyte must the nurse monitor closely?
Potassium (risk of hypokalemia).
A nurse is caring for a client with heart failure who is experiencing shortness of breath when lying flat, requires frequent rest during ambulation, and has pitting edema in the lower extremities. Which assessment finding would indicate the highest priority for immediate intervention?
A. Oxygen saturation of 88% on room air
B. 2+ pitting edema in bilateral ankles
C. Weight gain of 2 lbs in 24 hours
D. Dyspnea when climbing one flight of stairs
A. Oxygen saturation of 88% on room air