Think Like a Nurse
A postoperative client is restless, has a respiratory rate of 28 breaths/min, and an SpO₂ of 88%. Using ADPIE, identify the first phase and the three highest-priority data points the nurse should obtain immediately.
Assessment is the first phase. Immediately assess:
The nurse should also quickly assess lung sounds and level of consciousness while intervening for immediate threats.
Which organization accredits baccalaureate and graduate nursing education programs: BON, NPA, CCNE, or QSEN?
The Commission on Collegiate Nursing Education, or CCNE.
Which task is most appropriate to delegate to a trained UAP?
Defend your answer.
Ambulating a stable client may be delegated to a trained UAP. Initial assessments, client teaching, clinical judgment, and evaluation after medication administration remain the nurse’s responsibility. The nurse must give clear directions and follow up after the delegated task.
Which mineral is essential for hemoglobin to transport oxygen? Where is approximately 99% of the body’s calcium stored?
Iron is essential for hemoglobin to transport oxygen. Approximately 99% of the body’s calcium is stored in the bones and teeth.
Which potassium imbalance is more likely to occur after prolonged diarrhea? Which two body systems show the most dangerous effects of this imbalance?
Prolonged diarrhea can cause hypokalemia. The most dangerous effects involve:
A nurse groups confusion, dry mucous membranes, orthostatic hypotension, and decreased urine output into the problem “fluid volume deficit.” Which cognitive process is the nurse using?
Clinical reasoning. The nurse is collecting, connecting, and interpreting cues to develop an explanation for the client’s condition. Clinical judgment is the decision about what action should be taken.
A nurse questions an unsafe prescription, reviews current evidence, and reports the concern through the chain of command. Which professional nursing responsibilities is the nurse demonstrating?
A UAP reports that a client produced 20 mL of urine during the last hour. What minimum hourly urine output is generally expected for an adult, and what should the nurse do next?
The expected minimum is approximately 30 mL/hr or 0.5 mL/kg/hr.
The nurse should:
Classify vitamins A, B, C, D, E, and K as water-soluble or fat-soluble. What is the major toxicity concern associated with fat-soluble vitamins?
Fat-soluble vitamins are stored in the liver and fatty tissues. They can accumulate in the body and cause toxicity when taken in excessive amounts.
A client has muscle weakness, peaked T waves, and a potassium level of 6.4 mEq/L. Identify the electrolyte imbalance and the nurse’s first priority.
The client has hyperkalemia.
The nurse should:
Place these clinical judgment steps in the correct order:
Clara Barton is associated with which organization, and why is describing her as its “founder” more accurate than calling her the “first nurse”?
Clara Barton founded the American Red Cross. “Founder” accurately describes her organizational role. Calling her the “first nurse” would be incorrect because nursing existed before her work.
Convert the following information into a SOAP note:
“The client reports that the incision burns and rates the pain 7/10. The incision is red. The provider was notified, and a wound culture was ordered.”
Identify at least three functions of dietary fat other than providing energy.
A client receiving end-of-life care reports severe air hunger. Identify at least four nonpharmacological or nursing interventions that may relieve dyspnea before discussing medications.
Opioids may be prescribed for persistent end-of-life dyspnea.
Two clients deteriorate simultaneously. Identify the priority principle that takes precedence over “first come, first served.” Apply it to one client with a threatened airway and another with uncontrolled pain.
The client with the threatened airway must be treated first because airway compromise is an immediate threat to life. The client’s pain remains important but is not the first priority.
A nursing student states, “The hospital policy allows me to perform the procedure, so it must be within my scope of practice.” Correct this statement using the Nurse Practice Act.
The state Nurse Practice Act and nursing regulations establish legal nursing scope. Scope is further limited by the nurse’s license, education, demonstrated competence, employer policy, assignment, and the client’s condition. Employer policy cannot expand a nurse’s legal scope of practice.
What do the abbreviations DAR and PIE stand for? Which component in each documentation model records the client’s response or outcome?
Which sleep stage is most strongly associated with vivid dreaming? Which processes during sleep help transfer and consolidate short-term memories into long-term memories?
REM sleep is most strongly associated with vivid dreaming. Memory consolidation occurs throughout sleep. Deep NREM sleep strongly supports the consolidation of facts and declarative memories, while REM sleep contributes to procedural, emotional, and skill-related memory processing.
Describe Cheyne-Stokes respirations precisely. What is the most important information the nurse should provide to the client’s family?
Cheyne-Stokes respirations involve a repeating pattern in which breathing gradually becomes deeper and faster, then becomes slower and shallower, followed by a period of apnea.
The nurse should explain that this breathing pattern may occur naturally near the end of life. It does not necessarily mean that the client is suffering. Care should focus on comfort, positioning, calm reassurance, and symptom management.
A novice nurse follows a rule exactly even though the client’s condition and circumstances have changed. Using Benner’s Novice-to-Expert Model, contrast how a novice nurse and an expert nurse would approach the situation.
A novice nurse relies heavily on rules and has limited ability to adjust those rules to different situations. An expert nurse recognizes patterns, understands the complete clinical situation, and adapts interventions using extensive experience while continuing to validate safety.
Name all six QSEN competencies. Which competency is most directly demonstrated when a nurse reports a near-miss medication error?
The six QSEN competencies are:
During a safety concern, a nurse states:
“I am concerned. I am uncomfortable. This is a safety issue.”
Name this communication tool and the larger patient-safety program in which it is used.
This is the CUS communication tool used within TeamSTEPPS.
CUS provides graded assertiveness and communicates the seriousness of a safety concern.
A postoperative client with obstructive sleep apnea receives an opioid medication. Explain the dangerous interaction between OSA and opioids. What should be the nurse’s highest-priority monitoring focus?
OSA causes repeated upper-airway obstruction, while opioids reduce respiratory drive and increase sedation. Together, they significantly increase the risk of airway obstruction, hypoventilation, hypoxemia, respiratory arrest, and death.
Monitor:
Before removing a deceased client’s lines or tubes, what legal or safety determination must the nurse make? Which principles of dignity and respect should guide postmortem care?
The nurse must determine whether:
Postmortem care should include: