Assessment/Diagnosis
Subjective or Objective?
Patient has a 101.2 degree fever and is vomiting.
Objective
This type of planning is kept up to date, manages risk factors, and promotes function
Ongoing planning
A nurse is evaluating the effectiveness of a care plan for a diabetic patient. Which action represents the evaluation phase of ADPIE?
A) Teaching the patient how to administer insulin.
B) Assessing the patient’s blood glucose levels before meals.
C) Comparing the patient’s current HbA1c level to previous results.
D) Documenting the patient’s new diagnosis of diabetes mellitus.
C) Comparing the patient’s current HbA1c level to previous results.
A nurse needs to call the physician about a patient's worsening condition using ISBARR. Which statement correctly represents the "Situation" step?
A) "This is Nurse Jones from 4W, and I am calling about Mr. Smith in Room 402."
B) "Mr. Smith was admitted yesterday with pneumonia and has a history of COPD."
C) "Mr. Smith’s respiratory rate has increased to 30 breaths per minute, and his oxygen saturation is 86% on 4L nasal cannula."
D) "I recommend increasing the patient’s oxygen and obtaining an arterial blood gas."
C) "Mr. Smith’s respiratory rate has increased to 30 breaths per minute, and his oxygen saturation is 86% on 4L nasal cannula."
Which statement by the nurse demonstrates the "Assessment" phase of ADPIE?
A) "The patient’s blood pressure is 150/92 mmHg, and they report a headache."
B) "The patient is at risk for falls related to dizziness and weakness."
C) "The patient will maintain a blood pressure below 140/90 mmHg within one month."
D) "I will educate the patient about reducing sodium intake."
A) "The patient’s blood pressure is 150/92 mmHg, and they report a headache."
Who is the best source to get your assessment data from?
Patient
This type of planning addresses each problem listed in the prioritized nursing diagnosis
Initial planning
Which statement best describes an affective outcome?
A) The patient verbalizes three signs of hypoglycemia.
B) The patient performs insulin self-injection correctly.
C) The patient expresses confidence in managing their diabetes.
D) The patient’s blood glucose level remains within the target range.
C) The patient expresses confidence in managing their diabetes.
What is the primary purpose of the ISBARR communication framework?
A) To increase the number of orders given over the phone.
B) To encourage nurses to only report emergencies to providers.
C) To promote clear, structured communication and prevent errors.
D) To provide a legal defense for nurses in case of malpractice.
C) To promote clear, structured communication and prevent errors.
Which statement is an example of a SMART goal in the Planning phase?
A) "The patient’s pain will improve."
B) "The patient will walk 50 feet using a walker by the end of the shift."
C) "The patient should increase physical activity."
D) "The nurse will provide emotional support."
B) "The patient will walk 50 feet using a walker by the end of the shift."
What type of diagnosis is this?
Risk for infection as evidenced by surgical wound, compromised immune system, and prolonged hospitalization?
At Risk Diagnosis
This type of planning has to anticipate and plan for needs of the patient at home
Discharge planning
A nurse sets the goal: “The patient will demonstrate proper use of a walker by the end of the shift.” What type of outcome is this?
A) Cognitive
B) Psychomotor
C) Affective
D) Physiological
B) Psychomotor
A nurse is using ISBARR to report a deteriorating patient. Which statement should be included in the "Situation" step?
A) "This is Nurse Kim calling from the medical-surgical unit about Mr. Davis in Room 312."
B) "Mr. Davis was admitted with pneumonia and has a history of asthma."
C) "His respiratory rate is 36, and he is using accessory muscles to breathe."
D) "I think we need to start non-invasive ventilation and notify respiratory therapy."
C) "His respiratory rate is 36, and he is using accessory muscles to breathe."
Which of the following is an independent nursing intervention?
A) Administering prescribed IV fluids.
B) Ordering a chest X-ray.
C) Teaching a patient deep breathing exercises after surgery.
D) Changing a patient’s medication dosage.
C) Teaching a patient deep breathing exercises after surgery.
Which type of diagnosis describes disease and pathology?
Medical Diagnosis
Give a patient 50 mg Benadryl is an example of what type of intervention
Physician initiated
The nurse is reviewing the patient’s care plan and notices the goal states: “The patient’s temperature will remain below 100°F within 24 hours.” This goal is an example of what type of outcome?
A) Psychomotor
B) Affective
C) Cognitive
D) Physiological
D) Physiological
A nurse is calling a provider about a critically ill patient using ISBARR. The provider sounds rushed and distracted. After stating the situation and background, the provider interrupts and says, “Just give the patient fluids.” What is the nurse’s best response?
A) Follow the order and document the conversation.
B) Continue with the assessment and recommendation steps.
C) Politely end the call and reattempt later when the provider is less busy.
D) Ask the provider to clarify the fluid type, rate, and any additional interventions.
D) Ask the provider to clarify the fluid type, rate, and any additional interventions.
Which nursing diagnosis is correctly formatted?
A) "Pneumonia related to lung infection as evidenced by fever and cough."
B) "Risk for falls related to unsteady gait and weakness."
C) "Anxiety caused by stress at home as evidenced by crying."
D) "Pain due to surgery as shown by grimacing."
B) "Risk for falls related to unsteady gait and weakness."
Which part of this diagnosis is the etiology?
Ineffective breathing problem related to pneumonia as evidenced by increased respiratory rate and dyspnea.
Pneumonia
Turning patients every 2 hours is an example of what type of intervention
Nurse initiated
Which of the following is an example of a long term outcome?
A. The patient's blood pressure will decrease to 130/80 mmHg within 2 hours
B. The patient will verbalize 3 strategies to manage stress by the end of shift
C. The patient will maintain a blood pressure of 140/90 mmHg over the next 3 months
D. The patient will demonstrate correct use of hypertensive medications within 24 hours
C. The patient will maintain a blood pressure of 140/90 mmHg over the next 3 months
A nurse is using ISBARR to communicate a critical lab result (potassium level of 6.8 mEq/L) to the physician. The provider seems distracted and responds, “Okay, just give something to fix it.” What is the nurse’s priority action?
A) Document the provider’s response and administer a potassium-lowering medication.
B) Recommend a specific treatment, such as administering sodium polystyrene sulfonate (Kayexalate) or calcium gluconate.
C) End the call and notify the charge nurse that the provider was unresponsive to the situation.
D) Proceed with hospital protocol for hyperkalemia without further consultation.
B) Recommend a specific treatment, such as administering sodium polystyrene sulfonate (Kayexalate) or calcium gluconate.
A patient with COPD is short of breath. The nurse elevates the head of the bed and provides oxygen. Which step of ADPIE is this?
A) Diagnosis
B) Implementation
C) Planning
D) Evaluation
B) Implementation