Assessment
What is the first step of the nursing process?
Assessment
What is the proper way to write a nursing diagnosis?
A. Acute pain as evidenced by a pain rating of 8/10 related to surgical incision.
B. Acute pain related to surgical tissue injury as evidenced by patient reporting pain of 8/10, tachycardia, and guarding at the surgical site.
C. Surgical tissue injury as evidenced by acute pain related to patient reporting pain of 8/10.
C.
B. Acute pain related to surgical tissue injury as evidenced by patient reporting pain of 8/10, tachycardia, and guarding at the surgical site.
Which step of the nursing process involves establishing patient goals and expected outcomes?
Planning
During which step of the nursing process does the nurse carry out the interventions established in the patient's plan of care?
Implementation
Which step of the nursing process determines whether patient goals have been achieved?
Evaluation.
A patient tells the nurse, "My pain is an 8 out of 10." Is this subjective or objective data?
Subjective data
What is the difference between a medical diagnosis and a nursing diagnosis?
A medical diagnosis identifies a disease or medical condition, while a nursing diagnosis identifies the patient's response to a health condition.
What does SMART stand for when developing patient goals?
Specific, Measurable, Achievable, Relevant, and Time-bound
Which of the following is an independent nursing intervention?
A. Administering prescribed IV antibiotics.
B. Repositioning a patient every 2 hours to prevent pressure injuries.
C. Administering prescribed pain medication.
D. Initiating a blood transfusion
B. Repositioning a patient every 2 hours to prevent pressure injuries.
A patient's goal is to reduce pain from 8/10 to 3/10. After treatment, the patient reports pain of 2/10. Was the goal met? Why or why not?
Yes. The patient achieved the expected outcome.
The nurse measures a patient's blood pressure at 88/52 mmHg. What type of data is this?
Objective data because it is measurable.
A patient has difficulty walking because of muscle weakness. Which nursing diagnosis is most appropriate?
Impaired physical mobility
Which is a better patient goal?
A. Patient will improve their pain.
B. Patient will report pain of 3/10 or less within one hour of medication administration.
B. Patient will report pain of 3/10 or less within one hour of medication administration.
A nurse is caring for a patient who is at risk for falls. Which nursing intervention is most appropriate?
A. Encourage the patient to ambulate independently.
B. Keep all four side rails raised at all times.
C. Keep the bed in the lowest position and ensure the call light is within reach.
D. Encourage the patient to get out of bed without assistance.
C. Keep the bed in the lowest position and ensure the call light is within reach.
After teaching a patient how to use an incentive spirometer, the nurse asks the patient to demonstrate its use. What is the nurse evaluating?
The patient's understanding and ability to correctly perform the skill.
A nurse notices that a patient is short of breath. What additional assessment should the nurse perform?
Assess respiratory rate, oxygen saturation, lung sounds, and work of breathing.
A patient has an unsteady gait, confusion, and a history of falling. Which nursing diagnosis should the nurse identify?
Risk for falls
The nurse is caring for four patients. Which patient should the nurse prioritize?
A. A patient requesting a blanket.
B. A patient awaiting discharge teaching.
C. A patient reporting pain rated 5/10.
D. A patient experiencing difficulty breathing.
D. A patient experiencing difficulty breathing.
A nurse is preparing to administer a prescribed antihypertension medication. Before administration, the patient's blood pressure is 84/48 mmHg. What should the nurse do FIRST?
A. Administer the medication as prescribed.
B. Hold the medication pending reassessment, assess the patient, and notify the provider as indicated.
C. Give the patient water and administer the medication.
D. Document the blood pressure and administer the medicaiton.
B. Hold the medication pending reassessment, assess the patient, and notify the provider as indicated.
A. Goal met. The patient is doing much better today.
B. Goal met. Patient appears to be improving.
C. Goal met. Patient ambulated 100 feet with a walker and standby assistance by the end of the shift.
D. Goal met. Patient tolerated walking 100 feet well.
C. Goal met. Patient ambulated 100 feet with a walker and standby assistance by the end of the shift.
A nurse enters a patient's room and finds the patient pale, diaphoretic, and difficult to arouse. What should the nurse assess first?
Assess the patient's airway, breathing, and circulation (ABCs), prioritizing airway patency and breathing.
A patient has a respiratory rate of 30/min, an oxygen saturation of 86%, and difficulty breathing. Which nursing diagnosis takes priority?
Impaired Gas Exchange
What is the steps of the nursing process?
Assessment, diagnosis, planning, implementation, and evaluation.
A nurse administers pain medication to a patient reporting pain of 9/10. Thirty minutes later, the nurse returns to assess the patient's pain level. Which two phases of the nursing process have been demonstrated?
Implementation and Evaluation
What are the two parts of the evlauation process?
Short term and long term goals.