Nursing Plan of Care

Question 1

A four column nursing plan contains what four columns?

Answer 1

Nursing diagnoses
Goals/Desired outcomes
Nursing interventions
Evaluation

Question 2

A three-column nursing plan contain what three columns?

Answer 2

Nursing Diagnoses
Goals/desired outcomes
Nursing interventions

Question 3

A five-column nursing plan contains what five columns?

Answer 3

Assessment
Nursing diagnoses
Goals/desired outcomes
Nursing interventions
Evaluation

Question 4

Concept map

Answer 4

Enhances clinical reasoning by showing how individual steps of the nursing process relate to each other in a logical pattern.
Serves as a visual guide of clinical data to help prioritize client needs

Question 5

Standardized plan

Answer 5

Identifies nursing care needed for groups of clients with common health problems

Question 6

Clinical pathway

Answer 6

Standardized, evidence-based, multidisciplinary plan that outlines the expected care required for clients with common, predictable health problems.

Question 7

Low priority problems

Answer 7

Problems that can be resolved easily with minimal interventions and do not cause significant dysfunction.

Question 8

Medium priority problems

Answer 8

Problems that may cause unhealthy physical or emotional consequences but are not life threatening

Question 9

High priority problems

Answer 9

Life-threatening problems of airway breathing and circulation, or conditions that have a potential to become life threatening within a short amount of time

Question 10

Urgency Factor: Non-acute

Answer 10

A delay in providing these interventions would not negatively impact client outcomes

Question 11

Urgency Factor: Acute

Answer 11

A low potential for the client’s condition to become life threatening exists. Interventions are usually scheduled during the shift when time constraints of higher priorities are completed

Question 12

Urgency Factor: Critical

Answer 12

Considered medium-high urgency. The nurse needs to respond quickly to a high priority physical or psychological problem within a short period of time because of the potential for the client’s condition to become life threatening if the intervention is delayed.

Question 13

Urgency Factor: Imminent Death

Answer 13

Highest urgency level.
Interventions address airway obstruction, absence of breathing, or ineffective cardiac functioning.
Immediate intervention is needed to save the client’s life.

Question 14

Prioritizing by time constraints

Answer 14

Some interventions have time restraints. i.e. providing an antibiotic at the right time so that peak and trough drug levels are correctly measured

Question 15

Triage: Emergent or immediate

Answer 15

The client has a life-threatening issue that needs immediate intervention

Question 16

Triage: Urgent or delayed

Answer 16

The client has a serious health problem. However, delaying treatment would not cause a life-threatening situation

Question 17

Triage: Non-urgent or minor

Answer 17

The client has a health issue that does not require immediate care. The client can ambulate and is in no acute distress.

Question 18

Prioritizing care Ranking activities: Priority 1 or Must Do

Answer 18

Activities that take priority over any other interventions, such as suctioning secretions from a blocked endotracheal tube

Question 19

Prioritizing care Ranking activities: Priority 2 or Should Do

Answer 19

Activities that should be done, but are not essential, such as putting more paper towels next to the sink in the room of a client with a wound infection

Question 20

Prioritizing care Ranking activities: Priority 3 or Nice to Do

Answer 20

Actions can be done when there is available time, such as washing a client’s hair

Question 21

Factors to consider when prioritizing care: Ethics

Answer 21

The ethical principles of justice and fairness are used when prioritizing care

Question 22

Factors to consider when prioritizing care: Safety

Answer 22

Nurses protect clients and provide a safe environment by following the approach “to do no harm”

Question 23

Factors to consider when prioritizing care: Availability of resources

Answer 23

If resources are insufficient or absent, reprioritization may be needed.

Question 24

Factors to consider when prioritizing care: Time management

Answer 24

Nurses determine the amount of time needed to complete an intervention and the urgency in which to complete it.

Question 25

Factors to consider when prioritizing care: Multiple clients

Answer 25

Nurses determine which interventions are priorities for assigned clients and then set the priority for completion

Question 26

Factors to consider when prioritizing care: PT preferences

Answer 26

Nurses take the pts needs and desires into consideration when prioritizing care.

Question 27

Factors to consider when prioritizing care: Change in pt condition

Answer 27

Nurses must be aware of which pts health statuses have changed in order to reprioritize care actions.

Question 28

Factors to consider when prioritizing care: The unexpected

Answer 28

Things do not always go as planned and must reprioritize interventions as necessary to meet the most urgent client needs

Question 29

Factors to consider when prioritizing care: Nurse self-care

Answer 29

A short time away from pt care is beneficial to break up the intensity of the work environment and relieve stress

Question 30

Factors to consider when prioritizing care: Delegation

Answer 30

Delegation helps complete more priority interventions. Taks evaluation needs to be performed after completion.