WEEK 4

Question 1

When was the nursing process developed and by who?

Answer 1

The nursing process was developed by Ida Jean Orlando as a guide to direct nursing care in 1958

Question 2

define critical thinking

Answer 2

Thought process that is systematic and logical in reviewing information and data, that is open to reflection, inquiry and exploration in order to make informed decisions.

Question 3

How can a nurse promote spiritual well being?

Answer 3

assisting a client to observe a religious practice, providing a client time for meditation, or praying with a client

Question 4

How can a nurse promote mental wellbeing?

Answer 4

teaching the client relaxation techniques, taking the client for a walk outdoors, and assisting the client to maintain relationships with friends and family

Question 5

How can a nurse promote physical well being?

Answer 5

providing a nutritious diet, assisting the client to be physically active, and educating the client about recommended health screenings

Question 6

Assessment

Answer 6

Involves application of nursing knowledge to the collection, organization, validation and documentation of data about a client’s health status.

The nurse focuses on the client’s response to a specific health problem, including the client’s health beliefs and practices. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information.

Nurses must have excellent communication and assessment skills to plan client care.

Question 7

Analysis

Answer 7

Involves the nurse’s ability to analyze assessment data to identify health problems/risks and a client’s needs for health intervention.

The nurse identifies patterns or trends, compares the data with expected standards or reference ranges, and draws conclusions to direct nursing care.

Question 8

Planning

Answer 8

Involves the nurse’s ability to make decisions and problem solve. The nurse uses a client’s assessment data to develop measurable client goals/outcomes and identify nursing interventions. The nurse uses evidenced-based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client to achieve their goals.

Question 9

Implementation

Answer 9

Involves the nurse’s ability to apply nursing knowledge to implement interventions to assist a client to promote, maintain, or restore health.

The nurse uses problem-solving skills, clinical judgment, and critical thinking when using interpersonal and technical skills to provide client care.

During this step, the nurse will also delegate and supervise care and document the care and the client’s response.

Question 10

Evaluation

Answer 10

Involves the nurse’s ability to evaluate a client’s response to nursing interventions and to reach a nursing judgment regarding the extent to which the client has met the goals and outcomes.

During this step the nurse will also assess client/staff understanding of instruction and the effectiveness of interventions, and identify the need for further intervention or the need to alter the plan.

Question 11

define clinical judgement

Answer 11

observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.”

Question 12

Nurses must consider both environmental and individual factors when caring for clients. What is an examples of each?

Answer 12

Environmental- setting and situation considerations, equipment, and surroundings. Some other examples include staffing, supplies, health records, time pressures, cultural considerations, task complexity, and risk assessments.

Individual- nurse factors such as knowledge and skills; nurse characteristics that include attitudes, prior experiences, and level of experience, as well as cognitive load, such as demands on the nurse, stress, problem solving, and memory.

Question 13

Who developed the Clinical Judgement Action Model?

Answer 13

The National Council of State Boards of Nursing (NCSBN)

Question 14

Clinical Judgment: Recognize Cues (Assessment)

Answer 14

Filter information from different sources (i.e. signs, symptoms, health history, environment)

Question 15

Clinical Judgment: Analyze Cues (Analysis)

Answer 15

Link recognized cues to a client’s clinical presentation and establish probable client needs, concerns, or problems

Question 16

Clinical Judgment: Priortize Hypotheses (Analysis)

Answer 16

Establish priorities of care based on the client’s health problems (e.g., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values).

Question 17

Clinical Judgement: Generate Solutions (Planning)

Answer 17

Identify expected outcomes and related nursing interventions to ensure clients’ needs are met

Question 18

Clinical Judgement: Take Actions (Implementation)

Answer 18

Implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health

Question 19

Clinical Judgement: Evaluate Outcomes

Answer 19

Evaluate a client’s response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met

Question 20

The nursing process for RNs

Answer 20

Assessment
Analysis
Planning
Implementation
Evaluation

Question 21

Assessment

Answer 21

the nurse collects, organizes, and validates data by using critical-thinking skills. Assessment can come in many forms and should be assessed holistically for each client need.

Question 22

What should be done during the assesment part?

Answer 22

During assessment, the nurse obtains the client’s health history (interview), performs a physical assessment, and reviews the client’s medical record (laboratory results, diagnostic testing). Assessment also involves obtaining and documenting objective and subjective data that pertain to the client.

Question 23

Objective data

Answer 23

are measurable, based on facts and what the nurse can observe or notice by using the senses—seeing (inspection), hearing (auscultation), smelling, and touching (palpation)

Question 24

Examples of objective data

Answer 24

facial expressions, intake and output, physical assessment findings, and vital signs.

Question 25

Subjective data

Answer 25

derived from the client’s self-report or from a family member.

Question 26

Examples of subjective data

Answer 26

the client’s self-report of pain and the client’s reason for seeking care

Question 27

How to document subjective data?

Answer 27

using quotation marks to indicate the client’s verbatim remarks.

Question 28

What else is included in assesment?

Answer 28

he nurse should interview the client, asking about past medical history, medications, natural and herbal remedies utilized, substance abuse, sexual history, and support systems. The nurse should also assess the client holistically by asking questions about sociocultural, economic, and even spiritual needs.

Question 29

Difference between RNs and PNs in assessment?

Answer 29

RNs must perform initial assessments on both new clients and unstable clients. PNs can perform data collection on clients who are deemed stable by the RN. However, based on any data collected by a PN or AP, the RN must determine if further physical assessment data are needed to gain required information and make decisions regarding the client’s current health condition. This can require interviewing the client and asking questions; performing further assessments, either physical or psychosocial; or reviewing assessment data such laboratory values and diagnostic tests.

Question 30

Analysis

Answer 30

The analysis of assessment data to identify health problems/risks and a client s needs for health intervention. The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care.

Question 31

When would a nurse need to reassess and reanalysis a patient?

Answer 31

triaging client

Question 32

Planning

Answer 32

The planning step of the nursing process involves the nurse s ability to make decisions and problem solve. The nurse uses a client s assessment data to develop measureable client goals/outcomes and identify nursing interventions. The nurse uses evidenced based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client to achieve their goals.

Question 33

How should a nurse plan for a client who is in pain?

Answer 33

as administering prescribed pain medications, repositioning the client, providing a quiet and calming environment, and utilizing relaxation techniques.

Question 34

Implementation

Answer 34

it involves taking action to provide nursing care as outlined in the client’s plan of care the best action is no action at all while continuing to monitor the client. At other times, the RN will take specific actions such as administration of prescribed medications or therapies.

Question 35

Evaluation

Answer 35

the RN evaluates the effectiveness of the interventions provided and documents the client’s response

Question 36

Practical Nurses (PN) Nursing Process

Answer 36

Data collection planning implementation evaluation

Question 37

Data collection (PN)

Answer 37

This step is like the RN nursing process of assessment; however, the PN can collect data but cannot assess it. To collect subjective and objective data, the nurse can ask questions; collect information regarding the client’s physical state by using inspection, auscultation, and palpation techniques; obtain vital signs; review laboratory or diagnostic data; and so on. The PN should report any changes in client findings to the RN so that the RN can analyze the data—for example, a blood pressure that was previously within the expected reference range and is now elevated. Deviations from the client’s baseline may be clinically significant, so communication between the PN and the RN is crucial for client safety. The PN should document all findings in the client’s medical record.

Question 38

Planning (PN)

Answer 38

assisting and collaborating with the RN, not assuming full responsibility for planning.

Question 39

Implementation (PN)

Answer 39

he PN should collaborate with the RN to implement interventions included in the plan of care. Each state allows PNs to complete different tasks; therefore, PNs must be aware of the scope of practice within their state regulations and abide by these standards. Depending on the state, interventions may include medication administration, dressing changes, or intravenous fluid hydration, for example. All implementation of interventions should be recorded in the client’s medical record.

Question 40

Evaluation (PN)

Answer 40

the PN should evaluate the care provided with the assistance, and under the supervision, of the RN. For example, collecting data after nausea medication administration to determine effectiveness can be done by asking questions such as “Have you had any vomiting since you received your nausea medication? Is your nausea improved? Is your nausea gone completely?” The PN then records the data in the client’s medical record, and collaborates with the supervising RN as needed.

Question 41

Adverse situation

Answer 41

Prevention of a potential adverse situation is always better than having to treat a client for an actual adverse situation! Therefore, early detection through nursing assessment is crucial

Question 42

What is an example of early noticing?

Answer 42

rising blood pressure that could quickly escalate out of control, or recognizing that frequent urination after surgery could be an indication that the client needs an indwelling catheter to prevent bladder

Question 43

factors that influence RN decision making in acute care setting

Answer 43

Awareness of client status Goals/outcomes Options to meet goals Routines Education Nursing roles Teamwork Resources Support from other staff Patient education

Question 44

Nurses should remember what cannot be delegated?

Answer 44

clinical reasoning and clinical judgment cannot be delegated.

Question 45

What are the most common skills delegated to APs?

Answer 45

vital signs, ADLs assistance, and measurement of heigh and weight

Question 46

Time management matrix

Answer 46

A tool that divides activities into four quadrants: important, not important, urgent, not urgent.

Question 47

SMART goals

Answer 47

Specific Measurable Attainable Realistic Timely

Question 48

Acuity level

Answer 48

complexity of clients condition a client who is stable is on the low score of acuity level for example

Question 49

Direct care activities vs indirect care activites

Answer 49

direct care activities- require client contact, such as wound dressing change indirect care activities- those that take a great deal of time but do not require direct interaction with the client, such as charting.

Question 50

Three standard process for making client assignments

Answer 50

Direct nursing assignments: the nurse is assigned to care for a specific client, such as when maintaining a 1:1 nurse client ratio in a cardiac care unit (CCU). Area assignments: tend to be utilized in areas where clients have a shorter length of stay (LOS), such as the emergency department, intraoperative units, or obstetric units. In these situations, nurses are assigned to certain zones and care for the clients who temporarily reside there. An example of this type of client assignment would be a preoperative holding area where clients and nurses are assigned to specific bays. Group assignments: involve sorting clients into groups first, then assigning a nurse to each group. The group assignment method is useful on large units, or units with a larger client census, because it allows for grouping of clients based on location and acuity.

Question 51

IDEAL Discharge Planning

Answer 51

I: Include the client and caregivers. D: Discuss the five key areas—medications, home life, warning signs, test results, and follow-up. E: Educate the client on the condition, the discharge process, and next steps. A: Assess the effectiveness of the education. L: Listen to the client’s goals and preferences.

Question 52

Rights of delegations

Answer 52

right task, right circumstance, right person, right directions and communication, and right supervision and evaluation

Question 53

Maslow's hierarchy of needs

Answer 53

from bottom to top physiological needs safety needs love needs esteem needs self-acutalization

Question 54

ABCDE priority framework

Answer 54

airway breathing circulation disability exposure

Question 55

O2 sat

Answer 55

for clients w/o history of COPD- 92 to 96 w history of COPD- 88 to 92

Question 56

Breathing

Answer 56

During the breathing assessment step, the nurse may potentially detect the presence of a pneumothorax (lung collapse due to air entering the pleural space) or bronchospasms (a condition in which the muscles in the airways tighten, causing decreased airflow). If a client is having difficulty breathing, continuously monitor the oxygen saturation and check other vital signs. A Venturi mask may be required for the delivery of oxygen to maintain therapeutic oxygen levels. If the client is experiencing respiratory distress, the nurse should place the client in an upright position to promote lung expansion.

Question 57

Circulation

Answer 57

Adequacy of circulation is determined by evaluating a client’s blood pressure; capillary refill time; pulse rate, including volume and character; urine output; and level of consciousness, as well as by looking for changes in the client’s skin tone. Manifestations of decreased circulation or perfusion may include skin tone and temperature changes; decreased level of consciousness; prolonged capillary refill time; hypotension; changes in pulse rate, regularity, and volume; and decreased urine output. Impaired circulation can be caused by a number of factors, including acute and chronic cardiovascular conditions as well as alterations in circulating blood volume. Treatment for altered circulation depends on the cause, but usually includes fluid replacement, controlling bleeding, and restoring tissue perfusion.

Question 58

A nurse is caring for a client with asthma. Which action is a priority

Answer 58

auscultate lung sounds

Question 59

Airway

Answer 59

Nurse should see if airway is clear and listen to lung sounds

Question 60

least invasive/least restrictive priority framework

Answer 60

vInterventions are selected that maintain client safety while producing the least amount of restriction to the client; the nurse chooses interventions that are the least invasive.

Question 61

survival potential

Answer 61

based on doing the most good for the maximum number of clients at a time when health care resources are limited due to a large number of injuries This priority-setting method is utilized during mass-casualty incidents such as natural disasters (wildfires and earthquakes), major road accidents, and acts of terrorism.

Question 62

triage

Answer 62

to idenify the most severly injured clients with the highest survival potential

Question 63

triage four main categories

Answer 63

emergent (red)- transported away from the scene immediately ( a client who has a major hemorrhagic wound or a client experiencing chest pain would be tagged as emergent.) urgent or delayed (yellow)- clients who have a serious injury that does not pose an immediate threat to life. (For example, a client who has an open fracture without major bleeding would be tagged as delayed. Clients in this category have an injury or condition that requires treatment within 30 minutes to 2 hours.) nonurgent or minimal (green)- who have only minor injuries. aka the walking wounded and expectant (black) (dead)- either deseased or not expected to survive

Question 64

What are some examples of a short-term goal and a long-term goal for a post op patient?

Answer 64

short-term: decrease pain to a more manageable level by the end of shift long-term: manageable pain level by discharge or after discharge

Question 65

When does discharge begin?

Answer 65

At admission! EXAM QUESTION

Question 66

What is something that is never to be delegated?

Answer 66

Clinical judgement and clinical thinking and clinical reasoning EXAM QUESTION

Question 67

Five rights of delegation

Answer 67

right person right circumstance right task right communication and directions right supervision and evaluation EXAM QUESTION

Question 68

Team nursing

Answer 68

pairs two or more nurses together as a team to care for a group of clients long term care: has more aids than nurses (nursing home, pallative care) acute term care: has more nurses than APs (hospitals)

Question 69

What are some barriers in interprofessional collaboration?

Answer 69

miscommunication distrust lack of respect among provider types different levels of perceived importance misunderstanding of each other's roles

Question 70

What is the outcome of clinical thinking and the nursing process?

Answer 70

clinical judgement

Question 71

Does the nursing process have to go in order?

Answer 71

Initially yes, but once the nurse has seen more of the clients arising issues, it can and probably will have to go out of order

Question 72

When would you put someone in lithotomy position?

Answer 72

pap smear, vaginal examination, child birth

Question 73

What is a nurse initiated/independent interventions?

Answer 73

nurses use evidence and scientific rationale to take automonous actions that benefit clients that is in the SCOPE OF THEIR PRACTICE example: repoistening a client every 2 hrs to avoid skin breakdown, showing a client how to use progressive muscle relaxation, preforming a daily bath after the evening meal EXAM QUESTION

Question 74

What is a provider initiated/dependent intervention?

Answer 74

interventions that a nurse initiates as a RESULT OF A PROVIDER'S ORDERS AND PRESCRIPTIONS (written, standing, verbal) or THE FACULTIES PROTOCOL (blood administration procedures) examples: writing a prescription for morphine PRN, inserting NG tube to relieve gastric distension EXAM QUESTION

Question 75

What is a collaborative intervention?

Answer 75

interventions that nurses carry out in collaboration with other health care team professionals examples: make sure client receives and eats evening snack

Question 76

What is the difference between basic and complex critical thinking?

Answer 76

basic: a nurse trusts the experts and thinks concretely based on the rules. Basic critical thinking results from limited nursing knowledge and experience, as well as inadquate critical thinking experience example: a client reports pain 1 hr after receiving pain medication. Instead of reassesssing the client's pain, the nurse tells the client they have to wait two more hrs before receiving another dose. example: a nurse uses the faculty's procedure manual to change an IV dressing complex thinking: the nursing begins to express autonomy by analyzing and examining data to determine the best alternative. complex critical thinking results from an increase in nursing knowledge, experience, intuition, and more flexible attitudes example: a nurse realizes that a client is not ambulating as often as prescribed because of a fear or missing their daughter's phone call. The nurse assures the client that the staff will listen for and answer their phone when they are out of their room. example: a nurse repositions a client's arm to improve function of the infusion of an IV. EXAM QUESTION!

Question 77

A nurse is teaching newly licensed nurses about ergonomics. Which is true about ergonomics?

Answer 77

The use of ergonomics increases job satisfaction.

Question 78

A nurse is discussing proper body mechanics with a group of assistive personnel. Which is true regarding good body mechanics?

Answer 78

A stable center of gravity increases stability and balance. A wide base allows for good balance. Good body mechanics means the tightening of the abdomen.

Question 79

In what order should one DON PPE?

Answer 79

gown-face mask-face shield (if needed)-surgical bonnet(if needed)-shoe covering(if needed)-clean gloves always gloves last. EXAM QUESTION!

Question 80

In what order should one DOFF PPE?

Answer 80

gloves-bonnet-face shield-gown-shoe covers always gloves first EXAM QUESTION!

Question 81

When's the most common use of restraints?

Answer 81

Intubated patients in the ICU

Question 82

What is the spectrum of ways to do procedures?

Answer 82

from least intense to most intense clean: just clean hands aseptic: clean hands, gloves, environment, etc. sterile: as clean as one can get; absence of life!

Question 83

When would a women be considered sterile?

Answer 83

when she is infertile or after she gets a mastectomy

Question 84

What is a CAUTI (catheter associated urinary tract infection)?

Answer 84

A never event. it is something preventable that can be controlled using sterile techniques hospital pays for coverage when this happens. you can get this when: something isn't sterile OR something gets infected after insertion

Question 85

Rights of Medication Administration

Answer 85

right person right time right dose right medication right route right documentation right to refuse right assessment right education right evaluation

Question 86

Pharmacokinetics

Answer 86

study of absorption, distribution, metabolism, and excretion

Question 87

absorption of medicaiton

Answer 87

movement of medication in body from where it was administered to the circulatory systemh

Question 88

what is the most common spot to administer medicaiton?

Answer 88

oral (by mouth)

Question 89

distribution of medication

Answer 89

process of medication delivery to target organs/tissues, following absorption into the circulatory system

Question 90

What is distribution of medication effected by?

Answer 90

circulatory status (bradycardia)

Question 91

metabolism of medication

Answer 91

chemical process of converting a medication's structure (breaking down to be excreted easily)

Question 92

Where are most medications metabolised in?

Answer 92

liver but also kidney and small intestines

Question 93

Who is at a great risk for medication toxicity?

Answer 93

people with kidney disease or renal kidney failure older adults because their excretion process slows down

Question 94

excretion of medication

Answer 94

process by which medication is removed from body

Question 95

Where are most medications excreted from?

Answer 95

kidney

Question 96

What could be going on with this client? A nurse administers medication. The client is tachycardia, rash, and dyspnea. What is going on?

Answer 96

adverse drug reaction or anaphyaxis

Question 97

What is anaphyaxis?

Answer 97

a life-threatening reaction that causes... tachycardia, hypotension, and dyspnea (aka anaphylactic shock)

Question 98

Medication Reconciliation

Answer 98

educate clients to keep account of current medications and keep it updated admission, transfer, discharge, levels of care

Question 99

High Alert Medications

Answer 99

always need a second nurse to admin with you and make sure dose is right and that the medication is right as well insulin, potassium chloride

Question 100

Routes of Medication

Answer 100

Enteral: mouth, NG tube, feeding tube, stomach, GI, intestines, tablets, capsules, liquids, etc Topical: creams, patches Parental: IV, IM

Question 101

Parental Medication Routes

Answer 101

Intradermal: TB skin test, allergy test under the skin, barely, 26-27 gauge, forms a bleb, 10-15 degree angle Subcutaneous: insulin, heparin fatty tissues (adipose), 25-18 gauge, no more than 1.5 mL, 45-degree angle Intramuscular: vaccines muscle (multiple locations) 27-18 gauge, no more than 3mL (no more than 2mL in deltoid), 90 degree angle

Question 102

Intramuscular Injection Locations

Answer 102

Deltoid: small muscle=small amounts! most common for vaccines upper arm no more than 1mL is preferred Ventrogluteal: bigger muscle=can hold more medicine! antibiotics, antiemetics, steriods, pain meds below hip vastus lateralis: most common for small kinds thigh

Question 103

What position would you place someone who is having a seizure?

Answer 103

Lateral position to prevent aspiration

Question 104

What position would you place a client in for recieving a Foley catheter?

Answer 104

dorsal recumbant

Question 105

What is something that cannot be delegated to unlicensed personnel?

Answer 105

Clinical judgement and clinical reasoning

Question 106

Clinical judgement is..?

Answer 106

Clinical reasoning over an expanse of time