A client comes to the walk-in clinic with comparison alone will not determine C.

Implementation
reports of abdominal pain and whether the BP is normal. Gaps in the D. Evaluation
diarrhea. While taking the client's vital record (option 3) will not aid in B. Planning
signs, the nurse is implementing which interpreting the current measurement.
phase of the nursing process? Which of the following behaviors by Rationale: The planning step of the
the nurse demonstrates that the nurse nursing process involves formulating
A. Assessment is participating in critical thinking? client goals and designing the nursing
B. Diagnosis Select all that apply. interventions required to prevent,
C. Planning reduce, or eliminate the client's health
D. Implementation A. Admitting not knowing how to do a problems. Outcome goals are
A. Assessment procedure and requesting help documented on the client's care plan.
B. Using clever and persuasive Assessment data (option 1) is used to
Rationale: The first step in the nursing remarks to support an opinion or help identify a client's human
process is assessment, the process of position response, and once a plan is
collecting data. All subsequent phases C. Accepting without question the established, the interventions are
of the nursing process (options 2, 3, values acquired in nursing school implemented (option 3) and evaluated
and 4) rely on accurate and complete D. Finding a quick and logical answer, (option 4).
data even to complex questions When the client resists taking a liquid
E. Gathering three assistants to medication that is essential to
The nurse is measuring the client's transfer the client to a stretcher after treatment, the nurse demonstrates
urine output and straining the urine to noting the client weighs 300 lbs. critical thinking by doing which of the
assess for stones. Which of the A. Admitting not knowing how to do a following first?
following should the nurse record as procedure and requesting help
objective data? E. Gathering three assistants to A. Omitting this dose of medication
A. The client reports abdominal pain transfer the client to a stretcher after and waiting until the client is more
B. The client's urine output was 450 noting the client weighs 300 lbs. cooperative
mL B. Suggesting the medication can be
C. The client states, "I didn't see any Rationale: Critical thinking in nursing is diluted in a beverage
stones in my urine." self-directed, supporting what nurses C. Asking the nurse manager about
D. The client states, "I feel like I have know and making clear what they do how to approach the situation
passed a stone." not know. It is important for nurses to D. Notifying the physician inability to
B. The client's urine output recognize when they lack the give the client this medication
was 450 mL. knowledge they need to provide safe B. Suggesting the medication can be
Rationale: Objective data is care for a client (option 1). Nurses diluted in a beverage
measurable data that can be must also utilize their resources to
seen, heard, or verified by the acquire the support they need to care Rationale: Diluting the medication in a
nurse. The objective data is for a client safely (option 5). Options 2, beverage may make the medication
the measurement of the urine 3, and 4 do not demonstrate critical more palatable. Using critical thinking
output. A client's statements thinking. skills, the nurse should try to problem-
and reports of symptoms are The nurse has documented the solve in a situation such as this before
documented as subjective following outcome goal in the care asking for the assistance of the nurse
data, such as the data found plan: "The client will transfer from bed manager. Suggesting an alternative
in options 1, 3, and 4. to chair with two-person assist." The method of taking the medication
When evaluating an elderly client's charge nurse tells the nurse to add (provided that there are no
blood pressure (BP) of 146/78 mmHg, which of the following to complete the contraindications to diluting the
the nurse does which of the following goal? medication) should improve the
before determining whether the BP is likelihood of the client taking the
normal or represents hypertension? A. Client behavior medication.
B. Conditions or modifiers Which professionally appropriate
A. Compare this reading against C. Performance criteria response should the nurse make when
defined standards D. Target time a more stringent policy for the use of
B. Compare the reading with one D. Target time restraints is introduced on a surgical
taken in the opposite arm unit?
C. Determine gaps in the vital signs in Rationale: The outcome goal does not
the client record state the target timeframe for when the A. Use the previous, less restrictive
D. Compare the current measurement nurse should expect to see the client policy conscientiously
with previous ones behavior ("transfer"). The condition or B. Express immediate disagreement
A. Compare this reading against modifier is present ("with two assists"). with the new policy
defined The performance criterion is "from bed C. Ask for the rationale behind the new
Rationale: Analysis of the client's BP to chair." policy
requires knowledge of the normal BP The nurse who documents on the D. Obey the policy but continue to
range for an older adult. The nurse client's care plan the outcome goal voice disapproval of it to co-workers
compares the client's data against "Anxiety will be relieved within 20 to 40 C. Ask for the rationale behind the new
identified standards to determine minutes following administration of policy
whether this reading is normal or lorazepam (Ativan)" is engaged in
abnormal. Measuring the BP in the which step of the nursing process? Rationale: Understanding the rationale
other arm (option 2) and comparing behind a decision helps the nurse
the reading to previous ones (option 4) A. Assessment analyze the proposed change and
will give additional client data, but the B. Planning understand its purpose. Options 1, 2,
and 4 represent unprofessional D. Assess past compliance to reflect this problem?
behavior. Option 1 also places a medication regimens
client's safety at risk. C. Include the client and family when A. Risk for malnutrition related to clear
The nurse assigned to care for a setting goals and formulating the plan liquid diet
postoperative client has asked an of care B. Impaired skin integrity related to no
unlicensed assistive person (UAP) to protein intake
help the client ambulate in the hall. Rationale: In developing a plan of C. Risk for impaired skin integrity
Before delegating this task, the nurse care, nurses engage in a partnership related to malnutrition
must do which of the following? with the client and family. Nurses do D. Impaired nutrition related to current
not plan care for clients; instead they illness
A. Assess the client to be sure plan care with clients and families. C. Risk for impaired skin integrity
ambulation with assistance is an Assessment (option 4), goal setting related to malnutrition
appropriate care measure (option 1), and interventions (option 2)
B. Ask the client if he or she is ready to will be most accurate and effective Rationale: This is a risk diagnosis, and
ambulate when carried out in partnership with the diagnostic statement has two
C. Ask whether the UAP has time to the client and family. The other options parts: the human response (impaired
assist the client represent other actions to take, but skin integrity) and the related/risk
D. Ask the charge nurse whether they will have less overall factor (malnutrition). Options 1 and 2
UAPs have ambulated the client during effectiveness if the client and family do not have related factors that are
this shift are not part of the plan. under the control of the nurse (i.e.,
A. Assess the client to be sure Which nurse is demonstrating the type of diet ordered). The diagnosis in
ambulation with assistance is an assessment phase of the nursing option 4 does not specify the type of
appropriate care measure process? impairment (greater than or less than
body requirements) and is therefore
Rationale: Prior to delegating any A.The nurse who observes that the incomplete. It also does not provide
client care responsibilities, the nurse client's pain was relieved with pain direction for development of goals and
must assess the client to assure that medication interventions.
the delegation is appropriate to his or B. The nurse who turns the client to a The nurse would place which correctly
her care. Options 2, 3, and 4 would not more comfortable position written nursing diagnostic statement
constitute an assessment of the C. The nurse who ask the client how into the client's care plan?
client's current status. much lunch he or she ate
The nurse makes the following entry D. The nurse who works with the client A. Cancer relater to cigarette smoking
on the client's care plan: "Goal not to set desired outcome goals B. Impaired gas exchange related to
met. Client refuses to ambulate, C. The nurse who ask the client how aspiration of foreign matter as
stating, 'I am too afraid I will fall.' " The much lunch he or she ate evidenced by oxygen saturation of
nurse should take which of the 91%
following actions? Rationale: Assessment involves C. Imbalance nutrition: more than body
collecting, organizing, validating, and requirement related to overweight
A. Notify the physician documenting data about a client. status
B. Reassign the client to another nurse Option 1 represents the evaluation D. Impaired physical mobility related to
C. Reexamine the nursing orders phase. Option 2 represents the generalized weakness and pain
D. Write a new nursing diagnosis implemention phase. Option 4 B. Impaired gas exchange related to
B. Reexamine the nursing orders represents the planning phase. aspiration of foreign matter as
The client states, "My chest hurts and evidence by oxygen saturation of 91%
Rationale: The plan needs to be my left arm feels numb." The nurse
reassessed whenever goals are not interprets that this data is of which type Rationale: A nursing diagnosis
met. Nursing interventions should be and source? consists of two parts joined by related
examined to ensure the best to. The first part (the human response)
interventions were selected to assist A. Subjective data from a primary names/labels the problem. The second
the client achieve the goal. The goal source part (related factors) includes the
may be appropriate, but the client may B. Subjective data from a secondary factors that either contribute to or are
need more time to achieve the desired source probable etiologies of the human
outcome. The manner in which the C. Objective data from a primary response. Some formats include a
nursing interventions were source third part to the statement for actual
implemented may have interfered with D. Objective data from a secondary (not risk) diagnoses; this third part
achieving the outcome. source consists of the client's signs or
In developing a plan of care for a client A. Subjective data from a primary symptoms and is joined to the
with chronic hypertension, which source statement with the label as evidenced
nursing activity would be most by. This type of statement is the most
important? Rationale: The client states, "My chest complete. Option 1 is not a nursing
hurts and my left arm feels numb." The diagnosis but is a medical diagnosis.
A. Set incremental goals for blood nurse interprets that this data is of Options 3 and 4 are vague.
pressure reduction which type and source? Which of the following outcome goals
B. Instruct the client to make dietary The nurse feels a client is at risk for has the nurse designed correctly for
changes by reducing sodium intake skin breakdown because he has only the postoperative client's plan of care?
C. Include the client and family when had clear liquids for the last 10 days Select all that apply.
setting goals and formulating the plan (and essentially no protein intake). The
of care nurse would formulate which A. Client will state pain is less than or
diagnostic statement that would best equal to 3 on zero to ten pain scale
B. Client will have no pain A. Taking vital signs of clients on the
C. Client will state pain is less than or nursing unit
equal to a 3 on a 0-10 pain scale
within 24 hours Rationale: Part of the professional
D. Client will state pain is less than or nurse's role is to delegate
equal to a 5 on a 0-10 pain scale by responsibility for activities while
the time of discharge maintaining accountability. The nurse
E. Client will be medicated every 4 must match the needs of the client with
hours by the nurse the skills and knowledge of UAPs.
C. Client will state pain is less than or Certain skills and activities, such as
equal to a 3 on a 0-10 pain scale those in options 2, 3, and 4, are not
within 24 hours within the legal scope of practice for a
D. Client will state pain is less than or UAP.
equal to a 5 on a 0-10 pain scale by In giving a change-of-shift report,
the time of discharge which type of client information
communicated by the nurse is most
Rationale: An outcome goal should be appropriate?
SMART: specific, measurable,
appropriate, realistic, and timely. A. Vital signs are stable
Options 3 and 4 are SMART goals. B. Client is pleasant, alert, and
Options 1 and 2 have no timeframe to oriented to time, place, and person
achieve the goal and are therefore C. The chest x-ray results were
incomplete. Option 2 is also negative
unrealistic; the nurse cannot expect a D. Client voided 250 mL of urine 2
postoperative client to be pain free. hours after the urinary catheter
Option 5 is not a client goal. removal
The nurse questions if the dosage of a D. Client voided 250 mL of urine 2
medication is unsafe for the client hours after the urinary catheter
because of the client's weight and age. removal
The nurse should take which of the
following actions? Rationale: A change-of-shift report
should include significant changes
A. Administer the medication as (good or bad) in a client's condition.
ordered by the prescriber The information should be accurate,
B. Call the prescriber to discuss the concise, clear, and complete. Options
order and the nurse's concern 1 is vague and options 2 and 3 are
C. Administer the medication, but chart normal data and are therefore of lesser
the nurse's concern about the dosage importance to convey in the change-of-
D. Give the client half the dosage and shift report.
document accordingly Twenty minutes after administering
B. Call the prescriber to discuss the pain medication to the client, the nurse
order and the nurse's concern returns to ask if the client's level of
pain has decreased. The nurse
Rationale: Client safety is of the documents the client's response as
utmost importance when implementing part of which phase of the nursing
any nursing intervention. If the nurse process?
feels that an order is unsafe or
inappropriate for a client, the nurse A. Diagnosis
must act as a client advocate and B. Planning
collaborate with the appropriate C. Implementation
healthcare team member to determine D. Evaluation
the rationale for the order and/or C. Evaluation
modify the order as necessary. A
nurse accepts accountability for his or Rationale: Evaluating is the
her actions. Options 1, 3, and 4 are process of comparing client
inappropriate and unsafe. responses to the outcome
Which activity would be appropriate for goals to determine whether,
the nurse to delegate to an unlicensed or to what degree, goals have
assistive person (UAP)? been met. Diagnosing
identifies health problems,
A. Taking vital signs of clients on the risks, and strengths. Planning
nursing unit is the formulation of client
B. Assisting the physician with an goals and nursing strategies
invasive procedure (interventions) required to
C. Adjusting the rate on an infusion prevent, reduce, or eliminate
pump the client's health problems.
D. Evaluating achievement of client Implementing is carrying out
outcome goals or delegating the nursing
interventions.
Define the nursing process subjective describes an individual, family or
a systematic problem solving approach 2 sources of data group response to an actual or
toward providing individualized nursing primary & 2ndary potential problem.
care. primary source of data medical dx
What is NANDA-I ‐Information obtained from the patient ‐Identification of a disease condition
North American Nursing (only) based on specific
Diagnosis Association International secondary sources of data findings such as diagnostic tests and
What are the characteristics of the ‐ Family members procedures.
nursing process? ‐ Significant others ‐ Remains the same as long as the
1-framework for care to indiv, families, ‐ Past & current health records, disease is present.
& communities 2-orderly & systematic laboratory tests,diagnostic procedures, nursing dx
3-interdependent 4-provides specific consultations from other healthcare ‐ Clinical judgment in response to
care for the indiv, fam, & comm 5- professionals. actual or potential
client centered 6-appropriate for use collect the data then BLANK the data health problems.
throughout lifespan 7-used in ALL VALIDATE ‐ Provides a basis for providing nursing
settings ‐Confirm and verify the information. care through
What are the steps of the nursing ‐ Keep it free from errors, bias, or various interventions to achieve
process? misinterpretation. outcomes.
ADPIE A=assessment D=diagnosis Data is 1,2,3 ‐ Changes possibly from day to day as
P=planning I=implementation collected, validated, then clustered the patient's
E=evaluation clustering of data often contains response changes.
How does the nurse obtain defining characteristics which are what are the 4 types of NANDA-I dx
assessment info? specific assessment findings that 1. Actual diagnosis
1- initial (or admission assessment) 2- support a 2. Risk diagnosis
focused assessment 3- emergency nursing diagnosis. 3. Health promotion diagnosis
assesment during the clustering of data what is 4. Wellness diagnosis
How does the nurse obtain used actual dx
assessment info? critical thinking is used to analyze and Represents a problem that has been
past medical hx - family hx - reason for synthesize the information that is validated by the
admission - current meds - previous collected. The data is then put into presence of defining characteristics
hospitalizations & surgeries - specific clusters that describe a (signs and
psychosocial assessment - nutrition - specific client problem. symptoms).
complete physical assessment identify sources of data for obtaining risk dx
focused assessment information from the client Is defined by NANDA‐I , "describes
Collects data about a problem that has subjective & objective, primary & human responses to health
already been identified. This type of secondary, people, healthcare conditions/life processes that may
assessment determines whether professionals, medical chart, test & lab develop in a vulnerable individual,
the problem still exists, or any results etc family, or community. It is supported
changes. identify how you develop a nursing by risk factors that contribute to
focused assessment questions diagnosis increased
‐ What are your symptoms? As you cluster data, you begin to vulnerability" (NANDA, 2007). Ex.
‐ When did they start? consider various diagnoses that may infection after surgery
‐ What activity were you doing ? relate to the client. You must health promotion dx
‐ What makes it better or worse? remember that if certain defining Clinical judgment of a person, family,
‐ What are you doing to relieve the characteristics do not exist for a or community desire to enhance their
symptom? specific diagnosis, then you must not well being and readiness to implement
Emergency assessment use the diagnosis. health behaviors of a higher level. Ex.
Performed to identify a life‐threatening identify how you develop a nursing nutrition
problem (choking, stab wound, heart diagnosis (what is first / next etc) wellness dx
attack). 1. Complete thorough assessment of Describes the human responses to
subjective data the patient. levels of wellness in an individual,
Information verbalized or stated by the 2.Highlight or underline relevant family or community that have
client. symptoms (defining readiness to enhance well being.
objective data characteristics). Ex.Coping, readiness of enhanced
‐ Observable and measurable 3. Make a list of symptoms. related to successful cancer treatment.
information. 4. Cluster and interpret the symptoms. how do you formulate an actual
‐ Remember to include your senses: 5. Analyze and interpret the nursing dx; what does it consist of
smell, hearing, touch and sight. symptoms. A nursing diagnosis consists of 3 parts
sign 6. Select a nursing diagnosis based on or what is referred to PES format:
An objective finding perceived by the the definition P= Problem
examiner ex. (fever, rash, etc.) found in the nursing diagnosis manual E =Etiology
symptom by Doenges, S =Signs and Symptoms
Subjective findings verbalized or Moorhouse and Murr. what is the purpose of the problem
stated by the client ex. ("I have a 7. Remember to prioritize the identified to identify the health status or
headache" " I feel sick in my problems. problem of the individual using the
stomach.") what is the difference between a approved NANDA - I list. Ex.Pain,
signs are medical and nursing dx acute
objective A medical diagnosis describes a what is the etiology
symptoms are disease process. A nursing diagnosis
the cause ; Identifies the physiologic, An objective behavior or response you Implementing Interventions ;
psychological, sociologic, spiritual, or expect the client to achieve in a longer psychomotor skills
environmental factors assumed to be period of time possibly over several proper performance and knowledge of
the days, weeks, or months. skills
cause of the problem or a contributing what is an expected outcome what is the evaluation phase of the
factor. An outcome is a measurable change in nursing process
the etiology is linked to the problem the client's status that you expect to Evaluation is the final stage of the
with the phrase occur related to the implemented care. nursing process. You as the nurse
"related to" ; The etiology cannot be guidelines to remember when writing determine if the patient has achieved
related to a medical diagnosis. goals the expected outcomes not if the
signs & symptoms 1-client centered 2-singular 3- nursing interventions were completed.
Identified as subjective and/or observable 4-measurable 5-time the evaluation phase has 5
objective data that supports the limited 6-mutual 7-realistic components
problem. what are nursing interventions 1. Identifying criteria and standards.
‐ Identified by the nurse from the Are actions or treatments based on 2. Collecting data to determine if the
clustering of knowledge or judgment that the nurse criteria or
significant data including assessment performs to meet the patient standards are met.
findings. outcomes. 3. Interpreting and summarizing
signs & symptoms are linked to the what are the 3 types of nursing findings.
etiology by the phrase interventions - provide examples 4. Documenting findings and any
"as evidenced by" 1-independent ex. positioning 2- clinical judgment.
how do you formulate a risk dx? what dependent ex. med admin 3- 5. Terminating, continuing or revising
does a risk dx consist of? collaborative or interdependent ex. OT the care plan.
consist of a problem and the etiology what are frequent errors when writing
only - there are NO signs & sypmtoms nursing interventions
because it hasn't happened yet 1-Failure to be precise or fully indicate
what does the planning phase of the the nursing action. 2-Failure to indicate
nursing process consist of frequency 3-Failure to indicate quantity
develop a plan of care.This is 4-Failure to indicate method
accomplished by developing client what is the purpose of scientific
centered goals rationale for student nurses
and expected outcomes. - use critical is the reason for choosing the
thinking to develop nursing particular intervention based on
interventions to resolve the client's supportive evidence
problem and achieve the goals. from textbooks, journals, and/or online
3 helpful guides in prioritizing needs nursing
1-Maslow 2- Pt preference what does references (so we know why we are
the pt think is important 3-Anticipation doing the task we are doing)
or future problems what is the implementation phase of
Maslow the nursing process
Maslow's Hierarchy of Needs This step begins after the care plan
a. physiological needs has been developed by the nurse. This
b. safety needs is the step of the nursing process
c. love and belonging needs where the nurse performs the
d. self‐esteem needs interventions as a means
e. self‐actualization needs of achieving the goals.
prioritizing nursing dx ex 1 interventions can be BLANK or BLANK
1 -airway 2- urinary 3- sexual 4- skin direct (performed through interaction
integrity with the client) or indirect (without the
prioritizing nursing dx ex 2 client but on their behalf)
1-gas exchange 2-hypothermia 3- the implementation process takes into
knowledge defecit 4- infection account 5 activities
prioritizing nursing dx ex 3 1-reassessing 2-review/revise existing
1-pain 2-mobility 3- social isolation 4- nursing dx & care plan 3-organizing
self esteem resources & delivery of care 4-
define a goal Anticipating/preventing any
" a broad statement that describes the complications 5-Implementing
desired change in a client's condition interventions
or behavior." Implementing Interventions: requires 3
components of a correctly written goal skills
include expected outcomes or 1-cognitive 2-personal 3-psychomotor
measurable criteria to evaluate the Implementing Interventions :cognitive
achievement of the goal. skills
short term goal critical thinking ; good decisions
an objective behavior or response Implementing Interventions: personal
you expect the client to achieve in a skills
short period of time usually less than communication ; therapeutic
one week. interactions
long term goal