fundamentals of nursing critical thinking questions

NCLEX Practice Questions Test Bank for Free

Welcome to our collection of free NCLEX practice questions to help you achieve success on your NCLEX- RN exam! This updated guide for 2024 includes 1,000+ practice questions, a primer on the NCLEX-RN exam, frequently asked questions about the NCLEX, question types, the NCLEX-RN test plan, and test-taking tips and strategies.

Table of Contents

Nclex-rn practice questions test bank, what is nclex.

• What is Next Generation NCLEX (NGN)? 

Safe and Effective Care Environment

• Health Promotion and Maintenance 
• Psychosocial Integrity 

Physiological Integrity

Clinical judgment, integrated processes, item writers for nclex, computer adaptive test (cat), 95% confidence interval rule, maximum-length exam, run-out-of-time (r.o.o.t.) rule, zero/one (0/1) scoring, plus/minus (+/-) scoring, rationale scoring, pretest items, testing time, unfolding case study, stand-alone items, multiple response select all that apply.

• Multiple Response Select N 

Multiple Response Grouping

• Highlight in Text 

Highlight in Table

Matrix multiple response, matrix multiple choice.

• Drag and Drop Cloze 

Drag and Drop Rationale

Drop down cloze, drop down rationale, drop down in table, chart or exhibit questions, graphic option, select all that apply or multiple-response, fill-in-the-blank, ordered-response, how to register for the nclex, nclex-rn resources, want more practice questions, recommended resources.

Looking for the complete collection of practice questions? For more NCLEX practice questions, please visit our Nursing Test Bank here .

We have included more than 1,000+ NCLEX practice questions covering different nursing topics for this nursing test bank ! We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning .

We recommend you do all practice questions before you take the actual exam. Doing so will help reduce your test anxiety and help identify nursing topics you need to review. To make the most of the practice exams, try to minimize mistakes to less than 15 questions and take your time answering the questions, especially when reading the rationales.

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• Practice Exams : Engage with our Practice Exams to hone your skills in a supportive, low-pressure environment. These exams provide immediate feedback and explanations, helping you grasp core concepts, identify improvement areas, and build confidence in your knowledge and abilities.
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Included NCLEX-RN question sets for this nursing test bank are as follows. Please click on the links below and you’ll be redirected to the quiz page:

NEW UPDATE: Introducing Challenge Exams and Practice Exams

Engage with these new modes to enhance your learning journey, each tailored to meet different needs and propel you towards academic achievement.

• Dive into Practice Exam Mode for a supportive learning experience. Here, real-time feedback aids in understanding core concepts and building confidence. It’s your space for growth and preparation.
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The National Council Licensing Examination (NCLEX) is a comprehensive test administered by the National Council of State Boards of Nursing (NCSBN). It assesses whether candidates possess the necessary knowledge and skills to provide safe and effective nursing care at the entry level. The NCLEX is available in two versions: the NCLEX-RN for registered nurses and the NCLEX-PN for practical/vocational nurses.

The NCSBN, composed of nursing regulatory bodies from all 50 states in the US, the District of Columbia, and four US territories, is responsible for safeguarding the public by ensuring safe nursing care. It sets the standards and guidelines for nursing licensure and develops the NCLEX examinations.

Becoming a registered nurse (RN) requires meeting specific licensure requirements determined by the licensing authorities in each jurisdiction governed by the NCSBN. One of these requirements is passing the NCLEX-RN, which evaluates the competencies necessary for practicing safely and effectively as an entry-level RN. The NCLEX-RN is used by member boards of nursing and many Canadian nursing regulatory bodies to inform their licensure decisions.

What is Next Generation NCLEX (NGN)?

The Next Generation NCLEX (NGN) is currently in effect this April 2023 for RN and LPN / LVN candidates. The change in the NCLEX is driven by the need to adapt to the increasing complexity of client care, advancements in healthcare practice, and the demand for safe clinical decision-making . The NGN aims to address the declining ability of new nursing graduates to make safe clinical decisions by integrating clinical judgment as a key competency. The NGN test format will remain adaptive but with fewer test items. Candidates will encounter Unfolding Case Studies and Stand-Alone Items , scored using partial credit with three different scoring rules. These changes in the NGN aim to assess critical thinking and the ability to make safe clinical judgments during various phases of client care.

In summary, the following are the key changes between the previous NCLEX format and the Next Generation NCLEX (NGN): 

• Same adaptive test format but reduced number of items. The Next Generation NCLEX (NGN) will retain the adaptive test format, similar to the current NCLEX, but with fewer test items. Candidates will answer between 85 and 150 items, with 15 as pretest or unscored items. 
• Case studies. All candidates will encounter three (3) Unfolding Case Studies, each consisting of six test items (a total of 18 items). Clinical situation information will be presented to candidates in a medical record format resembling a table-like structure. These situations are designed to assess their ability to think critically and make safe clinical decisions across different phases of client care. In addition to the case studies, some candidates may have Stand-Alone Items for their NGN exam.
• New NGN item types. The NGN exam will feature new item types, which include questions in unfolding cases and stand-alone items, highlight, cloze, matrix, bow-tie, drag and drop, and extended multiple responses. 
• Scoring differences. NGN test items will be scored differently compared to the current NCLEX. They will utilize partial credit scoring with three different scoring rules: the 0/1 scoring rule, the +/- scoring rule, and the rationale scoring rule. These are explained further below. 

NCLEX-RN Test Plan

The NCLEX test plan is a content guideline to determine the distribution of test questions. NCSBN uses the “Client Needs” categories to ensure the NCLEX covers a full spectrum of nursing activities. It is a summary of the content and scope of the NCLEX to serve as a guide for candidates preparing for the exam and to direct item writers in the development of items.  Additionally, to assess the knowledge, skills, abilities, and clinical judgment necessary for entry-level nursing practice , the NCLEX-RN Test Plan utilizes Bloom’s taxonomy for the cognitive domain. This taxonomy provides a foundation for writing and coding examination items, focusing on application-level or higher-level cognitive abilities that require advanced thought processing.

The content of the NCLEX-RN is organized into four major Client Needs categories: Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Some of these categories are divided further into subcategories. Below is the NCLEX-RN test plan effective as of April 2023 until March 2026: 

There are two subcategories under Safe and Effective Care Environment.

• Management of Care category includes content that tests the nurse ‘s knowledge and ability to direct nursing care that enhances the care delivery setting to protect clients, significant others, and healthcare personnel. 
• Safety and Infection Control category includes content that tests the nurse’s ability required to protect clients, families, and healthcare personnel from health and environmental hazards. 

Health Promotion and Maintenance

Health Promotion and Maintenance category includes content that tests the nurse’s ability to provide and direct nursing care to the client that incorporates knowledge of expected growth and development, preventing and early detection of health problems, and strategies to achieve optimal health. 

Psychosocial Integrity

The Psychosocial Integrity category is content related to the promotion and support for the emotional, mental, and social well-being of the client experiencing stressful events and clients with acute or chronic mental illness . 

In the Physiological Integrity category are items that test the nurse’s ability to promote physical health and wellness by providing care and comfort , reducing risk potential, and managing health alterations. There are four subcategories under Physiological Integrity. 

• Basic Care and Comfort are content to test the nurse’s ability to provide comfort and assistance to the client in performing activities of daily living . 
• Pharmacological and Parenteral Therapies category includes content to test the nurse’s ability to administer medications and parenteral therapies (IV therapy, blood administration, and blood products). 
• Reduction of Risk Potential category includes content to test the nurse’s ability to prevent complications or health problems related to the client’s condition or prescribed treatments or procedures. 
• Physiological Adaptation category includes questions that test the nurse’s ability to provide care to clients with acute, chronic, or life-threatening conditions. 

Clinical judgment is a central component of the NCLEX-RN Test Plan, reflecting the evolving demands and complexity of nursing practice . Nurses must engage in an iterative, multi-step process that utilizes nursing knowledge to observe and assess situations, identify client concerns, and generate evidence-based solutions to ensure safe client care. Clinical judgment questions are represented through Unfolding Case Studies or individual Stand-Alone Items , with case studies addressing each step of clinical judgment. The following are the six clinical judgment cognitive skills: 

• Recognize cues “What matters most?” Identifying relevant and important information from various sources, such as medical history , laboratory studies, and vital signs.
• Analyze cues “What could it mean?” Organizing and connecting recognized cues to the client’s clinical presentation.
• Prioritize hypotheses “Where do I start?”   Evaluating and prioritizing hypotheses based on urgency, likelihood, risk, difficulty, time constraints, and other factors.
• Generate solutions “What can I do?” Identifying expected outcomes and using hypotheses to define a set of interventions aligned with the expected outcomes.
• Take action “What will I do?” Implementing the highest-priority solution(s) identified.
• Evaluate outcomes “Did it help?” Comparing observed outcomes to expected outcomes to assess the effectiveness of interventions.

Additionally, In contrast to the nursing process or ADPIE , the NCSBN focuses on AAPIE ( assessment , analysis, planning , intervention, evaluation ), wherein nursing diagnosis is not tested at the current NGN because it is not considered a universal language used in health care or the nursing profession. In nursing practice and for the NGN, students must use their pathophysiology knowledge to analyze client assessments and connect them with common conditions in healthcare settings. 

Integral to nursing practice, several processes are integrated throughout the Client Needs categories and subcategories:

• Caring. In an atmosphere of mutual respect and trust, nurses interact with clients, providing encouragement, hope, support, and compassion to help achieve desired outcomes .
• Clinical Judgment . An observed outcome of critical thinking and decision-making , clinical judgment (discussed above) is a dynamic and iterative process. It involves using nursing knowledge to observe and assess situations, prioritize client concerns, generate evidence-based solutions, and deliver safe client care.
• Communication and Documentation . Verbal and nonverbal interactions between nurses, clients, significant others, and the healthcare team. Accurate and comprehensive documentation ensures adherence to practice standards and accountability in care provision.
• Culture and Spirituality. Recognizing and considering the unique preferences, standards of care, and legal considerations of clients (individuals, families, groups, and populations) in the context of their culture and spirituality.
• Nursing Process. A systematic approach to client care encompassing assessment , analysis, planning, implementation , and evaluation .
• Teaching/Learning. Facilitating acquiring knowledge, skills, and abilities that promote behavioral change.

Who writes questions for the NCLEX? The NCSBN sets the criteria and selection process for item writers who are registered nurses. Many of them are nursing educators with an advanced degrees in nursing, so if you’ve completed an accredited nursing program, you have already taken several tests written by nurses with backgrounds similar to those who write for the NCLEX.

The NCLEX-RN is a crucial step for registered nurse (RN) candidates seeking licensure. Administered through computerized adaptive testing ( CAT ), this examination utilizes computer technology and measurement theory to create a personalized and accurate assessment of each candidate’s knowledge and skills. 

The CAT system employed in the NCLEX-RN ensures that each candidate receives a unique examination tailored to their abilities. As the test progresses, the computer selects items from a large item pool based on the candidate’s previous answers. These items are classified according to the test plan categories, difficulty levels, and clinical judgment steps. The CAT system continually recalculates the candidate’s ability estimate and selects subsequent items accordingly, creating an exam that aligns with the NCLEX-RN Test Plan requirements. This dynamic approach allows candidates to demonstrate their competence effectively.

Additionally, unlike traditional fixed-length exams, which assign the same items to all candidates, CAT selects items based on the candidate’s ability, resulting in a more accurate assessment. The CAT scoring algorithm estimates the candidate’s ability by considering all previous answers and the difficulty level of those items. By administering items that challenge the candidate appropriately, the exam gathers maximum information about their ability.

Pass or Fail Decisions: How to Pass the NCLEX?

Passing the NCLEX-RN requires you, the candidate, to meet a specific passing standard established by the NCSBN Board of Directors (BOD). The passing standard represents the minimum ability level necessary for safe and effective entry-level nursing practice. The BOD reevaluates this standard every three years, considering various factors such as a standard-setting exercise conducted by experts and psychometricians, historical data on candidate performance, and information on the educational readiness of aspiring nurses. Once the passing standard is set, it is uniformly applied to all candidates during the scoring process. The NCSBN indicates that these three rules govern pass-or-fail decisions: the 95% Confidence Interval Rule , Maximum-Length Exam Rule , and Run-Out-Of-Time Rule .

In this scenario, the computer stops administering test questions when it is 95% certain that your ability is clearly above the passing standard or clearly below the passing standard. 

When your ability is close to the passing standard, the CAT gives you items until the maximum number of items is reached. At this point, the computer disregards the 95% confidence rule and decides whether you pass or fail by your final ability estimate. If your final ability estimate is above the passing standard, you pass; if it is below, you fail. 

In the event that a candidate runs out of time before completing the maximum number of items and the computer has not reached a 95% certainty regarding the candidate’s pass or fail status, alternative criteria come into play.

• If the candidate has not answered the minimum required number of items, the candidate will automatically fail.
• If the candidate has answered at least the minimum required number of items, the final ability estimate will be determined based on all the responses given before the exam time expires. If the score meets or exceeds the passing standard, the candidate will pass. Otherwise, the candidate will fail.

New Scoring System in the Next Generation NCLEX

The Next Generation NCLEX (NGN) incorporates different item formats, and for items that have multiple correct answers, partial credit scoring is implemented . Unlike the previous exam format, where items are scored as either all correct or all incorrect, the NGN will use polytomous scoring models to evaluate partial understanding. For example, in the previous version of NCLEX (multiple response) SATA (select-all-that-apply) items, only endorsing all the correct options results in a correct score. However, the new approach will acknowledge partial understanding, allowing differentiation between candidates with different numbers of correct options. This change will provide a more accurate assessment of candidates’ knowledge, skills, and abilities.

Three methods are used to assign partial credit for these items: plus/minus scoring, zero/one scoring, and rationale scoring. Understanding the scoring models is crucial for NCLEX-RN takers to know how their answers are evaluated and how scores are determined.

The 0/1 scoring rule is used for multiple-choice items. Choosing the correct option earns one point while selecting an incorrect option gives a score of zero. This rule applies to single response items, including the example multiple-choice item.

The +/– scoring rule measures a candidate’s ability to identify relevant information. It assigns points for correct options and deducts points for incorrect options. It is used for multi-point items, and the total score is calculated by adding correct options and subtracting incorrect ones. The lowest possible score is zero. This rule is applied to NGN question types such as multiple-response and select all that apply.

The rationale scoring rule is used for questions that assess paired information. To earn a score of one point, both answer options must be correct. If either option is incorrect, the score is 0.

How Many Questions Are on the NCLEX?

All RN candidates must answer a minimum of 85 items , while a maximum of 150 items be administered during the five-hour time allotment. Each NCLEX-RN exam includes 15 pretest items (unscored), which are indistinguishable from operational (scored) items.

To ensure the effectiveness of computerized adaptive testing (CAT) in the NCLEX, the difficulty level of each item needs to be determined beforehand. This is achieved by administering these items as pretest items to a large group of NCLEX candidates. Since the difficulty of pretest items is initially unknown, they are not part of your score and are not considered when evaluating a candidate’s ability or determining pass-fail outcomes. Once a sufficient number of responses are collected, the pretest items undergo statistical analysis and calibration. If they meet the required NCLEX statistical standards, they can be used as operational items in future exams. Therefore, candidates must approach every item with their best effort, regardless of whether it is a pretest or an operational item.

The length of the NCLEX-RN examination varies for each candidate based on their responses, but there is a five-hour time limit for the exam, including all breaks. To ensure completion within the allotted time, candidates must maintain a reasonable pace, spending approximately one to two minutes per item . It’s important to note that the length of the examination does not determine pass or fail outcomes; candidates can succeed or fail regardless of the examination’s duration.

Case Studies in NGN

The Next Generation NCLEX (NGN) has introduced case studies that present practical clinical scenarios and include test items aligned with six cognitive abilities of the clinical judgment model. The scenario can occur in various settings, and the client’s outcome can vary, including improvement, stability, or decline with complications. Laboratory results, if included, are presented in a table, and abnormal values are highlighted with an “L” or “H”. There are two types of case studies: Unfolding Case Study with six test items assessing specific skills and Stand-Alone Items with a single test item independent of a case study.

An Unfolding Case Study presents a realistic client situation with evolving data resembling a medical record. It includes multiple phases over time, reflecting changes in the client’s condition. The case study evaluates all six cognitive skills of the clinical judgment model through six questions. Each test-taker receives three (3) unfolding case studies, totaling 18 items across those cases. 

Stand-Alone Items are case studies with a single question, with the item presented as a bow-tie or a trend question type. Candidates who take more than the minimum number of items on the NCLEX receive around six to seven stand-alone cases. 

Question Types in the NCLEX-RN

The different question types for the NCLEX-RN include the following: 

Extended Multiple Response

In Extended Multiple Response item types, test-takers can choose one or more options in Multiple Response Select All That Apply, select a specific number of items in Multiple Response Select N, or choose options from different groupings presented in a table in Multiple Response Grouping, with scoring rules based on the selected type. Extended multiple response may include the following formats:

The Multiple Response Select All That Apply item type allows test-takers to choose one or more answer options. It uses the +/- Scoring Rule, where selecting correct information earns points (+1), and selecting incorrect information results in points deducted (-1). The maximum points achievable are equal to the number of correct options, and the minimum score is 0, with no negative scores. The item must have a minimum of five options and can have up to ten options, with the possibility of all ten options being correct.

Multiple Response Select N

The Multiple Response Select N item type informs the test-taker about the specific number of items (N) that can be selected. The question provides a range of options, with a minimum of five and a maximum of ten options. It uses the 0/1 Scoring Rule, where each correct response earns 1 point, while any incorrect response results in 0 points.

The Multiple Response Grouping utilizes a table to present options, with a minimum of two and a maximum of five groupings. Each grouping consists of a minimum of two and a maximum of four options, ensuring an equal number of options within each grouping. Test-takers are required to select at least one option from each grouping. The item follows the +/- Scoring Rule, meaning there is no negative score per grouping. The total score for the item is determined by summing the points earned within each grouping. The maximum score achievable equals the number of keys (N).

For this NGN item type, the test-taker is presented with information and must highlight specific parts of the information provided.  Highlight question type include the following formats:

Highlight in Text

It involves a paragraph of information where the test-taker must select (highlight) specific parts of the text based on the question’s requirements. The item can include a maximum of ten options for selection and uses the +/- Scoring Rule. 

The Highlight in Table item type involves a table of information. The candidate is tasked with selecting (highlighting) specific parts of the text within the table based on the question’s prompt. The item can include a maximum of ten options for selection. The table has two columns, including a header, and can have up to five rows. This item type uses the +/- Scoring Rule. 

Matrix/Grid

In the Matrix NGN item type, test-takers are presented with a grid-like structure to which they must respond. There are two variations: Matrix Multiple Response, where each column can have multiple correct responses, and Matrix Multiple Choice, where test-takers select one answer option per row. Extended multiple response may include the following formats:

The Matrix Multiple Response item type consists of response columns, where each column can have multiple correct responses. The item can have between two and ten columns and four to seven rows. In each column, at least one response option must be selected, but it is possible to select one or more responses per column. The item follows the +/- Scoring Rule, with no negative score per column. The total score for the item is determined by summing the points earned within each column. The maximum score achievable is equal to the number of keys (N).

The item includes a minimum of four rows and a maximum of ten rows. It can have either two or three options/columns. Test-takers are allowed to select one answer option per row. The item follows the 0/1 scoring rule, where the test-taker earns 1 point for each correct response and 0 points for incorrect responses. The total score for the item is obtained by summing the scores over the rows. The maximum score achievable is equal to the number of rows.

Drag and Drop

In the Drag and Drop NGN question type, test-takers are presented with options to drag and drop into specific targets. There are two variations: Drag and Drop Cloze, where options are placed in response targets to complete sentences and Drag and Drop Rationale, where options are matched to causes and effects. Drag and drop may include the following formats:

Drag and Drop Cloze

The Drag and Drop Cloze item type includes a range of four to ten options. It can have one or more response targets where the options are dragged to. The item must have a minimum of one sentence with one target per sentence and up to five sentences, each with one target per sentence. The item follows the 0/1 Scoring Rule, where a correct response earns 1 point and incorrect responses earn 0 points. The total score is obtained by summing the scores across all targets, with the maximum score achievable being the number of targets.

The Drag and Drop Rationale type involves one sentence with one cause and one effect or one sentence with one cause and two effects. The sentence can be a single dyad (one sentence with two targets) or a single triad (one sentence with three targets). Each drag & drop target can have three to five options. The item follows the Rationale Scoring Rule where both answer options must be correct to earn a point. 

The Drop Down question type in NGN includes three variations: Drop Down Cloze, Drop Down Rationale, and Drop Down in Table. Drop down may include the following formats:

The Drop Down Cloze item type presents one or two sentences of information that require completion using drop-down options. Each drop-down can contain three to five options. The item must have a minimum of one sentence with one drop-down per sentence and can include up to five sentences, each with one drop-down. The item follows the 0/1 Scoring Rule, where the score is calculated by summing the correct responses across all drop-downs. The maximum score achievable is equal to the number of drop-downs.

The Drop Down Rationale item type presents either one sentence with one cause and one effect or one sentence with one cause and two effects. Each drop-down can contain three to five options. The scoring follows the Rationale Scoring Rule, where X and Y must be correct to earn one point. The maximum points that can be earned are 1 point for a dyad (one sentence with two targets) and 2 points for a triad (one sentence with three targets).

The Drop Down in Table item type presents a table of information with drop-down options located in various parts of the table. The item must have a minimum of three columns and three rows and a maximum of five columns and four rows. One column serves as the header column. Each row contains one drop-down. The item follows the 0/1 Scoring Rule, where the score is calculated by summing the correct responses across all drop-downs. The maximum score achievable is equal to the number of drop-downs.

The Bow-tie item type is visually designed to resemble a bow-tie shape. It consists of five options on the left side, five options on the right side, and four options in the middle well of the bow-tie. The item addresses all of the cognitive skills within a single item. The Bow-tie item follows the 0/1 scoring rule. The left and right wells have two answer options each, while the middle well has one answer option, resulting in a maximum possible score of 5 points. Each correct response earns 1 point, while incorrect responses earn 0 points.

The Trend item type presents information in a medical record or flow sheet format that spans over time, requiring the test-taker to analyze information across different points in time. The item addresses multiple cognitive skills within a single item. It can utilize any NGN item type except for the bow-tie. The scoring rule for the Trend item depends on the specific item type used.

Multiple-Choice Questions

Many questions on the NCLEX are in multiple-choice format. This traditional text-based question will provide you data about the client’s situation, and you can only select one correct answer from the given four options. Multiple-choice questions may vary and include: audio clips, graphics, exhibits, or charts.

A chart or exhibit is presented along with a problem. You’ll be provided with three tabs or buttons that you need to click to obtain the information needed to answer the question. Select the correct choice among four multiple-choice answer options. 

In this format, four multiple-choice answer options are pictures rather than text. Each option is preceded by a circle that you need to click to represent your answer.

In an audio question format, you’ll be required to listen to a sound to answer the question. You’ll need to use the headset provided and click on the sound icon for it to play. You’ll be able to listen to the sound as many times as necessary. Choose the correct choice from among four multiple-choice answer options. 

For the video question format, you must view an animation or a video clip to answer the following question. Select the correct choice among four multiple-choice answer options. 

Multiple-response or select all that apply (SATA) alternate format question requires you to choose all correct answer options that relate to the information asked by the question. There are usually more than four possible answer options. No partial credit is given in scoring these items (i.e., selecting only 3 out of the 5 correct choices), so you must select all correct answers for the item to be counted as correct. 

Tips when answering Select All That Apply Questions

• You’ll know it’s a multiple-response or SATA question because you’ll explicitly be instructed to “Select all that apply.”
• Treat each answer choice as a True or False by rewording the question and proceed to answer each option by responding with a “yes” or “no”. Go down the list of answer options one by one and ask yourself if it’s a correct answer.
• Consider each choice as a possible answer separate to other choices. Never group or assume they are linked together.

The fill-in-the-blank question format is usually used for medication calculation, IV flow rate calculation, or determining the intake-output of a client. You’ll be asked to perform a calculation in this question format and type in your answer in the blank space provided. 

Tips when answering Fill-in-the-Blank

• Always follow the specific directions as noted on the screen. 
• There will be an on-screen calculator on the computer for you to use. 
• Do not put any words, units of measurements, commas, or spaces with your answer, type only the number. Only the number goes into the box.
• Rounding an answer should be done at the end of the calculation or as what the question specified, and if necessary, type in the decimal point. 

In an ordered-response question format, you’ll be asked to use the computer mouse to drag and drop your nursing actions in order or priority. Based on the information presented, determine what you’ll do first, second, third, and so forth. Directions are provided with the question. 

Tips when answering Ordered-Response questions

• Questions are usually about nursing procedures. Imagine yourself performing the procedure to help you answer these questions.
• You’ll have to place the options in correct order by clicking an option and dragging it on the box on the right. You can rearrange them before you hit submit for your final answer.

A picture or graphic will be presented along with a question. This could contain a chart, a table, or an illustration where you’ll be asked to point or click on a specific area. Figures may also appear along with a multiple-choice question. Be as precise as possible when marking the location. 

Tips when answering Hotspot questions

• Mostly used to evaluate your knowledge of anatomy, physiology, and pathophysiology.
• Locate anatomical landmarks to help you select the location needed by the item.

So you’ve finally decided to take the NCLEX, the next step is registration or application for the exam. The following are the steps on how to register for the NCLEX, including some tips:

• Application to the Nursing Regulatory Board (NRB). The initial step in the registration process is to submit your application to the state board of nursing in the state in which you intend to obtain licensure. Inquire with your board of nursing regarding the specific registration process as requirements may vary from state to state.
• Registration with Pearson VUE. Once you have received the confirmation from the board of nursing that you have met all of their state requirements, proceed, register, and pay the fee to take the NCLEX with Pearson VUE . Follow the registration instructions and complete the forms precisely and accurately.
• Authorization to Test. If you were made eligible by the licensure board, you will receive an Authorization to Test (ATT) form from Pearson VUE. You must test within the validity dates (an average of 90 days) on the ATT. There are no extensions or you’ll have to register and pay the fee again. Your ATT contains critical information like your test authorization number, validity date, and candidate identification number.
• Schedule your Exam Appointment. The next step is to schedule a testing date, time, and location at Pearson VUE. The NCLEX will take place at a testing center , you can make an exam appointment online or by telephone. You will receive a confirmation via email of your appointment with the date and time you choose including the directions to the testing center. * Changing Your Exam Appointment. You can change your appointment to test via Pearson VUE or by calling the candidate services. Rules for scheduling , rescheduling, and unscheduling are explained further here . Failing to arrive for the examination or failure to cancel your appointment to test without providing notice will forfeit your examination fee and you’ll have to register and pay again. 
• On Exam Day. Arrive at the testing center on your exam appointment date at least 30 minutes before the schedule. You must have your ATT and acceptable identification (driver’s license, passport, etc) that is valid, not expired, and contains your photo and signature.
• Processing Results. You will receive your official results from the board of nursing after six weeks.

Important list and resources you need to know if you’re taking the NCLEX: 

• 2023 NCLEX Candidate Bulletin. This resource is a comprehensive guide for the NCLEX, providing essential information and contact details for candidates. It covers registration procedures, test fees, scheduling , testing accommodations, exam rules, and what to bring to the test site. The guide also includes details on the check-in process, breaks, technical issues, and the testing environment. It explains the results reporting process and retake-policy and provides information on the content, development, and test plans of the NCLEX. Additionally, it discusses the passing standard, item formats, and decision rules for passing or failing the exam.
• Sample Questions and Exam Preview. Get a headstart on your exam preparation with these sample test packs by the NCSBN. 
• Candidate Tutorial. With the new item types, we highly recommend testing how the Next Generation NCLEX (NGN) works. This tutorial guides you on interacting with different question types in your NCLEX exam. It provides a representative sample of items you may encounter during the test, allowing you to practice their functionality.

Please visit our Nursing Test Bank page if you’re looking to answer more practice questions from different topics and different question formats.

Recommended books and resources for your NCLEX success:

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Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

179 thoughts on “NCLEX Practice Questions Test Bank for Free”

How much are you charging for it?

Thanks for being generous

Thank you for your kindness & generosity. This is a big help for us, especially those with financial constraints.

How much for this

Thanks Matt Vera for your utmost effort in helping nurses to pass the exam

You’re most welcome! Good luck on your exams!

Hello Matt do you still have the Test Bank questions for 2021. If you do can I have them please and thank you.

Hi Winnie, Please visit our

Thanks heaps! Matt..

The site is very useful.

Thank you mam/sir

This is very helpful site. god bless🤗

Great website wish l knew about it before taking my nclex

Thank you so much for this free site. I found it just as helpful as Kaplan and Sanders which I paid for. I recommended this nurseslabs to some of my nurse friends preparing for the NCLEX. I used it to study and passed my NCLEX October 28. I will continue to use this as a reference. Once again Thank-You. A.Haynes RN

Hey Matt, I am impressed by your generosity. I couldn’t believe these were all free. In all fairness, there should be a tab for donations for the constant upkeep of the web. A very minimal way to show our gratitude.

Although I just started nursing school the i formation is mind blowing and very useful for me already. Thank you for your generosity. I will be using all the practice quizzes and test to prepare myself. Thank you again.

Thank you for this free nclex practice tests! May you have more blessings and success! I will take my exam next month.

Very informative and helpful

Thank you!You’re a big blessing to those who will take the exam.

I can’t thank you enough for this gift you have given us to use . God bless you.

Thank you so much Matt! This is helping me work toward my NCLEX with less pressure.

Thanks a lot can I get reading materials on PDF please

Thanks Matt Vera for ingenious effort.

You are heaven sent, Thank you Matt for helping us.

you guys all thank you so much for this massively hard work and huge success for all the nurses around the world .

Your efforts are immeasurable, you are not only helping nurses to pass their NCLEX exams but also increasing the number of qualified/competent nurses providing healthcare around the globe. We are grateful. I used this site to prepare for internal exams whilst I was in school and it really helped me. I’ll be writing NCLEX soon..

Planning to start this process, I think this will be so helpful to me. Thankyou very much

Thank you so much Nurse matt vera for this qbank,most beneficial, God bless you., if I may ask for some videos or pictures associated with the questions, will also help e.g lung sounds,abdominal sound etc thank you

I loved your blog and thanks for publishing this about NCLEX practice questions!! I am really happy to come across this exceptionally well written content. Thanks for sharing and look for more in future!! Keep doing this inspirational work and share with us.

My name is Daniel m Johnson from Tanzania I’m holding diploma in nursing and midwifery I’m looking for different nurse from different country so as we can share ideas and experience since I’m student I need to no much thing about nursing ….any one who is touched to please help me I wish to be came a good nurse and help different people from different society

What a wonderful thing to do for people! Thank you very much.

This very helpful to me, thank you.

You did a great job Matt…

This is so lovely

Very useful site. Thank you so much.

This is an amazing job Matt!! REALLY INCREDIBLE!!!

With all this I will certainly pass my NCLEX exams.

THANK YOU so so much Matt, this is great beyond measure.. I have been hook to this website. God will bless you and yours abundantly

You’re most welcome! :)

i just want to confirm for #39 it state pt need additional teaching so E should also be included to the answer cause it was contraindicated to MS right? . thank you :)

Yes, this has been corrected. Thank you! :)

Very informative and helpful. Thank you so much Sir/ madam

Thank you for providing regarding NCLEX preparation

Very informative. Thank you for update.

This is for sure the best nurse’s website ever. It really helped me a lot during my training.

Number 58 of NCLEX test 5 does not have the answers listed.

Hi Rebekah, this is now fixed. Thank you for letting us know!

This is very helpful

It’s very informative. Thanks

Thank you Matt Vera for providing information free of charge

Any advice of how well you can do on these question to build up your confidence?

Thanks a lot for great job. May the Lord Almighty shower His blessing upon you.

Thank you, this site is amazing. God bless you

Thanks alot.I,ve got a question What score ranges would be considered a Pass? I scored 69.33% overall. is that a Pass???

75% and above, from the analysis I got from a test after getting below 75

Thank you Nurse Matt. You deserve all the blessings! 🙏🏻😊

This is very helpful. Thank you Nurse Matt

Question 16 on practice test 9 asked about assessment during L sided CHF, yet the correct answer pertained to right sided HF. Just wanted to let you know…. Thanks for the practice questions! Appreciate all the work put into this.

Question 41 of NCLEX-RN Test 2 has two C choices. Thanks.

Hi, I like your questions, they’re very nice and challenging. Learning a lot from them.

I love this site.. Now all friends are learning serious from here

Thanks you guys are very generous

From Kenya, this site is so helpful,am learning a lot here.Thank you especially for the care plans.

Thank you so much

You Matt and your staff are such a blessing to us who will be taking the NCLEX RN exam. This site is very useful and helpful because it is very comprehensive and easy to understand. God bless and may tribe increase. Thank you so much

The site is very informative. I have learned a lot. Test questions are really amazing which I cannot find with other website. However, I got a low score, thus I need to further study especially on the areas wherein I got a below passing grade. I hope you will allow me. Thank you

thank you so much for creating this site for people like us. This excellent job. May God bless you in Jesus name —Amen

The Practice tests are awesome! The rationales are all well-explained which I love because it gives me more knowledge and insight. Thank you for creating this website free of charge.

Thank you so much. It was really helpful. I passed the exam. God bless real good.

Thank you Matt for the awesome and great website! its beyond compare. I want more practice test questions to hone my knowledge in Nursing practice, however, when I am trying to open one of the practice tests, I cant go through it. Could you please allow me? God bless

Thank you Matt for this practice test. Now I know my strength and weaknesses and will concentrate of the system that needs for further study. Can I practice more in practice test no 2? Please allow me to go trough with it. Kudos to you and your staff.

Hi this is what i got, im so nervous due to my nclex exam its gonna be this coming oct. Its doesnt say pass or not.

Your score 48% Categories Basic Care and Comfort 100% Health Promotion and Maintenance 53.85% Pharmacological and Parenteral Therapies 26.67% Physiological Adaptation 54.55% Psychosocial Integrity 100% Reduction of Risk Potential 36.36% Safety and Infection Control 100%

Thanks so much for this useful information. God bless you.

Thank you so much for all you do

The Practice tests are excellent. The rationales are all well-explained which I love because it gives me more knowledge and insight. Thank you for creating this website free of us. Remain blessed.

Like I am obsess with nurselab. A handy powerful tool, to keep you updated, thick and richly packed. You guys made reading so interesting and magnetic and very easy. Please do not stop. I recommend this to all nurses.

Love this. Thank you for sharing your generosity. I’ve been using this since I was still in college and I continue to use it until now.

Thank you so very much for this

I remain speechless but mostly grateful for your unconditional helpful assistance for this awesome richly throughout profound tool and opportunity given to me to increase my confidence, strengthen my knowledge, and be ready for my upcoming exam. Your questions and rationales are beyond my expectations. You are a God’ sent angel. Thank You. God Bless you. I will be forever grateful to you for making my dream come true! 🙌

This website can help me to review for NCLEX and it is for free! Thank you so much!

Amazing and really awesome job to you Matt and your entire team, may God replenish your source for giving us this for free. I have recommended to all my friends and family. Remain blessed and stay safe.

That’s very kind of you. Thank you so much! Bless you!

Your test questions have greatly helped me pass my NCLEX. I passed my NCLEX today and thank you to Nurseslabs. I came across this website by accident and I do not know how but it was divine intervention. I will definitely recommend Nurseslabs to my friends. The quality of the questions and rationales were very good and you would not think this is all for free the kind of work that came with it.

Kudos Nurseslabs and wishing all the future test takers all the best!

Wow Sam, congrats! What materials did you use other than nurseslabs? I’ve been answering nurseslabs also. My exam is on June. I hope I could also make it.

Thank you for this NCLEX sample test,as tool to determine areas i need to review/focus on for the proper exams.

This website can help me to review for NCLEX Thank you so much!

I just wanna ask why is that there are no more rationale posted after answering the question unlike before. Thanks by the way for the free and great Q & A bank. ❤

Sorry, we’re currently having some performance issues with that setup. Until we can resolve it, we have set each quiz to show results and rationales only after you have finished all the questions. Thank you for your understanding.

Hello, how do I get my score after taking the test to know if I am doing well or not

Hi, after you’re done answering all questions, the final item will direct you to the “Quiz Summary,” from there, click on the “Finish Quiz” button to get your final score.

Very great tool to study for the NCLEX. I passed my exam just by focusing on the questions and rationales provided here.

That’s great! Congratulations!

Thank you so much. It’s very helpful. God bless you…

Thank you for being generous. This is a big help.

I got 55/75.

Thank you so much for making this site.

Very helpful. Thank you and God bless…

Thank you so much, Nurse Matt for your generosity. Helping your fellow nurses and aspiring nurses to work abroad is such a selfless and noble act. God bless you and your team!

Thank you for your kind words, JB! Will pass on this message to the team. :) God bless!

The rationale after the question will really help us a lot specially when you are just using the question via online.

Hi Romel, we have temporarily changed this setting so that results and rationales will show only after you’ve finished the quiz. This is because we’re having some performance issues when using the previous setting. We’ll revert the changes once we’re sure the problem is resolved. Thanks for understanding!

I didn’t get my results after answering the 75 questions. Please why?

Hi Esther, did you click on the “Finish Quiz” button?

Thanks for all these questions where/how can i check my answers to these questions?

After answering the last item of the quiz, you’ll be redirected to the quiz summary. From there, click on the “Finish Quiz” button to view your score and results. You can also click on the “View Questions” button to review your answers and read the rationales.

Hi, thanks for providing so much useful information and all the test banks!

In RN practice Quiz 1:75 questions, for question 70, wonder if the correct phrase would be “would you NOT expect”?

Hi Cecilia, thanks for letting us know. We have corrected the question. Thank you! 🥰

Thank you for allowing me to practice the nurseslabs questions. The rationales are well explained. Thank you!

Thank you Ruth. Hope you’ve learned a lot from our practice questions. 🥰

God bless you

My name is Samuel. I just started with the RN practice questions. Thank you for the opportunity.

Hi, thank you so much for your generosity. Using this to prepare for my NCLEX and find it very informative. I will keep you posted on how it goes on the D-day

Frequently throughout the quiz, ARDS is given as “Adult Respiratory Distress Syndrome” instead of “Acute Respiratory Distress Syndrome”. This needs to be corrected.

Hi Bella, thanks for bringing this up.

Technically both terms are correct since “adult respiratory distress syndrome” is an earlier name referred to “acute respiratory distress syndrome” to differentiate it from respiratory distress syndrome in neonates and children. For the sake of uniformity, we have edited them to “acute respiratory distress syndrome”. You can read more about it here: https://doi.org/10.1164/ajrccm.149.3.7509706

This is so kind a gesture, remain blessed .The information is very understandable and helpful

I just wanted to thank you for taking the time to generate this website, this is really helpful and is free. God bless you

Thank you for your support and guide toward my nclex preparation.

Thanks for your generosity. I hope to pass my NCCLEX just on the first attempt Grateful for all your help

thanks for the help

Hi Sir, kindly explain why this question – The client with hyperemesis gravidarum is at risk for developing: Metabolic Acidosis is the answer. Thank you.

Quite familiar with the content. Thanks for this selfless initiative.

It has been a nice experience.

I love these practical questions. So helpful.

Thanks very much this is a good help for all students

Thank you for mett this free test which i have passed yesterday afternoon so ,it is greatest pleasure which will help me

Thank you so much for this great initiative.

Thanks for being kind God bless you

thank you for your help and kindness. It’s difficult to go back to school after 22 years of practice as a RN to take the test where you must cover a vast knowledge, which you do not use in everyday working (depends on the special field you are working. so I really appreciate your effort and dedication.

Matt Vera and all those helping us through this free medium, May God richly bless you abundantly. And may all your good desires come through

Hello Vera, I would start by thanking you for the great job you’ve done by helping us in our preparation for the exams. secondly would wish to know wther you have audio clips for lung, heart and abdominal sounds. thank you in advance and if any kindly let mh know pls.

What should we be scoring on these practice questions to let us know that we’re ready for the NCLEX

Do you have LPN test also?

Hi, please visit NCLEX-PN Practice Questions & Test Bank (200 Questions)

Thank you so much Nurse Matt you just don’t know how nurseslabs helped me in my nursing career and i even recommended nurseslabs to some of my friends. God bless you😊

Hi Matt, Thank you for this, indeed very helpful practice questions. Just a query though it says here to limit wrong answers to 15 or less? So is that the passing mark ? about 75-80%

Yes, that is correct. :)

Thank you so much for the practice questions. I learned a lot and it helped me to understand why I was getting my answers wrong. I used Kaplan and Saunders but it wasn’t helping me. I feel more confident than ever to retake my boards.

thank you…. wish this help a lot to my daughter to passed please pray for her God bless!!!

hi Matt, can l still use these question banks to study for the new NGN questions

Hi nurse Matt, May I gave all the questions please, need to prepare study for exam after been off school over 30 years, realize it for not giving up not try again, thank you 🙏

Thank you so much Nurselabs! I passed my NCLEX-RN exam using only your practice 75 question per day questions bank. I have a tight budget and not able to purchased online review and I just focused in answering your practice questions in just 2 weeks!!! Thank you for helping nurses! God Bless you more!

I want to practices questions

Hello Thanks so much for your good heart and good wish for us to practice and pass the NCLEX. Well appreciated. Please after your update I can’t get the answers and rationale to the 75 questions. This will help me to know my ability and where am lagging behind. Please how can this be rectified Thanks Hope

Hi Hope, did you finished all of the questions for the quiz? Your score together with the correct answers and rationale will only show after you’ve completed the whole quiz.

Hello Vera I finished all 75 questions submitted but no answer or rationale came up. I tried upto 3 times same. Even my friend I shared your content with complained of same thing, answers not coming. Please what can we do to access the answers and rationale Thanks Hope

What particular quiz?

Hello, great resource! I am a nurse that wants to help student nurses reach their full potential as nurses and pass the nclex. I would like to utilize your tests and quizzes to help my students learn to critically think through the questions and learn how to put their nursing knowledge to use. Would you allow me to utilize your questions in my content?

Thank you for the kind words! It’s awesome to hear that you’re dedicated to helping student nurses thrive. 🌟

Absolutely, you’re more than welcome to utilize our tests and quizzes for your students! We believe in collaborative efforts to strengthen the nursing community. Just ensure to give appropriate credit when using the content.

Out of curiosity, are there specific areas or topics you find students struggle with the most when preparing for the NCLEX? Maybe we can work together to create even more targeted resources!

Best of luck with your mission to guide the next generation of nurses!

Hi, I am studying for med surg 1 and med surg 2 upcoming exam. Need to pass both exams.

Sounds like you’ve got a busy study schedule ahead! MedSurg can be challenging, but with the right resources and dedication, you’ve got this. If you need specific materials, tips, or just a morale boost, don’t hesitate to reach out. Else, you can do practice all MedSurg exams on our Nursing Test Banks . Rooting for you to ace both exams! 💪

thank you so much… a big help

Hi Glacier and what a nice name!

You’re welcome! Really glad to hear the NCLEX practice questions were a big help. If you’ve got any other areas you’re prepping for or need more practice with, just let me know. Here to support your journey!

Thanks a lot @nurseslabs for this initiative I really believe by the time I sit my exam I will be a great nurse than ever before. I am learning a lot from the questions and explanation.

Hey Charles, You’re very welcome! I’m thrilled to hear that you’re finding our initiative helpful in your journey to becoming a great nurse. Remember, continuous learning is a key part of nursing practice, and it’s fantastic to see your dedication to it. If you ever come across any challenging topics or have questions about specific nursing concepts, please don’t hesitate to reach out. We’re here to support you every step of the way. Keep up the excellent work, and you’ll do great on your exam! 📖🏥🌟

Much help for beginners like us

Thank you so much Nurseslabs, I made it!!! Your practice exams, especially the rationales helped me a LOT…thank you!!!

Wow, that’s awesome news! 🌟 Huge congrats on making it through – your hard work and dedication really paid off. It’s super cool to hear how our practice exams and rationales played a part in getting you across the finish line.

Remember, this is just the beginning of an amazing journey in nursing. The field’s always changing and growing, and so will you. Keep that enthusiasm and curiosity going strong!

If you ever need a hand or just want to share your journey as you dive into your nursing career, give us a shout. We’re always here to cheer you on and lend support.

Big congrats again and best of luck out there!

Thanks for the information

thanks for the guide

Thank you for your kindness.

Thank you very much!

Thanks a lot for this whole range of knowledge; it’s now upon me to work extra hard to be a better nurse outside there or help other nurses be better at service delivery.

Hi Evans, You’re so welcome! I’m glad to hear that the range of knowledge from the NCLEX practice questions is empowering you to aim for excellence in nursing. Remember, every bit of effort counts towards becoming not just a better nurse but also a great mentor to others in the field. If you need more resources or advice along the way, I’m here to help. Keep up the fantastic work!

Please how can I practice questions please 🙏

In practice exam 5 question 22 asks about hyperemesis…. wouldn’t that cause alkalosis (rather than acidosis), since its acid from the stomach that is leaving the body?

Can I. Have free practice questions? NGN questions?

Thank you for the opportunity to know about all the information posted here. I strongly believe I will pass the NCLEX-RN exam at my first attempt through these useful resources available here. Thanks

Thanks a lot Nurselabs for the free test banks! It’s all what I focused to practice and read every rationale in each questions given. I just recently took my NCLEX-RN exam last week and i was able to make it. Your website is what i embraced and felt much comfortable and trusted what is in there. Thanks for helping lots of NURSES! Highly recommended!

Hello Brenda, Congratulations on passing your NCLEX-RN exam! 🎉 That’s a fantastic achievement, and I’m so thrilled to hear that our test banks and rationales were a valuable part of your preparation. Thank you for trusting Nurseslabs and for your kind words—it means a lot to us.

If you have any tips for future test-takers or any other resources you found particularly helpful, we’d love to hear about them. Your feedback not only celebrates your success but also helps us continue to improve and assist other nursing students.

Thanks again for recommending us, and best of luck in your exciting nursing career!

THIS IS GREAT. THANK YOU FOR SHARING.

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

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What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.

Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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nrs 130 test 3 fundamentals ebook questions-laura > Chapter 15 Critical Thinking in Nursing Practice > Flashcards

Chapter 15 Critical Thinking in Nursing Practice Flashcards

Rationale: This is an example of problem solving. The nurse collects information and tries options until she is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the patient’s IV and not on solving the patient’s health problem; thus this is not the diagnostic reasoning process.

• The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can’t concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:

A. Diagnostic reasoning. B. Competency. C. Inference. D. Problem solving.

A. Rationale: In this example the nurse collects information about the patient, sees patterns in the data collected, and makes a nursing diagnosis. This is an example of the diagnostic process.

• A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are:

A. Problem solving. B. Showing humility. C. Conducting reflective practice. D. Exercising responsibility.

C. Rationale:

Reflective practice is a conscious process of thinking, analyzing, and learning from previous work situations. The staff may discuss problems that occurred, but in this case they are reflecting on them to learn for future patient situations.

• A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, “I feel funny.” The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, “I believe that your patient is developing sepsis. I want to report symptoms I’m seeing.” What examples of critical thinking concepts does the nurse show? (Select all that apply.)

C & D Rationale: Among critical thinking concepts, the nurse shows analyticity (analyzing information, gathering additional findings, and sensing a problem), and self-confidence (calling the physician, which shows trust in his own reasoning). The nurse’s experience would have influenced the familiarity of patient symptoms, but in this text experience is considered a component of the critical thinking model and not a concept. Acting ethically is a critical thinking standard.

• A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.) A. Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. B. Think about past experience with patients who develop postoperative complications. C. Decide which activities can be combined for patients B and C. D. Carefully gather any assessment information and identify patient problems.

C & A Rationale: Considering how to involve patients in decisions and how to combine nursing activities to be more organized and allow for resolving more than one problem at a time are examples of clinical decision making for groups of patients. Thinking about past experience with patients is an example of reflection, an approach to strengthen critical thinking skills. Gathering assessment information is part of the process of diagnostic reasoning, which should be applied to each patient.

C Rationale: Use of the same pain scale for assessing pain acuity is an example of being consistent.

• During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient’s home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, “This hurts too much. I don’t see why I have to do this so many times.” The nurse applies the critical thinking attitude of integrity in which of the following actions?

A. “I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let’s go a bit more slowly and try to relax.” B. “I see that you’re uncomfortable. I’ll call your doctor to decide the next step.” C. “Show me exactly where your pain is and rate it for me on a scale of 0 to 10.” D. “Is anything else bothering you? Other than the pain, is there any other reason you might not want to do the exercises?”

A Rationale: The nurse reviews the position of requiring exercises to restore function and decides to try a different approach to proceed, which is an example of integrity. In calling the doctor for the next step, the nurse does not reinforce the importance of exercises, which is likely the standard of care for this type of patient. In asking the location and strength of the pain the nurse is interpreting further to determine if any other physical problems are developing. In attempting to learn if any other underlying problems exist, the nurse is showing curiosity.

• The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, “You can’t make me feel better; you don’t know what it’s like to lose a child.” Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.)

A. Data entry of time of day, who was present, and condition of the child B. Description of the efforts to restore the child’s blood pressure, what was used, and questions about the child’s response C. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient’s death D. A description of what the nurse said to the mother, the mother’s response, and how the nurse might approach the situation differently in the future

B, C & D Rationale

The nurse can reflect on the effects of the treatment and what was difficult or confusing about the outcome. The nurse reviews the meaning of the experience to help improve understanding of personal comfort and competence in dealing with death and how to respond in the future. The nurse reflects on the communication approach used with the mother to consider if it was appropriate.

C Rationale: This is an example of basic critical thinking, in which the nurse trusts that experts have the right answers for how to insert the Foley catheter and thus goes to the procedure manual. Thinking is concrete and based on a set of rules or principles.

B Rationale: The patient’s baseline for wound drainage was 40 mL, representing the initial assessment of the patient’s wound condition. In this example the nurse is evaluating to determine if there is a change in the amount of drainage, which indicates the progress of wound healing.

Rationale: The nurse reviewed knowledge that pertained to the patient’s clinical situation, allowing him to apply critical thinking in the patient’s care.

• A nurse is working with a nursing assistive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.)

A. A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. B. A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead. C. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. D. The nurse is in patient B’s room to check an intravenous (IV) line and collects the urine specimen while in the room. E. The nurse offers support to the NAP when needed but allows her to complete patient care tasks without constant oversight.

A, C, D Rationale: Successful delegation is represented by good communication, showing respect, and showing initiative. The example in answer 2 shows a lack of initiative on the part of the nurse.

• Which of the following is unique to the commitment level of critical thinking? A. Weighs benefits and risks when making a decision. B. Analyzes and examine choices more independently. C. Concrete thinking. D. Anticipates when to make choices without others’ assistance.

Rationale: Anticipating when to make choices during decision making is unique to the commitment level of critical thinking. Thinking concretely is basic critical thinking. Analyzing and examining choices and weighing benefits and risks are characteristic of complex critical thinking.

• In which of the following examples is the nurse not applying critical thinking skills in practice?

A. The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance. B. The nurse uses a fall risk inventory scale to determine a patient’s fall risk. C. The nurse observes a change in a patient’s behavior and considers which problem is likely developing. D. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

Rationale: The nurse is explaining how to provide care on the basis of knowledge. Considering personal experience is self-regulation through reflection. Determining a patient’s fall risk is evaluation, using a criteria-based screening scale. Observing a change in the patient’s behavior and considering likely developments is inference, in which the nurse looks for a relationship in findings.

nrs 130 test 3 fundamentals ebook questions-laura (6 decks)

• Chapter 15 Critical Thinking in Nursing Practice
• Chapter 16 Nursing Assessment
• Chapter 17 Nursing Diagnosis
• Chapter 18 Planning Nursing Care
• Chapter 19 Implementing Nursing Care
• Chapter 20 Evaluation
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Nursing Process And Critical Thinking Review Test

Welcome to our Nursing Process and Critical Thinking Review Test, a comprehensive tool designed to elevate your nursing expertise and decision-making abilities. This quiz is essential for nursing students and practicing nurses who aim to refine their assessment, planning, implementation, and evaluation skills, all through the lens of critical thinking. Our quiz meticulously covers all phases of the nursing process, integrating critical thinking scenarios that challenge you to apply theoretical knowledge in practical, real-world healthcare situations. You'll encounter a variety of question formats that probe your ability to analyze information, prioritize patient care, and make informed decisions quickly and effectively. Read more Whether you are preparing for your NCLEX exams, brushing up on your clinical practices, or seeking to enhance your professional development, this test provides the perfect opportunity to assess and improve your critical thinking and nursing process skills. Dive into our Nursing Process and Critical Thinking Review Test today to test your knowledge, sharpen your critical thinking, and ensure you're fully prepared to provide the highest quality of care in any nursing setting.

Nursing Process and Critical Thinking Questions and Answers

What is the "nursing process" select all that apply.

Organizational framework for the practice of Nursing

Systematic method by which nurses plan and provide care for patients

The application of the nursing process only applies to RN's and not LPN's

The Nursing Scope and Standards of Practice of the ANA outlines the steps of the nursing process

Rate this question:

ANA defines it as a"systematic dynamic process by which the nurse, through interaction with the client, significant others  and health care providers collect and analyzes data about the client

Physical Check-up

Hospital evaluation

Which of the following is not true about Focused ASSESSMENT

When patient is critically ill or disoriented

When patient is unable to respond

Preferably early in the morning before breakfast.

When drastic changes are happening to a patient.

A synonym for significant data that usually demonstrate an unhealthy response. 

Interpretative

Headache, itchiness, warmth

Secondary source of data. (select all that apply) .

Diagnostic procedures

Medical record

Personal interview

Significant other

Which of the following is not a method of data collection?

Biographic data

Social media

Health history

If the first method of data collection is to conduct an interview, what is the second method?

Laboratory work

Diagnostic Tests

Performance of a physical examination

After establishing a database and before the identification of nursing diagnosis, what does a nurse do? 

Documentation of database

Analysis of database

Filing of database

Acquiring a database of information

Data Clustering

Analyzing signs and symptoms

Identifying patient statements

Grouping related cues together

Entering patient data in the computer

Deficient Fluid Volume (Select all that apply)

Dry skin and dry oral mucous

Decreased urine output

Which of the following refers to the definition of a Nursing Problem?

Nurse overload and nurse burnout

When the nurse calls in sick

Any health care condition that requires diagnostic, therapeutic, or educational actions.

Lose of employment

 Clinical judgment

Job description of a clinical nurse

Data collection

Health intervention

Components of a Nursing Diagnosis. Select all that apply  

Nursing diagnosis title or label

Definition of the title or label

Data clustering

Contributing, etiologic or related factors

Defining characteristics

Which of the following are true regarding nursing diagnosis? 

A nursing diagnosis is any problem related to the health of a patient

When writing a nursing diagnosis, place the adjective before the noun modified

A nursing diagnosis is usually the etiology of the disease

Both medical and nursing diagnosis can be converted into a nursing intervention.

Clear, precise description of a problem 

Intervention

Risk factors

Description of a problem

Analysis of a health issue

Possible illness

Circumstances that increase the susceptibility of a patient to a problem

Clinical cues, signs, symptoms that furnish evidence that the problem exists. 

Nursing diagnosis

How cues, signs and symptoms identified in patient's assessment are written

Diagnosed by

Explained by

Manifested by

"Constipation related to insufficient fluid intake manifested by increased abdominal pressure". What is the defining characteristic? 

Constipation

Insufficient fluid

Increased abdominal pressure

What is RISK NURSING DIAGNOSIS as described by NANDA-I?  Select all that apply

Human responses to health conditions/life processes that may develop in a vulnerable individual/family

Describes the symptoms of the disease

Supported by risk factors that contribute to increased vulnerability

Proof that the person is suffering from an illness

How many parts does a RISK NURSING DIAGNOSIS have?

Which of the following is a risk nursing diagnosis statement .

Risk for falls related to unstable balance

Constipated because of fecal impaction

Risk for Diarrhea

Constipation related to dehydration

Syndrome Nursing Diagnosis

An isolated disease with numerous symptoms

Numerous symptoms describing a single disease

Used when a cluster of actual or risk nursing diagnosis are predicted to be present

Numerous symptoms leading to an idiopathic disorder

Wellness Nursing Diagnosis

Absence of illness

Not strictly a diagnosis

Human responses to levels of good health in an individual, family or community

All of the above

Certain Physiologic complications that nurses monitor to detect their onset or changes in the patient's status.    

Collaborative problems

Clustered Syndrome

Signs of death

Potential complications: hypoglycemia.  This is a sample of what?

Syndromatic pathology

Definite Variance

Collaborative problem

Idiopathic etiology

Identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory test and procedures. 

Health Analysis

Nursing Problem

Medical Diagnosis

Difference between Medical and Nursing Diagnoses

Medical is etiology; Nursing is human response

Medical is disease; Nursing is the cause of disease

Medical is illness; Nursing is illness too

Medical is to heal the disease: Nursing is to discover the disease

Difference between a goal statement and an outcome statement

A good outcome statement is specific to the patient

Goals are general deadlines that are to be met

An outcome statement refers to what the nurse will do

Goals and Statements are practically the same

The purpose to which an effort is directed 

Which of the following statements describe a well-written patient outcome statement select all that apply.  .

Uses a measurable verb

Focuses on the completion of nursing interventions

Does not interfere with the medical care plan

Includes a time frame for patient reevaluation

A common framework that helps guide the prioritization of nursing tasks during the process of planning

Ericsson's psychosocial development

Maslow's hierarchy

Glasgow Scale

Bernoulli principle

Nursing interventions

Depend on the tasks delegated by the nursing supervisor

A sequence of prioritized tasks that describe a nurse's job

Activities that promote the achievement of the desired patient outcome

An act of taking care of the sick

Which of the following is not a Physician Prescribed intervention?

Ordering diagnostic tests

Drug administration

Performing wound care

Elevating an edematous leg

Which of the following is not a nurse-prescribed intervention?

Turning the patient every two hours

Providing a back massage

Offering a vitamin supplement

Monitoring a patient for complications

Which of the following statements about the nursing process is true. 

A nursing process is written together with a nursing care plan

A nursing care plan is a product of the nursing process

Both the nursing process and the nursing care plan are purely critical thinking strategies

The nursing process is not an accurate clinical theory

IN which of the following scenarios would a standardized nursing care plan be appropriate? 

Trauma center

Center for infection control

Intensive care unit

Maternity floor without a single Cesarean delivery

Prioritization of tasks belongs to which phase of the Nursing Process? 

Implementation

Documentation is a vital component of which phase of the nursing process?

Validation of patient outcome and goals, evidence based practice.

Past educational knowledge

Theoretical research

Expertise of specialists

Integration of research and clinical experience

Which of the following is not considered a standardized language in nursing?

A research method

Patient does not achieve expected outcome

Similar to zoning

Not the same

Which of the following is not the role of the LPN/LVN in the nursing process?

Suggest interventions

Gather further data to confirm problems

Discuss details of the disease as part of patient education

Observe and report signficant cues

Which of the following are functions of managed care? Select all that apply. 

Provides control over health care services

Standardized diagnosis and treatment

Control Cost

Primary resource for patient advocacy

Clinical pathway

Nursing career development plan

Multidisciplinary action

A concept map for care plans

Specific location in a healthcare facility

A reflective reasoning process that guides a nurse in generating, implementing and evaluating approaches for dealing with client care and professional concerns

Nursing process

Critical thinking

Nursing care plan

Nursing logic

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02.01 Critical Thinking

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If you have gone to one day of nursing school you understand that “critical thinking” is a buzzword.

Nursing schools love to talk about critical thinking.

The job of a nurse is essentially to take millions of data points and be able to arrive at a correct decision based on that data.

This is no easy task and there are few jobs which require this on the scale of nursing or with human lives in the balance.

What is Critical Thinking?

Critical thinking is defined as: Clear, rational thinking involving critique. Its details vary amongst those who define it. According to Barry K. Beyer (1995), critical thinking means making clear, reasoned judgments. During the process of critical thinking, ideas should be reasoned, well thought out, and judged. The National Council for Excellence in Critical Thinking defines critical thinking as the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.  Source .

So, while you are familiar with making decisions on a daily basis, most daily decisions do not require critical thinking (what color of shirt should I wear, what should I eat for dinner, etc).

It is a skill that can grow and develop with time and as you enter nursing school you are not expected to be an expert in the skill.

However, what you should understand is that critical thinking involves a level of decision making far beyond normal day to day decision making. With critical thinking you are analyzing, conceptualizing, and digging deep into the questions presented.

When it comes to nursing, often times you are presented with real life or death situations. You are presented with saving one patient or determining what the most important solution is to a highly complex problem.

Those nurses who develop advanced critical thinking skills find increased success in their careers.

Critical Thinking in Nursing

So let’s talk about critical thinking and how it applies to everything we are talking about here.

The NCSBN website states the following: Since the practice of nursing requires you to apply knowledge, skills and abilities, the majority of questions on the NCLEX are written at the cognitive level of apply or higher. And these questions, by nature, require critical thinking.

Answering these correctly will require you to do something with what you have learned, to manipulate previously learned material in new ways or find connections between many facts.

Again, since the majority of NCLEX questions fall into this category, this is exactly the type of questions you need to practice answering!

There it is again . . . the BUZZ word (critical thinking) . . . but once again no tips or information on what that means or how to develop it is given.

So let’s dive in and provide you with a simple framework and method for developing critical thinking.

How to Critically Think in Nursing

While there are many frameworks and methods for developing critical thinking, here we will provide you with a basic 4 step method.

At the risk of sounding oversimplified, this simple method will allow you to cut through the clutter, think critically, and arrive at correct decisions in even the most complex of scenarios.

Essentially there are 4 steps to critical thinking . . . in nursing and in life . . . and developing the ability to critically think will work wonders in your life.

• Suspend ALL Judgement
• Collect ALL Information
• Balance ALL Information
• Make a Complete and Holistic Decision

Before diving into the four individual steps let’s point out the use of the word “ALL” in each of the steps.

This is important because few individuals can make decisions with this inclusive word. It literally means ALL. To make a complete and holistic decision based upon critical thinking you have to have and weight ALL information. Otherwise you are just making a regular old decision.

•   Suspend All Judgement

You have to start by suspending all judgement. In other words, if you walk into a patients room and see them tachycardic an amature decision would be to run and grab the metoprolol to try to drop the heart rate.

An advanced clinician will WAIT until they have more information . . . not leaving the patient untreated . . . but not jumping freakishly into the WRONG treatment because they learned that tachycardia is bad . . .

Suspending judgement means that you don’t make a decision based upon the first sign. You also don’t walk into any situation of NCLEX question with a decision already made. You will treat all facts as equal until you can gather the needed information.

Not suspending judgment leaves you open to make biased decisions. This is detrimental in medicine and nursing. This will also result in poor success on nursing exams and the NCLEX.

As you read through nursing questions you must force yourself to refrain from jumping to conclusions until you have read the question in full. Do not allow yourself to assume what the question is asking or what the patient outcome is until you have read the question in full.

Obviously this sounds simple, but it is this step that, if missed, will through more nursing students and nurses off.

• Collect All Information 

Now you must collect ALL information. This is clutch! Don’t make a decision until you have collected every piece of data that you need to collect . . . on a tachycardic patient you can check BP, temp, run an EKG, check urine output.

Think of this as data mining. You are looking to have every piece of information you can find to put the puzzle pieces together.

When it comes to taking nursing tests you only have one place that you can collect the information . . . and that is from the test question itself. Do not go looking outside of the question of infer any details that are not provided within the question.

One thing we have noticed students doing almost more than anything else on test questions is reading into them. Don’t do this. Gather all the information you can . . . and when it comes to NCLEX questions, the only place you can gather information is from the question itself.

• Balance All Information

Now, balance all information. This means take all the data that you have and start weighing it to find out what is pertinent and what you can ignore. If the temp is 98.9 . . . it’s probably not the cause. If the BP is 74/56 are we looking at a volume issue?

In this step you are deciding what is important and what isn’t. While a pressure ulcer is important, if the patient is actively having a heart attack . . . it just doesn’t matter. At least, not until we take care of the MOST important issue.

NCLEX style questions will be FULL of extra information, things that you just really do not need to know to make a decision on the patient.

The NCSBN (who administers the NCLEX) in an effort to simulate real life nursing writes questions that include both important information and details that you just simply don’t need to know. It is your job to sift through the data and determine what you actually need to know.

Balancing means giving each data point a level of importance for your given patient. Some pieces of information will score much higher than others.

At this point you must all consider the implications of the possible options. Look at the available options and think to yourself, “if I choose this option, what happens next?”. As it relates to nursing, ask yourself these questions:

“Does this achieve a desired patient outcome?”

“If I do this and then go home, what happens to my patient?”

Forcing yourself to consider the implications allows you to look beyond the information presented and consider the RESULTS of your choices. Critical thinking thrives on looking beyond the presented data.

• Make a Holistic Decision

Finally, make your decision . . . with all the data in and after looking over it all very closely you can begin to make your decision.

Your goal is to make the decision that best serves the patient and addresses their most immediate concerns.

Critical Thinking in Nursing and on the NCLEX®

Lastly, I just want to talk briefly about how this applies to NCLEX questions . . .

Here is an actual practice NCLEX question from our Nursing Practice Questions Program (or NPQ, as we like to call it)!

A 56-year-old male patient has been admitted to the cardiac unit with exacerbation of heart failure symptoms. The nurse has given him a nursing diagnosis of decreased cardiac output related to heart failure, as evidenced by a poor ejection fraction, weakness, edema, and decreased urinary output. Which of the following nursing interventions are most appropriate in this situation?

42% of the students that have taken this question have selected this answer:

Administer IV fluid boluses to increase urinary output

The problem with that answer is that it fails to weigh the most important issue facing this patient.

Test takers see urine output as low . . . and want to correct that quickly with fluids.

However, this is a CHFer . . . you can’t (shouldn’t) bolu especially during an exacerbation . . . you could send the patient into pulmonary edema and drastically impact their respiratory status.

So the lesson here. . . . in school, on the NCLEX, and on the clinical floor . . . slow down, stay calm and start thinking at an analysis level.

And I promise you this helps in “REAL” life too . . . not just in nursing. You will begin to be a tad more skeptical and deliberate with your decisions.

Here are a couple resources that will help you in the process of developing critical thinking.

• CriticalThiking.org
• US News 5 Tools
• Thinking Fast and Slow
• NPQ – Nursing Practice Questions

The process for developing critical thinking is slow and arduous. However, don’t be hard on yourself. According to  CriticalThiking.org  the vast majority of colleges are not appropriately incorporating critical thinking into the college classroom. This means that while you might not being taught the skill as you should . . . most people aren’t. Using the strategies outlined above will put you light years ahead of most.

The nurse that is able to follow these four steps is a tremendous asset on a clinical floor.

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Test taking for the nclex®.

The Test-Taking course is the best place to start when you’re trying to figure out how to navigate NCLEX®-Style questions. Nursing school presents a unique challenge when it comes to test-taking. You’re no longer just looking for the right answer - you’re now looking for the most right answer or multiple right answers. In this course, we break down how to understand what these questions are even asking you, and our best tips for how to answer them. We also provide some strategies for goal-setting, studying, and note-taking that are sure to set you up for success on your exams and on the NCLEX®.

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Home / NCLEX-RN Practice Test Questions

NCLEX-RN Practice Test Questions

You've learned about the NCLEX-RN exam, studied the sections, and are ready to put your knowledge to the test. Take our practice NCLEX exam below to get ready for the real deal.

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Click on the section names below to jump to a particular section of the RegisteredNursing.org NCLEX-RN Practice Exam.

• The Safe and Effective Care Environment: The Management of Care
• The Safe and Effective Care Environment: Safety and Infection Control
• Health Promotion and Maintenance
• Psychosocial Integrity
• Physiological Integrity: Basic Care and Comfort
• Physiological Integrity: Pharmacological and Parenteral Therapies
• Physiological Integrity: Reduction of Risk Potential
• Physiological Integrity: Physiological Adaptation

The NCLEX-RN Test Plan is organized into four major Client Needs categories. Two of the four categories are divided into subcategories as shown below:

• Management of Care – 17% to 23%
• Safety and Infection Control – 9% to 15%
• Health Promotion and Maintenance – 6% to 12%
• Psychosocial Integrity – 6% to 12%
• Basic Care and Comfort – 6% to 12%
• Pharmacological and Parenteral Therapies – 12% to 18%
• Reduction of Risk Potential – 9% to 15%
• Physiological Adaptation – 11% to 17%

For more practice test questions from professional sources try these .

The Safe & Effective Care Environment: The Management of Care Practice Questions

You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions.

• You should be aware of the fact that the wife of the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
• You should be aware of the fact that the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
• You should reinforce the wife’s belief that legally married spouses automatically serve for the other spouse’s durable power of attorney for health care decisions and that others than the spouse cannot be legally appointed while people are married

Correct Response: A

Both the client and the client’s spouse have knowledge deficits relating to advance directives. Legally married spouses do not automatically serve for the other spouse’s durable power of attorney for health care decisions; others than the spouse can be legally appointed while people are married.

• Privacy and to have their medical information confidential unless the client formally approves the sharing of this information with others such as family members.
• Make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so.
• Be fully informed about all treatments in term of their benefits, risks and alternatives to them so the client can make a knowledgeable and informed decision about whether or not to agree to having it
• Make decisions about who their health care provider is without any coercion or undue influence of others including healthcare providers.

Correct Response: B,D

The Patient Self Determination Act, which was passed by the US Congress in 1990, gives Americans the right to make healthcare decisions and to have these decisions protected and communicated to others when they are no longer competent to do so. These decisions can also include rejections for future care and treatment and these decisions are reflect in advance directives. This Act also supports the rights of the client to be free of any coercion or any undue influence of others including healthcare providers.

The Health Insurance Portability and Accountability Act (HIPAA) supports and upholds the clients’ rights to confidentially and the privacy of their medical related information regardless of its form. It covers hard copy and electronic medical records unless the client has formally approved the sharing of this information with others such as family members.

The elements of informed consent which includes information about possible treatments and procedures in terms of their benefits, risks and alternatives to them so the client can make a knowledgeable and informed decision about whether or not to agree to having it may be part of these advanced directives, but the law that protects these advance directives is the Patient Self Determination Act.

• Call the doctor and advise them that the client’s physical status has significantly changed and that they have just had a cardiopulmonary arrest.
• Begin cardiopulmonary resuscitation other emergency life saving measures.
• Notify the family of the client’s condition and ask them what they should be done for the client.
• Insure that the client is without any distressing signs and symptoms at the end of life.

Correct Response: B

You must immediately begin cardiopulmonary resuscitation and all life saving measures as requested.by the client in their advance directive despite the nurse’s own beliefs and professional opinions. Nurses must uphold the client’s right to accept, choose and reject any and all of treatments, as stated in the client’s advance directive.

You would not call the doctor first; your priority is the sustaining of the client’s life; you would also not immediately notify the family for the same reason and, when you do communicate with the family at a later time, you would not ask them what should or should not be done for the client when they wishes are already contained in the client’s advance directive.

Finally, you would also insure that the client is without pain and all other distressing signs and symptoms at the end of life, but the priority and the first thing that you would do is immediately begin cardiopulmonary resuscitation and all life saving measures as requested by the client in their advance directive, according to the ABCs and Maslow’s Hierarchy of Needs.

• Case manager
• Collaborator
• Coordinator of care

Correct Response: D

The priority role of the nurse is advocacy. The nurse must serve as the advocate for both the fetus and the mother at risk as the result of this ethical dilemma where neither option is desirable. As an advocate, the nurse would seek out resources and people, such as the facility’s ethicist or the ethics committee, to resolve this ethical dilemma.

• Client advocate
• Entrepreneur

A nurse who organizes and establishes a political action committee (PAC) in their local community to address issues relating to the accessibility and affordability of healthcare resources in the community is serving as the client advocate. As you should know, the definition of “client” includes not only individual clients, and families as a unit, but also populations such as the members of the local community.

Although the nurse, as the organizer of this political action committee (PAC), will have to collaborate with members of the community to promote the accessibility and affordability of healthcare resources in the community, this is a secondary role rather than the primary role.

Additionally, although the nurse is serving in a political advocacy effort, the nurse is not necessarily a politician and there is no evidence that this nurse is an entrepreneur.

• The right task, the right circumstances, the right person, the right competency, and the right supervision or feedback
• The right task, the right circumstances, the right person, the right direction or communication, and the right supervision or feedback
• The right competency, the right education and training, the right scope of practice, the right environment and the right client condition
• The right competency, the right person, the right scope of practice, the right environment and the right client condition

The Five Rights of Delegation include the right task, the right circumstances, the right person, the right direction or communication, and the right supervision or feedback.

The right competency is not one of these basic Five Rights, but instead, competency is considered and validated as part of the combination of matching the right task and the right person; the right education and training are functions of the right task and the right person who is able to competently perform the task; the right scope of practice, the right environment and the right client condition are functions of the legal match of the person and the task; and the setting of care which is not a Right of Delegation and the matching of the right person, task and circumstances.

• The American Nurses Association’s Scopes of Practice
• The American Nurses Association’s Standards of Care
• State statutes
• Federal law

Correct Response: C

The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on state statutes that differentiate among the different types of nurses and unlicensed assistive personnel that are legally able to perform different tasks.

Although the American Nurses Association’s Standards of Care guide nursing practice, these standards are professional rather than legal standards and the American Nurses Association does not have American Nurses Association’s Scopes of Practice, only the states’ laws or statutes do.

Lastly, scopes of practice are within the legal domain of the states and not the federal government.

• Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately established priorities.
• Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately completed priority tasks.
• Ask the staff member how they feel like they have been able to employ their time management skills for the last six months.
• Collect outcome data over time and then aggregate and analyze this data to determine whether or not the staff member has completed reasonable assignments in the allotted time before the end of their shift of duty.

The best way to objectively evaluate the effectiveness of an individual staff member’s time management skills in a longitudinal manner is to collect outcome data over time, and then aggregate and analyze this data to determine whether or not the staff member has completed reasonable assignments in the allotted time before the end of their shift of duty. Another way to perform this longitudinal evaluation is to look at the staff member’s use of over time, like the last six months, when the unit was adequately staffed.

Observing the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately established priorities is a way to evaluate the short term abilities for establishing priorities and not assignment completion and observing the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately completed priority tasks is a way to evaluate the short term abilities for completing established priorities and not a complete assignment which also includes tasks that are not of the highest priority.

Lastly, asking the staff member how they feel like they have been able to employ their time management skills for the last six months is the use of subjective rather than objective evaluation.

• An unlicensed staff member who has been “certified” by the employing agency to monitor telemetry: Monitoring cardiac telemetry
• An unlicensed assistive staff member like a nursing assistant who has been “certified” by the employing agency to insert a urinary catheter: Inserting a urinary catheter
• A licensed practical nurse: The circulating nurse in the perioperative area
• A licensed practical nurse: The first assistant in the perioperative area

An unlicensed staff member who has been “certified” by the employing agency to monitor telemetry can monitor cardiac telemetry; they cannot, however, interpret these cardiac rhythms and initiate interventions when interventions are indicated. Only the nurse can perform these roles.

Unlicensed assistive staff member like a nursing assistant cannot under any circumstances be certified” by the employing agency to insert a urinary catheter or insert a urinary catheter because this is a sterile procedure and, legally, no sterile procedures can be done by an unlicensed assistive staff member like a nursing assistant.

Lastly, the role of the circulating nurse is within the exclusive scope of practice for the registered nurse and the role of the first assistant is assumed only by a registered nurse with the advanced training and education necessary to perform competently in this capacity. Neither of these roles can be delegated to a licensed practical nurse or an unlicensed assistive staff member like a nursing assistant or a surgical technician.

• Only the VA health care services because he is not 65 years of age
• Medicare because he has been deemed permanently disabled for 2 years
• Medicaid because he is permanently disabled and not able to work
• Choices B and C

This client is legally eligible for Medicare because he has been deemed permanently disabled for more than 2 years in addition to the VA health care services. People over the age of 65 and those who are permanently disabled for at least two years, according to the Social Security Administration, are eligible for Medicare.

Based on the information in this scenario, the client is not eligible for Medicaid because has a “substantial” VA disability check on a monthly basis and is not indigent and with a low income.

• The case manager’s role in terms of organization wide performance improvement activities
• The case manager’s role in terms complete, timely and accurate documentation
• The case manager’s role in terms of the clients’ being at the appropriate level of care
• The case manager’s role in terms of contesting denied reimbursements

Registered nurse case managers have a primary case management responsibility associated with reimbursement because they are responsible for insuring that the client is being cared for at the appropriate level of care along the continuum of care that is consistent with medical necessity and the client’s current needs. A failure to insure the appropriate level of care jeopardizes reimbursement. For example, care in an acute care facility will not be reimbursed when the client’s current needs can be met in a subacute or long term care setting.

Nurse case managers do not have organization wide performance improvement activities, the supervision of complete, timely and accurate documentation or challenging denied reimbursements in their role. These roles and responsibilities are typically assumed by quality assurance/performance improvement, supervisory staff and medical billers, respectively.

• The ProACT Model: Registered nurses perform the role of the primary nurse in addition to the related coding and billing functions
• The Collaborative Practice Model: The registered nurse performs the role of the primary nurse in addition to the role of the clinical case manager with administrative, supervisory and fiscal responsibilities
• The Case Manager Model: The management and coordination of care for clients throughout a facility who share the same DRG or medical diagnosis
• The Triad Model of Case Management: The joint collaboration of the social worker, the nursing case manager, and the utilization review team

The Triad Model of case management entails the joint collaboration of the social worker, the nursing case manager, and the utilization review team.

The Professionally Advanced Care Team, referred to as the ProACT Model, which was developed at the Robert Wood Johnson University Hospital, entails registered nurses serving in the role of both the primary nurse the clinical case manager with no billing and coding responsibilities; these highly specialized and technical billing and coding responsibilities are done by the business office, medical billers and medical coders.

The Case Manager Model entails the registered nurses’ role in terms of case management for a particular nursing care unit for a group of clients with the same medical diagnosis or DRG. In contrast to this Case Manager Model of Beth Israel Hospital, the Collaborative Practice Model of case management entails the role of some registered nurses in a particular healthcare facility to manage, coordinate, guide and direct the complex care of a population of clients throughout the entire healthcare facility who share a particular diagnosis or Diagnostic Related Group.

• The Case Manager Model
• The ProACT Model
• The Collaborative Practice Model
• The Triad Model of Case Management

The Case Manager Model and the Collaborative Practice Model of case management are the only models of case management that employ the mandated and intrinsic use of critical pathways which are multidisciplinary plans of care that are based on the client’s current condition, and that reflect interventions and expected outcomes within a pre-established time line.

The ProACT Model, the Collaborative Practice Model and the Triad Model of Case Management do not necessarily employ critical pathways; these models can use any system of medical records and documentation.

• An opt out consent
• An implicit consent
• An explicit consent
• No consent at all is given

The type of legal consent that is indirectly given by the client by the very nature of their voluntary acute care hospitalization is an implicit consent indirectly given by the client by the very nature of their voluntary acute care hospitalization is an implicit consent.

An explicit consent, on the other hand, is the direct and formal consent of the client; and an opt out consent is given when a patient does NOT refuse a treatment; this lack of objections by the patient indicates that the person has consented to the treatment or procedure with an opt out consent.

• Take the photographs because these photographs are part of the holiday tradition at this facility
• Take the photographs because all of the residents are properly attired and in a dignified condition
• Refuse to take the photographs unless you have the consent of all to do so
• Refuse to take the photographs because this is not part of the nurse’s role

You should refuse to take the photographs unless you have the consent of all to do so because to do otherwise is a violation of the residents’ rights to privacy and confidentiality as provided in the Health Insurance Portability and Accountability Act (HIPAA). This, rather than the false belief that this is not part of the nurse’s role, is the reason that you would not automatically take these photographs.

Regardless of whether or not these photographs are part of the holiday tradition at this facility and whether or not the residents are properly attired and in a dignified condition, no photographs can be legally taken without the residents’ permission and consent.

• The Patient Self Determination Act: The client’s right to choose the level of care
• The Patient Self Determination Act: The clients’ right to healthcare insurance coverage for mental health disorders
• The Mental Health Parity Act: The privacy and security of technological psychiatric information
• The Health Insurance Portability and Accountability Act (HIPAA): The privacy and security of technological medical information

The Health Insurance Portability and Accountability Act (HIPAA) protects the client’s legal rights to the privacy, security and confidentiality of all medical information including data and information that is technologically stored and secured.

The Patient Self Determination Act uphold the client’s right to choose and reject care and not the level of care that is driven and decided upon as based on medical necessity and health insurance reimbursement; this Act also does not give client’s the right to any health insurance including healthcare insurance coverage for  mental health disorders.

Lastly, the Mental Health Parity and Addiction Equality Act, passed in 2008, mandates insurance coverage for mental health and psychiatric health services in a manner similar to medical and surgical insurance coverage; it does not protect the privacy and security of technological psychiatric information, HIPAA does.

• The physical therapist
• The occupational therapist
• The podiatrist
• The nurse practitioner

The member of the multidisciplinary team that you would most likely collaborate with when the client is at risk for falls due to an impaired gait is a physical therapist. Physical therapists are licensed healthcare professionals who assess, plan, implement and evaluate interventions including those related to the patient’s functional abilities in terms of their gait, strength, mobility, balance, coordination, and joint range of motion. They also provide patients with assistive aids like walkers and canes and exercise regimens.

Occupational therapists assess, plan, implement and evaluate interventions including those that facilitate the patient’s ability to achieve their highest possible level of independence in terms of their activities of daily living such as bathing, grooming, eating and dressing.

Podiatrists care for disorders and diseases of the foot; and nurse practitioners, depending on their area of specialty, may also collaborate with nurses when a client is affected with a disorder in terms of gait, strength, mobility, balance, coordination, and joint range of motion, however the member of the multidisciplinary team that you would most likely collaborate with when the client is at risk for falls due to an impaired gait is a physical therapist.

• The dietician

The member of the multidisciplinary team that you would most likely collaborate with when the client can benefit from the use of adaptive devices for eating is the occupational therapist. Occupational therapists assess, plan, implement and evaluate interventions including those that facilitate the patient’s ability to achieve their highest possible level of independence in terms of their activities of daily living such as bathing, grooming, eating and dressing. Many of these interventions include adaptive devices such as special eating utensils and grooming aids.

Physical therapists are licensed healthcare professionals who assess, plan, implement and evaluate interventions including those related to the patient’s functional abilities in terms of their gait, strength, mobility, balance, coordination, and joint range of motion. They also provide patients with assistive aids like walkers and canes and exercise regimens.

Dieticians assess, plan, implement and evaluate interventions including those relating to dietary needs of those patients who need regular or therapeutic diets. They also provide dietary education and work with other members of the healthcare need when a client has dietary needs secondary to physical disorders such as dysphagia; and podiatrists care for disorders and diseases of the foot.

• To fulfill the nurse’s role in terms of collaboration
• To plan and provide for optimal client outcomes
• To solve complex multidisciplinary patient care problems
• To provide educational experiences for experienced nurses

The primary goal of multidisciplinary case conferences is to plan care that facilitates optimal client outcomes. Other benefits of multidisciplinary case conferences include the fulfillment of the nurse’s role in terms of collaboration and collegiality, to solve complex multidisciplinary patient care problems so that optimal client outcomes can be achieved and also to provide educational experiences for nurses; these things are secondary rather than primary goals.

• A Pedorthist
• A pediatric nurse practitioner
• A trauma certified clinical nurse specialist
• A prosthetist

The member of the multidisciplinary team would you most likely collaborate with when your pediatric client has had a traumatic amputation secondary to a terrorism blast explosion a month ago or more ago is a prosthetist. Prosthetists, in collaboration with other members of the healthcare team, assess patients and then design, fit and supply the patient with an artificial body part such as a leg or arm prosthesis. They also follow-up with patients who have gotten a prosthesis to check and adjust it in terms of proper fit, patient comfort and functioning.

Pedorthists modify and provide corrective footwear and employ supportive devices to address conditions which affect the feet and lower limbs. Lastly, you may collaborate with a trauma certified clinical nurse specialist and a pediatric nurse practitioner but this consultation and collaboration should begin immediately upon arrival to the emergency department, and not a month after the injury.

• Conceptualization conflicts
• Avoidance - Avoidance conflicts
• Approach - Approach conflicts
• Resolvable conflicts
• Unresolvable conflicts
• Double Approach - Avoidance conflicts
• Approach-Avoidance conflicts

Correct Response: B, C, F, G

According to Lewin, the types of conflict are Avoidance-Avoidance conflicts, Approach- Approach conflicts, Double Approach - Avoidance conflicts and Approach-Avoidance conflicts.

• Frustration: The phase of conflict that is characterized with personal agendas and obstruction
• Conceptualization: The phase of conflict that occurs when contending parties have developed a clear and objective understanding of the nature of the conflict and factors that have led to it
• Taking action: The phase of conflict that is characterized with individual responses to and feelings about the conflict
• Resolution: The type of conflict that can be resolved
• Avoidance-Avoidance: A stage of conflict that occurs when there are NO alternatives that are acceptable to the contending parties
• Approach- Approach Conflicts: The type of conflict that occurs when the people involved in the conflict want more than one alternatives or actions that could resolve the conflict.
• Approach-Avoidance Conflicts: The type of conflict that occurs when the people involved in the conflict believe that all of the alternatives are NEITHER completely satisfactory nor completely dissatisfactory.

Correct Response: C, F, G

Taking action is the phase of conflict that is characterized with individual responses to and feelings about the conflict; Approach- Approach conflicts are a type of conflict that occurs when the people involved in the conflict want more than one alternatives or actions that could resolve the conflict; and Approach-Avoidance conflicts are a type of conflict that occurs when the people involved in the conflict believe that all of the alternatives are NEITHER completely satisfactory or completely dissatisfactory.

Frustration is the phase of conflict that occurs when those involved in the conflict believe that their goals and needs are being blocked and not met, and not necessarily characterized with personal agendas and obstruction; conceptualization is the phase of conflict that occurs when those involved in the conflict begin to understand what the conflict is all about and why it has occurred. This understanding often varies from person to person and this personal understanding may or may not be accurate, clear or objective, and not a clear and objective understanding of the nature of the conflict and factors that have led to it; resolution is a phase of conflict resolution, not a type of conflict, that is characterized when the contending parties are able to come to some agreement using mediation, negotiation or another method; an Avoidance-Avoidance conflict is a type of conflict and not a phase of conflict, that occurs when there are NO alternatives that are acceptable to any the contending parties; Approach- Approach conflicts occur when the people involved in the conflict want more than one alternative or action that could resolve the conflict; and lastly, Double Approach - Avoidance is a type of conflict and not a stage of conflict that occurs when the people involved in the conflict are forced to choose among alternatives and actions, all of which have BOTH  positive and negative aspects to them.

• Competition
• Accommodating Others

Conflicts can be effectively resolved using a number of different strategies and techniques such as compromise, negotiation, and mediation.

Avoidance of the conflict, withdrawing in addition to other passivity, competition, and accommodating others are not effective and healthy conflict resolution techniques.

• Conceptualization
• Frustration
• Taking action

Correct Response: B, A, D, C

The stages of conflict and conflict resolution in the correct sequential order are frustration, conceptualization, and taking action.

• The Patient Self Determination Act
• The Mental Health Parity Act
• The Health Insurance Portability and Accountability Act
• The Americans with Disabilities Act of 1990

The federal law is most closely associated with the highly restrictive “need to know” is the Health Insurance Portability and Accountability Act. This law restricts access to medical information to only those persons who have the need to know this information in order to provide direct and/or indirect care to the client.

The Mental Health Parity Act passed in 2008, mandates insurance coverage for mental health and psychiatric health services in a manner similar to medical and surgical insurance coverage.

And, lastly the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 forbid and prohibit any discrimination against people with disabilities.

• The facility’s Performance Improvement Director who is not a healthcare person and who has no direct contact with clients
• A nursing student who is caring for a client under the supervision of the nursing instructor
• The facility’s Safety Officer who is not a healthcare person and who has no direct contact with clients
• A department supervisor with no direct or indirect care duties

A department supervisor with no direct or indirect care duties does not have the “right to know” medical information; all of the others have the “right to know” medical information because they provide direct or indirect care to clients.

For example, both the facility’s Performance Improvement Director who is not a healthcare person and who has no direct contact with clients and the facility’s Safety Officer who is not a healthcare person and who has no direct contact with clients provide indirect care to clients. For example, they collect and analyze client data in order to fulfill their role and responsibilities in terms of process improvements and the prevention of incidents and accidents, respectively.

Nursing and other healthcare students also have the “need to know” medical information so that they can provide direct client care to their assigned client(s).

• “A computer in the hallway was left unattended and a client’s medical record was visible to me.”
• “I just saw a nursing student looking at the medical record for a client that they are NOT caring for during this clinical experience.”
• “As I was walking past the nursing station, I saw a dietician reading the progress notes written by members of the laboratory department in addition to other dieticians’ progress notes.”
• “I refused the nursing supervisor’s request to share my electronic password for the new nurse on the unit.”

A staff members comment, “As I was walking past the nursing station, I saw a dietician reading the progress notes written by members of the laboratory department in addition to other dieticians’ progress notes” “indicates the need for the Nurse Manager to provide an educational activity relating to confidentiality and information security because dieticians often have the “need to know” about laboratory data so that they can, for example, assess the client’s nutritional status in terms of their creatinine levels.

The report that the nursing student was “looking at the medical record for a client that they are NOT caring for during this clinical experience” indicates that the  reporting staff member is correctly applying the principles for maintaining confidentiality and privacy of information; the report that a “computer in the hallway was left unattended and a client’s medical record was visible to me” indicates that the  reporting staff member is correctly applying the principles for maintaining confidentiality and privacy of information; and lastly, “I refused the nursing supervisor’s request to share my electronic password for the new nurse on the unit” also indicates that the staff member is knowledgeable about privacy and confidentiality.

• Case management
• Continuity of care
• Medical necessity
• Critical pathway

The continuity of care is defined as the sound, timely, smooth, unfragmented and seamless transition of a client from one area within the same healthcare facility, from one level of care to a higher and more intense level of care or to a less intense level of care based on the client’s status and level of acuity, from one healthcare facility to another healthcare facility and also any discharges to the home in the client’s community.

Case management and critical pathways may be used to facilitate the continuity of care, but they are not the sound, timely, smooth, unfragmented and seamless transition of the client from one level of acuity to another. Lastly, medical necessity is necessary for reimbursement and it is one of the considerations for moving the client from one level of acuity to another but medical necessity is not the continuity of care.

• The Four P's

The standardized “hand off” change of shift reporting system that you may want to consider for implementation on your nursing care unit is ISBAR. Other standardized change of shift “hand off” reports, as recommended by the Joint Commission on the Accreditation of Healthcare Organization, include:

• SBAR, not IBAR
• The Five Ps not the Four Ps and

Lastly, MAUUAR is a method of priority setting and not a standardized “hand off” change of shift reporting system.

• SBAR: Symptoms, background, assessment and recommendations
• ISBAR: Interventions, symptoms, background, assessment and recommendations
• The Five Ps: The patient, plan, purpose, problems and precautions
• BATON: Background, assessment, timing, ownership and next plans

The Five Ps are the patient, plan, purpose, problems and precautions.

The elements of the other standardized reporting systems are listed below:

SBAR stands for:

• S: Situation: The patient’s diagnosis, complaint, plan of care and the patient's prioritized needs
• B: Background: The patient’s code or DNR status,  vital Signs, medications and lab results
• A: Assessment: The current assessment of the situation and the patient’s status and
• R: Recommendations:  All unresolved issues including things like pending diagnostic testing results and what has to be done over the next few hours

ISBAR stands for:

• I: Introduction: The introduction of the nurse, the nurse’s role in care and the area or department that you are from
• R: Recommendations: All unresolved issues including things like pending diagnostic testing results and what has to be done over the next few hours

BATON stands for:

• B: Background: Past and current medical history, including medications
• A: Actions: What actions were taken and/or those actions that are currently required
• T: Timing: Priorities and level of urgency
• O: Ownership: Who is responsible for what? and
• N: Next: The future plan of care

IPASS stands for:

• I ntroduction: The introduction of the nurse, the nurse’s role in care and the area or department that you are from
• P: Patient: The patient’s name, age, gender, location and other demographic data
• A: Assessment: The current assessment of the situation and the patient’s status
• S: Situation: The patient’s diagnosis, complaint, plan of care and the patient's prioritized needs and
• S: Safety concerns: Physical, mental and social risks and concerns
• Atrial fibrillation
• First degree heart block
• Shortness of breath upon exertion
• An obstructed airway
• Fluid needs
• Respect and esteem by others
• 3,4,2,1,5,6
• 3,4,5,1,2,6
• 2,3,5,1,4,6
• 3,2,4,1,5,6

Correct Response:

Client needs are prioritized in a number of different ways including Maslow’s Hierarchy of Human Needs and the ABCs. In terms of priorities from # 1 to # 6 the conditions above are prioritized as follows:

The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order; and Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.

• Understanding level

One of the 2 nd priority needs according to the MAAUAR method of priority setting is risks.

The ABCs / MAAUAR method of priority setting places the ABCs, again, as the highest and greatest priorities which are then followed with the 2 nd and 3 rd priority level needs of the MAAUAR method of priority setting.

The 2 nd priority needs according to the MAAUAR method of priority setting after the ABCs include M-A-A-U-A-R which stands for:

• M ental status changes and alterations
• A cute pain
• A cute urinary elimination concerns
• U naddressed and untreated problems that require immediate priority attention
• A bnormal laboratory and other diagnostic data that are outside of normal limits and
• R isks including those relating to a healthcare problem like safety, skin breakdown, infection and other medical conditions

The 3 rd level priorities include all concerns and problems that are NOT covered under the 2 nd level priority needs and the ABCs. For example, increased levels of self care abilities and skills and enhanced knowledge of a medical condition are considered 2 nd level priority needs.

• Time management skills
• Communication skills
• Collaboration skills
• Supervision skills

Time management skills are most closely related to successfully meeting the established priority needs of a group of clients.

In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to effectively manage their time; they should avoid unnecessary interruptions, time wasters and helping others when this helping others could potentially jeopardize their own priorities of care.

Although good communication skills, collaboration skills and supervision are necessary for the delivery of nursing care, it is time management skills that are most closely related to successfully meeting the established priority needs of a group of clients.

• Client rights

Morals are most closely aligned with ethics. Ethics is a set of beliefs and principles that guide us in terms of the right and wrong thing to do which is the most similar to ethics.

Laws and statutes defined what things are legal and what things are illegal. Lastly, client rights can serve as a factor to consider when ethical decisions are made; but they are not most closely aligned with ethics, but only, one consideration of many that can be used in ethical decision making.

• Deontology: The school of ethical of thought that requires that only the means to the goal must be ethical.
• Utilitarianism: The school of ethical of thought that requires that only the end goal must be ethical.
• Deontology: The school of ethical of thought that requires that only the end goal must be ethical.
• Utilitarianism: The school of ethical of thought that requires that only the means to the goal must be ethical.

The two major classifications of ethical principles and ethical thought are utilitarianism and deontology. Deontology is the ethical school of thought that requires that both the means and the end goal must be moral and ethical; and the utilitarian school of ethical thought states that the end goal justifies the means even when the means are not moral.

• Justice: Equally dividing time and other resources among a group of clients
• Beneficence: Doing no harm during the course of nursing care
• Veracity: Fully answering the client’s questions without any withholding of information
• Fidelity: Upholding the American Nurses Association’s Code of Ethics

Fully answering the client’s questions without any withholding of information is an example of the application of veracity into nursing practice. Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress.

Justice is fairness. Nurses must be fair when they distribute care and resources equitably, which is not always equally among a group of patients. Beneficence is doing good and the right thing for the patient; it is nonmaleficence that is doing no harm.

• Planning a way to evaluate the effectiveness of the class by seeing a decrease in the amount of referrals to the facility’s Ethics Committee
• Establishing educational objectives for the class that reflect the methods and methodology that you will use to present the class content
• The need to exclude case studies from the class because this would violate client privacy and confidentiality
• Some of the most commonly occurring bioethical concerns including genetic engineering into the course content

You would consider including some of the most commonly occurring bioethical concerns including genetic engineering into the course content.

You would also plan how you could evaluate the effectiveness of the class by seeing an increase, not a decrease in the amount of referrals to the facility’s Ethics Committee, because one of the elements of this class should address ethical dilemmas and the role of the Ethics Committee in terms of resolving these.

You would additionally establish educational objectives for the class that reflect specific, measurable learner outcomes and not the methods and methodology that you will use to present the class content; and lastly, there is no need to exclude case studies from the class because “sanitized” medical records can, and should be, used to avoid any violations of client privacy and confidentiality.

• Serve as the witness to the client’s signature on an informed consent.
• Get and witness the client’s signature on an informed consent.
• Get and witness the durable power of attorney for health care decisions’ signature on an informed consent.
• None of the above

One of the roles of the registered nurse in terms of informed consent is to serve as the witness to the client’s signature on an informed consent.

Other roles and responsibilities of the registered nurse in terms of informed consent include identifying the appropriate person to provide informed consent for client, such as the client, parent or legal guardian, to provide written materials in client’s spoken language, when possible, to know and apply the components of informed consent, and to also verify that the client comprehends and consents to care and procedures.

The registered nurse does not get the client’s or durable power of attorney for health care decisions’ signature on an informed consent, this is the role and responsibility of the physician or another licensed independent practitioner.

• Self determination
• Nonmalficence

Self-determination is most closely aligned with the principles and concepts of informed consent. Self-determination supports the client’s right to choose and reject treatments and procedures after they have been informed and fully knowledgeable about the treatment or procedure.

Justice is fairness. Nurses must be fair when they distribute care and resources equitably, which is not always equally among a group of patients; fidelity is the ethical principle that requires nurses to be honest, faithful and true to their professional promises and responsibilities by providing high quality, safe care in a competent manner; and, lastly, nonmaleficence is doing no harm, as stated in the historical Hippocratic Oath.

• The purpose of the proposed treatment or procedure
• The expected outcomes of the proposed treatment or procedure
• Who will perform the treatment or procedure
• When the procedure or treatment will be done

The minimal essential components of the education that occurs prior to getting an informed consent include the purpose of the proposed treatment or procedure, the expected outcomes of the proposed treatment or procedure, and who will perform the treatment or procedure. It is not necessary to include when the treatment or procedure will be done at this time.

Other essential elements include:

• The benefits of the proposed treatment or procedure
• The possible risks associated with the proposed treatment or procedure
• The alternatives to the particular treatment or procedure
• The benefits and risks associated with alternatives to the proposed treatment or procedure
• The client’s right to refuse a proposed treatment or procedure
• The Security Rule
• The American Nurses Association’s Code of Ethics
• The American Hospital’s Patients’ Bill of Rights
• The Autonomy Rule

Prohibitions against sharing passwords are legally based on the Security Rule of HIPAA mandates administrative, physical, and technical safeguards to insure the confidentiality, integrity, and availability of electronic protected health information.  This rule relates to electronic information security as well as other forms of information.

The American Nurses Association’s Code of Ethics and the American Hospital’s Patients’ Bill of Rights both address client confidentiality and their rights to privacy, however, these statements are not legal, but instead ethical and regulatory statements; and lastly, there is no autonomy law or rule.

• Social networks and cell phone cameras pose low risk in terms of information technology security and confidentiality.
• The security of technological data and information in healthcare environments is most often violated by those who work there.
• The security of technological data and information in healthcare environments is most often violated by computer hackers.
• Computer data deletion destroys all evidence of the data.

The security of technological data and information in healthcare environments is most often violated by those who work there. The vast majority of these violations occur as the result of inadvertent breaches with carelessness and the lack of thought on the part of employees. Technology is a double edged sword.

Technological advances such as cell phone cameras, social networks like Facebook, telephone answering machines and fax machines pose great risk in terms of the confidentiality and the security of medical information. Computer data deletion does not always destroy all evidence of the data; data remains.

• Assault: Touching a person without their consent
• Battery: Threatening to touch a person without their consent
• Slander: False oral defamatory statements.
• Slander: False written defamatory statements.

Slander is false oral defamatory statements; and libel is written defamation of character using false statements.

Assault, an intentional tort, is threatening to touch a person without their consent; and battery, another intentional tort, is touching a person without their consent.

• Ensured the client’s safety which is a high patient care priority
• Violated Respondeat Superior
• Violated the client’s right to dignity
• Committed a crime

When you loosely apply a bed sheet around your client’s waist to prevent a fall from the chair, you have falsely imprisoned the client with this make shift restraint. False imprisonment is restraining, detaining and/or restricting a person’s freedom of movement. Using a restraint without an order is considered false imprisonment even when it is done to protect the client’s safety.

Respondeat Superior is the legal doctrine or principle that states that employers are legally responsible for the acts and behaviors of its employees. Respondeat Superior does not, however, relieve the nurse of legal responsibility and accountability for their actions. They remain liable.

There is no evidence in this question that you have violated the client’s right to dignity.

• Respondeat Superior does not mean that a nurse cannot be held liable.
• Respondeat Superior does not mean that a nurse cannot be held libel.
• Respondeat Superior is an ethical principle.
• Respondeat Superior is a law.

Respondeat Superior does not mean that a nurse cannot be held liable and not libel which is a written defamation of character using false statements. Liability is legal vulnerability.

Respondeat Superior is the legal doctrine or principle and not a law or ethical principle.

• Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and direct rather than indirect harm to the client.
• Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and direct and/or indirect harm to the client.
• Causation, correlation, damages to the patient, a duty that was owed to the client and this duty was breached, and direct and/or indirect harm to the client.
• Causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and a medical license.

The six essential components of malpractice include causation, foreseeability, damages to the patient, a duty that was owed to the client and this duty was breached, and, lastly, this breach of duty led to direct and/or indirect harm to the client.

A medical license is not necessary; nurses and other healthcare professionals can be found guilty of malpractice. Lastly, correlation is the relationship of simultaneously changing variables. For example, a ppositive correlation exists when the two variables both increase or decrease; and a negative occurs when one variable increases and the other decreases.

• Sound structures like policies and procedures
• Processes and how they are being done
• Optimal client outcomes
• Optimal staff performance

The current focus of performance improvement activities is to facilitate and address optimal client outcomes. Throughout the last several decades performance improvement activities have evolved from a focus on structures to a focus on process and now, to a focus on outcomes.

Staff performance is not the focus of performance improvement activities but instead the focus of competency assessment and validation.

• An adverse event
• A root cause
• A healthcare acquired event
• A sentinel event

A sentinel event is an event or occurrence, incident or accident that has led to or may have possibly led to client harm. Even near misses, that have the potential for harm, are considered sentinel events because they have the potential to cause harm in the future.

An adverse event, like an adverse effect of a medication, has actually led to an adverse response; it is not a near miss. A root cause is a factor that has led to a sentinel event; and there is no such thing as a healthcare acquired event.

• Discover a process flaw
• Determine who erred
• Discover environmental hazards
• Determine basic client needs

The primary purpose of root cause analysis is to discover process flaws. Root cause analysis and a blame free environment are essential to a successful performance improvement activity, therefore, root cause analysis does not aim to determine who erred and made a mistake. Root cause analysis explores and digs down to the roots of the problem, its root causes and the things, not people, which are the real reasons why medical errors and mistakes are made.

It is nursing assessment that determines the basic client needs and environmental surveillance that discovers environmental safety hazards, and not root cause analysis.

Root cause analysis activities ask “Why”, rather than “Who”, which would place blame on a person or group of people: and What? and When? Questions are rarely asked.

• Historical data and performance improvement activities focus on current data.
• Current data and performance improvement activities focus on historical data.
• Decreasing financial liability and performance improvement activities focus on process improvements.
• Decreasing falls and performance improvement activities focus on process improvements.

The primary distinguishing characteristic of risk management when compared and contrasted to performance improvement is that risk management activities focus on decreasing financial liability and performance improvement activities focus on process improvements.

Risk management focuses on decreasing and eliminating things that are risky and place the healthcare organization in a position of legal liability. Some examples of risk management activities include preventing hazards and adverse events such as patient falls and infant abduction and the legal liabilities associated with these events.

Referrals complement the healthcare teams’ abilities to provide optimal care to the client.

• Referrals simply allow the client to be discharged into the community with the additional care they need.
• Nurses facilitate referrals to only the resources within the facility.

When clients have assessed needs that cannot be fulfilled and met by the registered nurse in collaboration with other members of the nursing care team, the registered nurse should then seek out resources, as well as utilize and employ different internal or external resources such as a physical therapist, a clergy member or a home health care agency in the community and external to the nurse’s healthcare agency.

The Safe & Effective Care Environment: Safety & Infection Control Practice Questions

• The sensitizing dose of penicillin can lead to anaphylaxis.
• The second dose of penicillin can lead to distributive shock.
• You should be aware of the fact that about 10% of the population has an allergy to both penicillin and latex.
• You should be aware of the fact that about 20% of the population has an allergy to both penicillin and latex.

The second dose of penicillin can lead to anaphylactic shock which is a form of distributive shock.

The first exposure to penicillin, referred to as the “sensitizing dose”, sensitizes and prepares the body to respond to a second exposure or dose. It is then the second exposure or dose that leads to anaphylaxis, or anaphylactic shock.

It is estimated that approximately 10% of people have had a reaction to penicillin. Some of these reactions are an allergic response and others are simply a troublesome side effect. There is no scientific data that indicates that 10% or 20% of the population has an allergy to both penicillin and latex.

• A 77 year old female client in a client room that has low glare floors.
• An 87 year old female client in a client room that has low glare floors.
• A 27 year old sedated male client.
• A 37 year old male client with impaired renal perfusion.

The 27 year old sedated male client is at greatest risk for falls.

Some of the risk factors associated with falls are sedating medications, high glare, not low glare, floors and other environmental factors such as clutter and scatter rugs, not low glare floors, a history of prior falls, a fear of falling, incontinence, confusion, sensory deficits, a decreased level of consciousness, impaired reaction time, advancing age, poor muscular strength, balance, coordination, gait and range of motion and some physical disorders, particularly those that affect the musculoskeletal or neurological systems; falls are not associated with poor and impaired renal perfusion.

• The nurse should advise clients in a smoke filled room to open the windows.
• The first thing that the nurse should do when using a fire extinguisher to put out a small fire is to aim the fire extinguisher at the base of the fire.
• Rapidly lift and move a client away from the source of the fire when their slippers are on fire.
• The home health care nurse should advise the client that the best fire extinguisher to have in the home is an ABC fire extinguisher.

The home health care nurse should advise the client that the best fire extinguisher to have in the home is an ABC fire extinguisher because this one fire extinguisher is a combination of a type A fire extinguisher, a type B and a type C, which put out all types of fires including common household solids like wood, household oils like kitchen grease and electrical fires.

The nurse should advise the client GET LOW AND GO if a room fills with smoke. They should not take any time to open window.

The first thing to do when using a fire extinguisher is to pull the pin and then aim it at the base of the fire. Later, you would squeeze the trigger and sweep the spray over and over again over the base of the fire. The acronym PASS is used to remember these sequential steps.

When a person has clothing that has caught on fire, the person should STOP, DROP AND ROLL. Tell the person, to STOP, DROP, and to not run, and as you also cover the person with a blanket to smother the fire.

• A tornado that has touched down on the healthcare facility
• A severe cyclone that has destroyed nearby homes
• A massive train accident that brings victims to your facility
• An act of bioterrorism in a nearby factory

A tornado that has touched down on the healthcare facility is an example of an internal disaster because this tornado has directly affected the healthcare facility. Tornados, cyclones, hurricanes and other severe weather emergencies can be both an internal disaster when they affect the healthcare facility and also an external disaster when they impact on the lives of those living in the community. Hurricane Katrina is a good example of a weather emergency that affected not only healthcare facilities but also members of the community.

• Use a slide board.
• Use a mechanical lift.
• Use a gait belt.
• Notify the client's doctor that the client cannot be safely transferred by you.

The best and safest way to transfer this paralyzed client when you suspect that you will need the help of another for the client’s first transfer out of bed is to use a mechanical lift. It is not necessary or appropriate to notify the doctor.

Mechanical lifts are used mostly for patients who are obese and cannot be safely moved or transferred by two people, and also for patients who are, for one reason or another, not able to provide any help or assistance with their lifts and transfers, such as a person who is paralyzed.

A gait or transfer belt and slide boards are assistive devices that can be used to assist with transfers and lifting however, they are not appropriate for this client as based on your assessment.

• Advise the nurse that the legs must be close together for stability during lifting and transfers.
• Advise the nurse that the legs should be one in front of the other and not spread apart during a transfer.
• Validate the nurse’s competency in terms of the application of body mechanics principles during a transfer.
• Validate the nurse’s competency in terms of the application of ergonomics principles during a transfer.

You should validate the nurse’s competency in terms of the application of body mechanics principles during a transfer because the nurse had spread her legs apart during the transfer to provide a wide base of support, which is a basic principle of body mechanics and not ergonomics.

Simply defined ergonomics addresses correct bodily alignment such as the lumbar curve accommodation in an ergonomically designed chair; and body mechanics is the safe use of the body using the correct posture, bodily alignment, balance and bodily movements to safely bend, carry, lift and move objects and people.

• The client has refrigerated foods labelled with an expiration date.
• You assess that the home is free of scatter rugs that many use to protect the feet against hard floors.
• The client uses the FIFO method for insuring food safety.
• The client assures you that the smoke alarm batteries are replaced annually to insure that they work.

When the client assures the nurse that they replace their smoke alarm batteries annually to insure that they work, the assessing nurse should immediately know that the client is in need of education relating to the fact that smoke alarm batteries should be changed at least twice a year.

The client has demonstrated that they are knowledgeable about food safety and environmental safety because they have expiration dates on refrigerated foods, they use the FIFO method for food safety and they do not use scatter rugs which can lead to falls.

The FIFO rule is F irst I n is F irst O ut. In other words, the first foods in the pantry or refrigerator are the first foods that should be consumed or discarded.

• It is clear?
• It is damaging to the lungs.
• It is damaging to the spleen and the liver.
• It leads to the over production of hemoglobin.

Carbon monoxide is particularly dangerous because it is clear, invisible and odorless. Carbon monoxide poisoning can occur when a person is exposed to an excessive amount of this odorless and colorless gas; it  severely impairs the body to absorb life sustaining oxygen which is the result of this deadly gas and not damage to the lungs. This oxygen absorption deficit can lead to serious tissue damage and death. For these reasons, home carbon monoxide alarms are recommended.

These dangers are associated with deoxygenation and not splenic or hepatic damage or the over production of hemoglobin.

• Sentinel event.
• System variance.
• Adverse effect.
• Provider variance.

The lack of necessary supplies and equipment to adequately and safely care for patients is an example of a system variance.

A variance is defined as a deviation that leads to a quality defect or problem. Variances can be classified as a practitioner variance, a system/institutional variance, a patient variance, a random variance and a specific variance.

A sentinel event is defined as is an event or occurrence, incident or accident that has led to or may possibly lead to client harm. Adverse effects are serious and unanticipated responses to interventions and treatments, including things like medications.

• Notify the doctor.
• Render care.
• Assess the cleint.
• Notify the nurse manager.

The first thing that you should do immediately after a client accident is to assess the client and the second thing you should do is render care after this assessment and not before it.

Lastly, notifications to the doctor and the nurse manager are only done after the client is assessed and emergency care, if any, is rendered.

• Counsel the staff about their need to stop wasting the resources of this department.
• Check the equipment yourself to determine the accuracy of this equipment department.
• Ignore it because everyone can make an innocent mistake.
• Plan an educational activity about determining what equipment to send for repairs.

You should plan an educational activity about determining what equipment should and should not be sent for repairs. This data suggests that the staff members need education and training about the proper functioning of equipment used on the nursing care unit.

Counseling the staff about their need to stop wasting the resources of this department is placing blame and this blame may prevent future valid returns of equipment.

You should not check the equipment yourself to determine the accuracy of this equipment department because they are the experts, not you, with these matters.

You should also not ignore it because everyone can make an innocent mistake. The issue has to be addressed and corrected.

• Education and training on all pieces of equipment
• Pilot testing new equipment
• Reading all the manufacturer’s instructions
• Researching the equipment before recommending its purchase

Education and training on all pieces of equipment is an essential component for insuring that medical equipment is being used safely and properly by those who you supervise. Other essential components include validated and documented competency to use any and all pieces of equipment by a person qualified to do so, preventive maintenance and the prompt removal of all unsafe equipment from service.

Pilot testing new equipment, researching the equipment before recommending its purchase, and reading the entire manufacturer’s instructions are things done prior to the purchase of the equipment and these things do not impact on the safety of the piece of medical equipment.

• A possible vulnerability of the facility’s information technology to hacking
• The assisted suicide of a client in your facility by the spouse of the client
• Vulnerability to computer hacking
• Potential information theft

The assisted suicide of a client in your facility by the spouse of the client is a security concern that is also a sentinel event that must be reported.

A possible vulnerability of the facility’s information technology to hacking, vulnerability to computer hacking and potential information theft is security concerns but they are not sentinel events that must be reported.

• Training all nurses to serve as a part of a security response team
• Training all clerical staff to be a part of a security response team
• The restriction of visitors in a special care area
• Bar coded client identification bands to insure proper identification

The restriction of visitors in a special care area is an effective security plan that you may want to consider for implementation within your facility.

Some of the other security measures that you may want to consider include security alert systems to alert staff to a security breach such as security breach of the newborn nursery, the use of visitor identification badges or stickers that identify people who are authorized to be in a facility, closed circuit monitoring and alarm systems in high risk areas such as the emergency care area, automatically locking security doors, and electronic wristbands for the newborn and the mother to prevent infant abductions.

Special assignments and training for a group of people so that this specially trained group can act when a security breach occurs is also a good idea but it is not necessary to train all nurses or clerical staff; it is sufficient to train a limited group of people, provided an ample number of these team members are assigned and available on all tours of duty around the clock, including on holidays.

• Sterile items ONLY are placed on the sterile field.
• The nurse must keep the sterile field below waist level.
• Coughing or sneezing over the sterile field contaminates the sterile field.
• The nurse must maintain a 1/2 inch border around the sterile field that is not sterile.
• Moisture and wetness contaminate the sterile field.
• Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained

Correct Response: A, C, E

Sterile items ONLY are placed on the sterile field; coughing or sneezing over the sterile field contaminates the sterile field; and all moisture and wetness contaminate the sterile field.

Some of the other principles that are applied to setting up and maintaining a sterile field include keeping the sterile field above the waist level and preventing coughing or sneezing by professional staff and the client during the set up and during the maintenance of the sterile field. If there is a danger that anyone may cough or sneeze over the field, the professional staff and/or the client should don a mask to prevent contamination. Lastly, a one inch border, not a ½ border that is not sterile is maintained around the perimeter of the sterile field.

• A physical restraint: A physical restraint is a manufactured device that is used, when necessary, to prevent falls.
• A physical restraint: A physical restraint is any mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.
• A chemical restraint: A chemical restraint is a drug used for sedation to prevent falls.
• A chemical restraint: A chemical restraint is a drug used for discipline or convenience and not required to treat medical symptoms.

A chemical restraint: A chemical restraint is a drug used for discipline or convenience and not required to treat medical symptoms, according to the Centers for Medicare and Medicaid Services.

The most complete and accurate definition of a physical restraint is any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body and is NOT a safety devices that is routinely used for certain procedures, according to the Centers for Medicare and Medicaid Services.

• Informed consent for the restraint
• The reason for the restraint
• The type of restraint to be used
• Client behaviors that necessitated the restraints

The minimal components of orders for restraint include the reason for and rationale for the use of the restraint, the type of restraint to be used, how long the restraint can be used, the client behaviors that necessitated the use of the restraints, and any special instructions beyond and above those required by the facility’s policies and procedures.

Informed consent is not necessary for the initiation or the use of restraints

• The vascular phase
• The prodromal phase
• The incubation phase
• The initial injury
• The exudate phase
• The convalescence phase

The stages of the inflammatory process in correct sequential order are:

• The initial tissue injury which can result from an infection or a traumatic cause
• The vascular response. The release of histamine, prostaglandins and kinins. These substances lead to vasodilation which increases the necessary blood supply to the injured tissue and the area surrounding
• The exudate response. The release of leukocytes, including macrophages and neutrophils, to the injured area to combat the infection.

The signs of infection such as the incubation, prodromal and convalescence stages, in the correct sequential order are:

• The incubation period
• The illness stage
• The convalescence stage

Health Promotion & Maintenance Practice Questions

• The infant had doubled their birth weight at twelve months.
• The infant had tripled their birth weight at twelve months.
• The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
• The infant had grown ¼ inch since last month.

The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age.

The mother’s reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight.

As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.

• The Programmed Longevity Theory
• The Immunological Theory of Aging
• The Endocrine Theory
• The Rate of Living Theory

The theory of aging that supports your belief that strict infection control prevention measures are necessary is the Immunological Theory of Aging. The Immunological Theory of Aging states that aging leads to the decline of the person’s defensive immune system and the decreased ability of the antibodies to protect us against infection.

The Programmed Longevity Theory of aging states that genetic instability and changes occur such as some genes turning on and off lead to the aging process; the Endocrine Theory of aging states that aging results from hormonal changes and the biological clock’s ticking; and Rate of Living Theory states that one’s longevity is the result of one’s rate of oxygen basal metabolism.

Other theories of aging are:

• Wear and Tear Theory: This theory describes aging as a function of the simple wearing out of the tissues and cells as one ages.
• Cross Linking Theory: This theory of aging explains that aging results for cell damage and disease from cross linked proteins in the body.
• Free Radicals Theory: This theory is based on the belief that free radicals in the body lead to cellular damage and the eventual cessation of organ functioning.
• Somatic DNA Damage Theory: Somatic DNA Damage theory is based on the belief that aging and death eventually occur because DNA damage, as continuously occurs in the human cells, continues to the point where they can no longer be repaired and replaced and, as a result, they accumulate in the body.
• Increased creatinine clearance.
• Impaired immune system.
• Decreased hepatic metabolism.
• Increased bodily fat.

The elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a decrease in terms of their hepatic metabolism secondary to the hepatic functioning changes of the elderly secondary to a decreased hepatic blood flow and functioning.

The elderly have decreased rather than increased creatinine clearance; the immune system is also decreased in terms of its functioning, however, this change impacts on the elderly’s ability to resist infection rather than impacting a medication’s side effects, adverse drug reactions, toxicity and over dosages; and, lastly, a decrease in terms of bodily fat, rather than an increase in terms of bodily fat impacts on medications. The distribution of drugs is impaired by decreases in the amount of body water, body fat and serum albumin; drug absorption is decreased with the aged patient’s increases in gastric acid pH and decreases in the surface area of the small intestine which absorbs medications and food nutrients.

The expected date of delivery is calculated using Nagle’s rule which is:

The first day of last menstrual period – 3 months + 7 days = the estimated date of delivery

For example, when the first day of the last menstrual period is 10/20/2016 you would:

• Subtract three months from 10/20/2016 and then you get 7/20/2016 and then
• Add seven days to 7/20/2016 and then get 7/27/2016, after which you would
• Add one year to 7/27/2016 to get the estimated date of delivery for7/27 of the following year which is 7/27/2017.
• You should explain that fetal lie is where the fetus’ presenting part is within the birth canal during labor, among other information about the other assessments.
• You should explain that fetal presentation is the relationship of the fetus’s spine to the mother’s spine, among other information about the other assessments.
• You should explain that fetal attitude is the relationship of the fetus’ presenting part to the anterior, posterior, right or left side of the mother’s pelvis, among other information about the other assessments.
• You should explain that fetal station is the level of the fetus’ presenting part in relationship to the mother’s ischial spines, among other information about the other assessments.

You should explain that fetal station is the level of the fetus’ presenting part in relationship to the mother’s ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother’s ischial spines.  Fetal station is -1 to -5 when the fetus is from 1 to 5 centimeters above the ischial spines and it is from +1 to +5 when the fetus is from 1 to 5 centimeters below the level of the maternal ischial spines.

Fetal lie is defined as the relationship of the fetus’s spine to the mother’s spine. Fetal lie can a longitudinal, transverse or oblique life. Longitudinal lie, the most common and normal lie, occurs when the fetus’ spine is aligned with the mother’s spine in an up and down manner; a transverse lie occurs when the fetus’ spine is at a right ninety degree angle with the maternal spine; and, lastly, an oblique lie occurs when the fetus’ spine is  diagonal to the mother’s spine.

Fetal presentation is defined by where the fetus’ presenting part is within the birth canal during labor. The possible fetal presentations are the cephalic presentation, the cephalic vertex presentation, the cephalic sinciput presentation, the cephalic face presentation, the cephalic brow presentation, the breech presentation, the complete breech presentation, the frank breech presentation, the shoulder breech presentation, and the footling presentation.

Fetal attitude is the positioning of the fetus’s body parts in relationship to each other. The normal attitude is general flexion in the “fetal position”. All attitudes, other than the normal attitude, can lead to a more intense and prolonged labor.

Fetal position is the relationship of the fetus’ presenting part to the anterior, posterior, right or left side of the mother’s pelvis.

• You should apply the principles of initiative when caring for preschool children.
• You should apply the principles of sensorimotor thought when caring for preschool children.
• You should apply the principles of intimacy when caring for the adolescent.
• You should apply the principles of concrete operations when caring for the adolescent.

You should apply the principles of initiative when caring for preschool children. The developmental task for preschool children is initiative, according to Eric Erickson.

The other developmental tasks, according to Eric Erickson are:

• Infant: Trust
• Toddler: Autonomy
• School Age Child: Industry
• Adolescent: Identity formation
• Young Adult: Intimacy
• Middle Aged Adult: Generativity
• Older Adults: Ego integrity

In the correct sequential order, Jean Piaget’s levels of cognitive development include:

• Sensorimotor thought: Infancy to About 2 Years of Age
• Preoperational and symbolic functioning: From 2 to 7 Years of Age
• Concrete operations: 7 to 11 Years of Age
• Formal operations: 12 Years of Age
• Childhood immunizations
• Separation anxiety

The expected life transition should you apply into your practice for these pediatric clients as you are caring for pediatric clients of all ages is puberty.

Throughout the life span, there are several significant expected life transitions that require the person to cope and adjust. Some of these expected life transitions include puberty, maternal and paternal attachments and bonding to the neonate, pregnancy, care of the newborn, parenting, and retirement.

Although young children will experience separation anxiety and they will also be maintained on an immunization schedule, these are not expected life changes.

• The Biophysical Dimension
• The Psychological and Emotional Dimension
• The Spiritual Dimension
• The Health Systems Dimension

The Dimensions Model of Health includes six dimensions that impact on the client, including the community. The Spiritual Dimension is not one of these six dimensions.

These dimensions are the:

• Biophysical Dimension
• Psychological and Emotional Dimension
• Health Systems Dimension
• Behavioral Dimension
• Socio-Cultural Dimension
• Physical Environment Dimension
• Mediterranean ethnicity for cystic fibrosis.
• African American ethnicity for Tay Sachs disease.
• British Isles ethnicity for psychiatric mental health disorders.
• Saudi Arabian ethnicity for sickle cell anemia.

You would identify a client who is of Saudi Arabian ethnicity for sickle cell anemia. Other ethnicities at greatest risk for sickle cell anemia include those who are African, Latin Americans, Southern Europeans and some clients from some Mediterranean nations.

Other disorders and diseases and the ethnicities associated with them are listed below

• Thalassemia: Clients with a Mediterranean ethnicity
• Tay Sachs Disease: Ashkenazi Jewish people
• Cystic Fibrosis: Clients with a European ethnicity
• Psychiatric Mental Health Disorders: African Americans and Native Americans
• Hypertension: African Americans, Pacific  Islanders , Native  Americans, Alaskan natives, Hispanic and Caribbean clients
• Diabetes: African Americans, Caribbeans, Native Americans and clients from India, Pakistan and Bangladesh
• Cancer: Caucasians and clients from Scotland and Ireland
• The need for a targeted assessment is based on the application of the nurse’s knowledge of pathophysiology and the presenting symptoms.
• The need for a targeted assessment is based on the application of the nurse’s knowledge of developmental needs and developmental delays.
• Targeted assessment is done on an annual basis for existing clients rather than a complete assessment that is done for new clients.
• Targeted assessments consist of a brief medical history and a complete assessment consists of a complete health history and a complete physical assessment.

The need for a targeted assessment is based on the application of the nurse’s knowledge of pathophysiology and the presenting symptoms. Targeted assessments and screenings are done in addition to routine and recommended screenings when a particular disorder has a genetic pathophysiological component for risk and when a client is presenting with a particular sign or symptom.

For example, a targeted assessments relating to nutritional status may be indicated when an infant or young child is listless and not gaining weight according the established criteria; an adolescent may be target screened for visual acuity when a high school teacher reports that the teen does not seem to be able to read things on the blackboard; and a toddler may be target screened when the parent reports that the child is not responding to their name.

• Genetic predisposition
• Lifestyle choices
• High risk behaviors
• An external locus of control

Life style choices are the risk factors that are most likely able to be corrected. Poor life style choices place a person at risk and they are often considered also risky behaviors.

As discussed before, some risks are preventable and correctable and others are not. For example, genetics, age and gender are NOT modifiable risks, but the risks associated with life style choices are modifiable, correctable and able to be eliminated when the person changes their behavior in reference to these risky behaviors.

Some risky life style choices include:

• Excessive sun exposure
• The lack of regular exercise
• A poor diet
• Cigarette smoking and the use of other tobacco products
• Alcohol use
• Illicit drug use
• Unprotected sex
• Avocational and hobby choices such as rock climbing
• Inadequate sleep and rest

Genetic predisposition is an innate and not correctable risk factor and an external locus of control can lead to poor life style choices, however, this is not the most likely correctable risk factor.

• A transdermal contraceptive patch
• A diaphragm
• A vaginal contraceptive ring

You would not recommend any of the above methods of contraception for this family.

You would not recommend the use of a transdermal contraceptive patch or a vaginal contraceptive ring for the couple because both of these contraceptive methods are contraindicated when the woman has a history of deep vein thrombosis and cigarette smoking; and you would also not recommend a diaphragm because the compliance of this couple cannot trusted because the couple has a history of the lack of adherence to medical regimens.

• Information about the lack of scientific evidence regarding the effectiveness of all herbs.
• Data to support the fact that magnets can be effective in terms of fibromyalgia pain, and as such, may be a good choice for this client.
• Research that suggests that prayer is an effective alternative method to relieve pain and stress that can be helpful to this client.
• Information that contraindicates the use of biofeedback because this alternative, complementary health practice can interfere with the client’s pacemaker functioning.

Scientific data now indicates that prayer is effective for the relief of stress, anxiety and pain, and as such, may be helpful to this client.

Some herbs, minerals and supplements are scientifically deemed as safe and effective and others are not scientifically effective and they can also lead to harm; at the current time, the National Institutes of Health (NIH) states that magnets are not scientifically effective and they are also not considered safe for clients with a pacemaker or insulin pump because these internally implanted devices can be adversely affected by the magnetic force of the magnet; and, lastly, biofeedback does not interfere with the client’s pacemaker functioning.

• A social worker
• A physical therapist
• An occupational therapist
• A speech therapist

The healthcare professional would you most likely refer this family to in order to address this deficit in terms of their instrumental activities of daily living (ADLs) is a social worker.

The activities of daily living are differentiated in terms of the basic activities of daily living and the instrumental activities of daily living. Examples of basic activities of daily living include things like bathing, mobility, ambulation, toileting, personal care and hygiene, grooming, dressing, and eating. Deficits in terms of the basic activities of daily living are best addressed by a physical and/or occupational therapist.

The instrumental activities of daily living are more advanced than the basic activities of daily living. The instrumental activities of daily living include things like grocery shopping, housework, meal preparation, the communication with others using something like a telephone, and having transportation. Deficits in terms of the instrumental activities of daily living are best addressed by a social worker. For example, the social worker may assist the client in terms of their transportation and they can also teach the client about how to grocery shop, for example.

• Olfactory Cranial Nerve: The sensory nerve that transmits the sense of smell to the olfactory foramina of the nose
• Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain.
• Oculomotor Cranial Nerve: This motor and sensory nerve controls eye movements and visual acuity.
• Trochlear Cranial Nerve: This motor nerve innervates eye ball movement and the superior oblique muscle of the eyes.
• Abducens Cranial Nerve: This motor nerve innervates and controls the abduction of the eye using the lateral rectus muscle.
• Facial Cranial Nerve: This motor nerve controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue.
• Glossopharyngeal Cranial Nerve: This sensory nerve This nerve gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands

Correct Response: A,B,D,E

The olfactory cranial nerve is a sensory nerve that transmits the sense of smell to the olfactory foramina of the nose; the optic cranial nerve is also a sensory nerve and it transmits the sense of vision from the retina to the brain.

The trochlear cranial nerve is a motor nerve that innervates eye ball movement and the superior oblique muscle of the eyes; and the abducens cranial nerve is a motor nerve that innervates and controls the abduction of the eye using the lateral rectus muscle.

The oculomotor cranial nerve is a motor nerve controls eye movements, the sphincter of the pupils and the ciliary body muscles; it has no sensory function. The facial cranial nerve is a motor and sensory nerve which controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue. And, lastly, the glossopharyngeal cranial nerve is both a motor and sensory nerve that gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands.

• The Taylor test
• The Rinne test
• The Babinski test
• The APGAR test

The sense of hearing is assessed using the Rinne test and the Weber test and a tuning fork.

A Taylor hammer, not a Taylor test, is used to check reflexes like the biceps and triceps reflexes; the Babinski sign occurs when the foot goes into dorsiflexion and the great toe curls up; this sign is an abnormal response to this stimulation and it can indicate the presence of deep vein thrombosis. And lastly, the APGAR test is used to assess the neonate immediately after birth in terms of the infant’s appearance, grimace and reflexes, appearance in terms of skin color, and respiratory rate and effort.

• Light palpation
• Deep palpation

Deep palpation is cautiously done after light palpation when necessary because the client’s responses to deep palpation may include their tightening of the abdominal muscles, for example, which will make the light palpation less effective for this assessment, particularly if an area of pain or tenderness has been palpated.

Inspection is typically the first step and percussion of the abdomen should be done prior to any palpation, particularly deep palpation.

The five types of sounds that are elicited during percussion are flatness, resonance, hyperresonance, tympany and dullness. Dullness is heard when percussion is done over a solid organ like the liver and spleen.

Flatness is normally assessed over muscles and bones; resonance is a hollow sound that is heard, for example, over the air filled lungs; and hyperresonance, which is a booming sound that is heard over abnormal lung tissue, as occurs among clients with chronic obstructive pulmonary disease (COPD); and, lastly, tympany is heard over the stomach with air as a drum like sound.

• A complete medical history, a general survey and a complete physical assessment.
• A complete medical history, a general survey and a focused physical assessment.
• A client interview, a significant other interview, a general survey and a complete physical assessment.
• A client interview, a significant other interview, a general survey and a focused physical assessment.

A comprehensive health assessment includes a complete medical history, a general survey and a complete physical assessment.

Although a complete medical history is done using a client interview and a significant other interview for much data, it is the health history and not the interview that is part of the comprehensive health assessment. A focused assessment is done as based on some pathology, sign or symptom and it is not considered a part of a comprehensive health assessment.

• Tympany: A hollow sound
• Dullness: A thud like sound
• Dullness: A hollow sound
• Resonance: A booming sound

Dullness is a thud like sound and not a hollow sound. Tympany is a drum like sound; and resonance is a hollow sound.

Psychosocial Integrity Practice Questions

• A couple which consists of a husband and wife both of whom are affected with Alzheimer’s disease
• A poverty stricken couple without any healthcare resources in the community
• A pregnant woman and a husband who was physically abused as a young child
• A wealthy couple with feelings that they are immune from punishment and above the law

A pregnant woman and a husband who was physically abused as a young child is the couple is at most risk for domestic violence because pregnancy and a personal prior history of abuse are two commonly occurring risk factors among abused woman and male abusers, respectively.

Current research indicates that abuse and neglect affect all people of all ages and of all socioeconomic classes including the wealthy as well as the poverty stricken.

Other patient populations at risk of abuse and neglect include female gender, infants, children, the cognitively impaired, the developmentally challenged, the elderly and those with physical or mental disabilities; some of the other traits and characteristics associated with abusers include substance related use and abuse, a psychiatric mental health disorder, poor parenting skills, poor anger management skills, poor self-esteem, poor coping skills, poor impulse control, immaturity, and the presence of a current crisis.

• Restrain the client
• Place the client in seclusion
• Get an order for a sedating medication
• Establish trust with the client.

The first thing that you should do to prevent violence towards others is to establish trust with the client. The first step in the nurse-client relationship is to establish trust in this therapeutic relationship. Without trust future collaboration, interventions and client outcomes cannot be accomplished to facilitate appropriate and safe behaviors.

Restraints and seclusion are not indicated until others are in imminent danger because of this client’s current violent behaviors and not a history of it. Lastly, sedating medications to prevent violence are also not the first things that are done.

• Psychological dependence secondary to amphetamine use
• Substance abuse secondary to amphetamine use
• Addiction secondary to amphetamine use
• Physical dependence secondary to amphetamine use

The appropriate nursing diagnosis for this client is “Psychological dependence secondary to amphetamine use”. Psychological dependence is defined as the person’s need to continue the use of the substance to avoid any unpleasant feelings and experiences that can occur when the substance is not taken. Amphetamines and hallucinogenic drugs like LSD are often associated with psychological dependence.

Substance abuse, simply defined, is one’s overindulgence of an addictive substance which can be alcohol, prescription drugs and/or illicit, illegal drugs. Substance abuse does not include prescribed medications, such as narcotic pain medications, that are being used for medical reasons; however, these same medications when used after there is no longer a medical need to use them is considered substance abuse.

Addiction is defined as the unending and constant need for the person to have the chosen substance even when the use of the substance causes the client to have serious physical, psychological, social and/or economic consequences and harm including a loss of control over the substance abuse and use. Contrary to popular opinion, addiction can occur with and without physical dependence.

Physical dependence occurs when the cessation of a drug causes adverse physical effects; these ill effects are typically greater and more intense when the cessation of the drug is rapid and abrupt. Some of the drugs that are most often associated with physical dependence include cocaine, opioid drugs, alcohol and benzodiazepines. As previously stated, physical dependence does not necessarily indicate addiction; addiction can be present with or without any physical dependency.

• Orem’s Self Care Model
• Nagi's Model
• A cognitive model of disability
• A biomedical model of disability

Nagi’s Model of disability model describes disabilities and its limitations are the result of a discrepancy between the client’s abilities and the limitations of the physical and social environment within which the client lives.

Although clients with disabilities should be assessed and have interventions related to their self care abilities, Dorothea Orem’s Self Care Model is not a model of disability. This model describes self care needs and abilities as wholly compensatory, partly compensatory and supportive educative.

Cognitive models of disability focus on the importance of affected client’s ability to remain as independent as possible and ways that the empowered client can exercise their own self-determination, confidence, self efficacy, and control.

Lastly, biomedical models address pathology, impairments and the manifestations of impairments that can be cured or lead to death.

The characteristics of the stages or phases of crisis, in the correct sequential order, are:

• Level 1 Crisis Signs and Symptoms: Patients experiencing a level one crisis typically experience anxiety and they also typically begin to use one or more psychological ego defense mechanisms.
• Level 2 Crisis Signs and Symptoms: Patients experiencing a level two crisis most likely exhibit some loss of their ability to function. They may also try to experiment with alternative methods of coping in order to deal with the crisis that is not being effectively coped with using one’s currently used coping mechanisms.
• Level 3 Crisis Signs and Symptoms: Patients experiencing a level three crisis show the signs and symptoms of the General Adaptation Syndrome which is characterized with fight, flight and panic as discussed above under the section entitled “Coping Mechanisms: Introduction”.
• Level 4 Crisis Signs and Symptoms: Clients experiencing a level four crisis exhibit severe signs and symptoms such as being totally detached and removed from others, feeling overwhelmed, becoming disoriented, and even with thoughts of violence toward self and others.
• Displacement
• Sublimation
• Dissociation
• Reaction formation

Dissociation is the psychological ego defense mechanism occurs when the client detaches and dissociates with person or time to avoid the stress until they are ready to cope with it.

Displacement transforms the target of one’s anger and hostility from one person to another person or object. Displacement allows the person to ventilate and act out on their anger in a less harmful and a more socially acceptable manner.

A client uses the ego defense mechanism of sublimation when they transform and replace unacceptable urges and feelings into a socially acceptable urge or feeling.

A client is using reaction formation when the client acts and behaves in a manner that is completely the polar opposite of their true feelings.

• Jean Watson's
• Martha Rogers'
• Nagi's theory
• Madeleine Leininger’s theory

The theoretical framework that you would recommend that this committee should consider when addressing mutiethnicity and the culturally diverse nature of this facility for this philosophy is Madeleine Leininger’s theory.

Madeleine Leininger’s theory of Transcultural Nursing and her book “Culture Care Diversity and Universality: A Theory of Nursing” “searches for comprehensive and holistic care data relying on social structure, worldview, and multiple factors in a culture in order to get a holistic knowledge base about care” (Leininger, 2006, p. 219)

Jean Watson’s Jean Watson developed the Human Caring Theory which states that caring is the essence of nursing. Watson's theory has the four major concepts of health, nursing, society/environment and human being. Caring consists of the following 10 nursing interventions that demonstrate genuine caring.

Martha Rogers’ theory is the Science of Unitary Human Beings which is based on general systems theory without any focus on multiethnicity and cultural diversity; and lastly, Nagi’s Model of disability model describes disabilities and its limitations are the result of a discrepancy between the client’s abilities and the limitations of the physical and social environment within which the client lives.

• The client will accept impending death
• Guilt related to past transgressions
• Spiritual distress related to guilt
• Pain related to end of life symptoms

“The client will accept impending death” is the client goal would be the most likely appropriate and expected for the vast majority of these clients. In fact, one of the primary goals of hospice and palliative care is to facilitate the client’s and family member’s acceptance.

Other goals are the freedom for guilt, spiritual distress and pain at the end of life; therefore, these diagnoses are not expected.

• The client will be free of constipation
• The client will remain free of pain and distress
• The administration of an antiemetic to prevent vomiting and further dehydration
• The administration of an enema to correct the constipation

Based on this client’s signs and symptoms and the fact that the client is expected to die in a day or two, the appropriate client outcome for this client is that the client will remain free of pain and distress.

“The client will be free of constipation” requires interventions such as an enema which are not indicated when death is imminent unless, of course, the client is adversely affected with pain and discomfort as the result of it which is not the case with this client. Additionally, the administration of an antiemetic to prevent vomiting is not indicated because there is no evidence in this question that the client is actually vomiting.

• “You should try to come to a few sessions at least because they may be very informative to you”.
• “You are probably correct. This really is not your problem”.
• “Despite the fact that it is your grandson’s drug addiction, situations such as this affect all members of the family including grandparents who live in the home.”
• "You should attend because the doctor has ordered family therapy for you as extended family members”.

You should respond to the grandparents’ statement with “Despite the fact that it is your grandson’s drug addiction, situations such as this affect all members of the family including grandparents who live in the home”.

After this statement, you should also educate the grandparents about the fact that group and family therapy is often indicated when the family unit is affected with stressors and dysfunction because family members may not fully understand the need for the entire family unit to participate when only one member of the family is adversely affected with a stressor and poor coping and that all family members are affected when only one member of the family unit is adversely affected.

You would NOT state “You should try to come to a few sessions at least because they may be very informative to you” because these sessions are therapeutic and not educational; you would not state “You are probably correct. This really is not your problem” because this statement is not true; and you should also not state “You should attend because the doctor has ordered family therapy for you as extended family members” because this is not the real reason why attending these sessions is needed.

• Engel's theory
• Kubler Ross' theory
• Lewin's theory
• Warden's theory

The theory of grief and loss would you most likely integrate into your practice as you perform this role is Warden’s Four Tasks of Mourning. This theory has four tasks that people go through after the loss of a loved one. These tasks are accepting the loss, coping with the loss, altering, modifying and changing the environment to cope with and accommodate for the absence of the lost person, and, finally, resuming one’s life while still having a healthy connection with the loved one.

Engel’s Stages of Grieving include stages both prior to and after a loss and these stages are:

• Shock and disbelief
• Developing awareness
• Restitution
• Resolving the loss
• Idealization

Kubler Ross’s Stages of Grieving occur prior to the death and these stages include:

Lastly, Lewin developed theories of change, leadership and conflict and NOT a theory related to grief after the loss of a loved one.

• The concern related to the client’s cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
• Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
• Concerns related to the compliance with psychological treatment regimens because of the client’s lack of social support systems
• The concern related to the culturally based client apathy about nursing care and nursing assessments

The concern related to the client’s cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders which is a barrier to assessment because the client fears being stigmatized and rejected when divulging psychological data including anxiety and other symptoms.

The lack of financial and health insurance resources to pay for psychological care, the lack of social support systems, and the client’s apathy are barriers to psychological care but these factors are not a barrier to a psychological assessment and these factors are not cultural, but instead social and psychological.

• Cognitive psychotherapy
• Behavioral psychotherapy
• Cognitive behavioral psychotherapy
• Psychoanalysis

Behavioral psychotherapy is particularly useful among clients who are adversely affected with phobias, substance related disorders, and other addictive disorders. Some of the techniques that are used with behavioral therapy include operant conditioning as put forth by Skinner, aversion therapy, desensitization therapy, modeling and complementary and alternative stress management techniques.

Cognitive psychotherapy is most often used to treat clients, including groups of clients, with depression, eating disorders, anxiety, and anxiety disorders to facilitate the altering of the clients’ attitudes and perspectives relating to stressors.

Cognitive behavioral psychotherapy, which is a combination of cognitive psychotherapy and behavioral psychotherapy and also referred to as dialectical behavioral therapy is most often used for clients affected with a personality disorder and those at risk for injury and harm to self and/or others.

Psychoanalysis, in contrast to cognitive behavioral therapy and other individual and group therapies, dives into the client’s subconscious and it often focuses on the past as well as the client’s current issues. This therapy is not conducted by registered nurses but, instead, by experienced psychotherapists.

The client religion that is the most pertinent to the role of the admissions coordinator of hospital who assigns the rooms and beds of clients who will be admitted is the Islam religion which requires that the followers face Mecca for daily prayer, therefore, Islam clients should be placed in a room that faces the holy city of Mecca.

Although most religions impact on the care of the client, only Islam is pertinent to the admissions coordinator. Other religions practices and their impact on health care are shown below:

• Christians: End of life rituals like the Sacrament of the Sick, baptisms for newborns, fasting, and the Eucharist.
• Judaism: Religious based circumcisions, a kosher diet which separates dairy foods from meat based foods, and death rituals called a Shiva.
• Hinduism: Many followers are vegetarian; personal hygiene is paramount and they also have death rituals without the prolongation of life.
• Mormonism: Baptism for the newborn, last rites at the time of death, communion, and burials of the dead. Additionally, the Mormon religion prohibits alcohol, tobacco, and caffeine.
• Jehovah’s Witnesses: Prohibitions against blood transfusions, foods containing blood, homosexuality, sex before marriage, abortion, suicide, gambling, alcoholic beverages, tobacco and illicit drugs.
• Psychotic symptoms related to sensory overload
• Psychotic symptoms related to a previously undiagnosed psychosis
• Visual disturbances related to dementia
• Visual disturbances related to delirium

“Visual disturbances related to delirium” is the most appropriate nursing diagnosis for this client, as based on their signs, symptoms, past history and current medical status.

Delirium is characterized with a sudden and abrupt onset of episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. Visual hallucinations are a sign of delirium and delirium can result from a number of different causes including dehydration and anticholinergic medications.

The signs and symptoms of sensory overload do not include visual hallucinations and a sudden and abrupt onset of episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. Instead, the signs and symptoms of sensory overload include anxiety, restlessness, sleep deprivation, fatigue, poor problem solving and decision making skills, poor performance, and muscular tension.

There is no evidence in this question that the client has psychotic symptoms related to a previously undiagnosed psychosis; all the evidence substantiates the suspicion that the client is affected with delirium.

Lastly, dementia has a gradual and progressive onset rather than an abrupt and sudden onset.

• Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data during the series and after the series is completed.
• Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data after the series is completed.
• Ask the clients how often they use the stress management techniques that they have learned during this educational series.
• Use a questionnaire at the end of the series that asks the participants how they liked the class and what they learned during this educational series.

The best way to evaluate the effectiveness of this educational series is to collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data during the series and after the series is completed. This technique entails evaluating the outcomes of the education in terms of changes in the client and it also includes formative evaluation during the series and summative evaluation at the end of the series.

Collecting baseline blood pressure readings prior to the beginning of this educational series and then collecting and comparing blood pressure data after the series is completed gives us only summative evaluation; it does not provide you with formative evaluation.

Because the primary goal of this series is to lower the blood pressures of clients through the use of stress management techniques, asking  the clients how often they use the stress management techniques that they have learned during this educational series and using a questionnaire at the end of the series that asks the participants how they liked the class and what they learned during this educational series does not reflect data and information about the effectiveness of the classes in terms of reducing the blood pressures of hypertensive clients.

Tai Chi is a type of a mind body exercise that deeply focuses on breathing, movement and meditation. Yoga is similar to tai chi in that yoga also employs a combination of breathing, movement and meditation.

Reiki is done for the client when the therapist places their hands on or near the person’s body to promote the client’s energy field and its own natural healing processes. Feng shui is an eastern method of decorating using colors, items and the placement of objects in the environment to promote a harmonious relationship of man and its environment; and lastly Jiu Jitsu is a martial art.

• You should advise the couple to move closer to their children so that they can care for their father.
• You should teach the wife about this progressive disease and the need to promote as much independence as possible.
• You should teach the wife about this progressive disease and the need to do all that she can for the husband to avoid his depression and frustration.
• You should advise the couple to decrease their social activities in order to preserve the husband’s dignity and self-esteem.

You should teach the wife about this progressive disease and the need to promote as much independence as possible.  Client’s with Alzheimer’s disease and other disabilities, including physical disabilities, should be coached and encouraged to be as independent as possible.

Moving closer to the children may not be appropriate advice particularly if the children are unable or unwilling to care for their father. Lastly, you should advise the couple to continue their social activities and to only avoid those situations where the necessary compassion and understanding about the client and his condition are absent.

• According to the Global Deterioration Scale, clients in the first stage of Alzheimer’s disease tend to cover up their failing abilities
• According to the Reisberg Scale, clients in the first stage of Alzheimer’s disease tend to cover up their failing abilities
• According to the Global Deterioration Scale, clients in the third stage of Alzheimer’s disease tend to cover up their failing abilities
• According to the Reisberg Scale, clients in the fourth stage of Alzheimer’s disease tend to cover up their failing abilities

According to the Global Deterioration Scale, also referred to as the Reisberg Scale, clients in the third stage of Alzheimer’s disease tend to cover up their failing abilities.

The Global Deterioration Scale stages Alzheimer’s according to seven stages. These stages include

• Stage 1: Cognitive abilities are intact.
• Stage 2: Minimal and hardly noticeable forgetfulness occurs.
• Stage 3: Mild changes in terms of cognition occur. The client may have difficulty in terms of their memory, which at times the client may “cover up” to avoid the detection by others. The signs and symptoms of this stage are similar to those of the Early Stage of Alzheimer’s disease, as discussed immediately above.
• Stage 4: This stage is characterized with increasing confusion about recent events and conversations, mild problems with math and some rather routinized sequential tasks such as cooking. The client may withdraw from others and debate the fact that they are having some cognitive issues.
• Stage 5:  Early Dementia occurs. Short and long term memory losses, a lack of orientation to place and time, poor judgment, and some of the client’s self care in terms of the activities of daily living become progressively more problematic. The client may need the assistance and supervision of others to promote the client’s highest possible level of independence in the performance of their basic activities of daily living.
• Stage 6: This stage is referred to a Middle Dementia and moderately severe Alzheimer’s disease. There is almost complete short term and long term memory loss, communication is highly limited and it may only consist of nonverbal behavioral responses, and the client needs complete care to manage their activities of daily living. Sundowner’s syndrome is present and hallucinations as well as agitation may occur.
• Stage 7: This stage is referred to as Late or Severe Dementia and Failure to Thrive. The client is in need of complete care; and immobilization, in addition to the hazards of immobility, may affect the client and the family members at this stage.
• Probing for more information from the client
• Sublimation to determine hidden messages
• Providing privacy so the client is comfortable
• Silence to allow contemplation and thought
• A safe environment of care that is conducive to the prevention of medical errors.
• A client care area that provides personal privacy and the confidentiality of medical information.
• A European method of design and color to promote health and wellness.
• The provision of a therapeutic environment of consistency to promote health.

A therapeutic milieu eliminates as many stressors from the environment as possible. The goal of this environment is to facilitate the client’s coping and recovery without the need to cope with these extraneous and avoidable stressors. Some of the elements of a therapeutic milieu environment include consistency, client rules, limitations and boundaries, and client expectations, including contracts, relating to appropriate behavior.

Physiological Integrity: Basic Care & Comfort Practice Questions

• Psychomotor domain: The client will slightly bend their elbows when holding the hand grips.
• Psychomotor domain: The client will rest their weight on the padded areas on the top of the crutches.
• Cognitive domain: The client will slightly bend their elbows when holding the hand grips.
• Cognitive domain: The nurse will tell the client how often the tips on the crutches must be replaced.

The client goal that is paired with its learning domain that should be included in the patient teaching plan for this client and the parents is “The client will slightly bend their elbows when holding the hand grips” which is part of the psychomotor domain and not the cognitive domain. Lastly, the “nurse will” is an intervention and not a client goal or expected outcome which should be learner, not nurse, oriented.

• An aphasia aid
• A button hook
• Honey thickened liquids
• A word board

The basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination is a button hook that would be used for the dressing activity of daily living.

An aphasia aid and a word board are assistive devices to facilitate communication when the client is affected with a communication deficit such as aphasia; and, lastly honey thickened liquids are indicated for clients with a swallowing disorder and they are not indicated for clients with poor fine motor coordination.

• Place the client in a wheelchair to protect their safety in the clinic.
• Remove the cane from the client to protect their safety.
• Teach the client about the proper length of a cane.
• Have the client use a wheelchair rather than the cane.

You should teach the client about the proper length of a cane. The proper length of the cane should be the length that only permits the client’s elbow to be slightly flexed. Some canes like a wooden cane are not adjustable to the client’s height and others can be adjusted to meet the height needs of the client.

You would not place the client in a wheelchair or ask the client to use a wheelchair and you would also not take the cane, which is their personal property, away from them. You would use this observation as a learning need assessment and, as such, you should teach the client about the proper length of a cane and help them to adjust the height of the cane if the client’s cane is a height adjustable one.

• A cleansing enema
• A retention enema
• A return-flow enema

The most likely intervention for this client, after getting a doctor’s order, is a return flow enema. Return-flow enemas, similar to a carminative enema, are used to relieve flatus and stimulate peristalsis which is frequently a problem after a client has received anesthesia.

Cleansing enemas are used to relieve constipation; and a retention enema is used to administer a medication, to soften stool and to lubricate the rectum so that it is easier and more comfortable for the client to defecate.

Finally, the data in this question does not indicate that the client is constipated and in need of a laxative.

• Both can lead to infection.
• Both are invasive procedures.
• Both are considered sentinel.
• Both are the last resort.

The commonality that is shared in terms of both restraints and urinary catheters is that both are the last, not the first, treatment of choice. Both indwelling urinary catheters and restraints pose risks and complication; therefore, both of these interventions must be prevented with the use of preventive measures.

Indwelling urinary catheters are invasive but restraints are not invasive; indwelling urinary catheters can lead to infection but restraints do not. Lastly, neither are sentinel. A sentinel event is an event or occurrence, incident or accident that has led to or may have possibly led to client harm. Even near misses, that have the potential for harm, are considered sentinel events because they have the potential to cause harm in the future.

• Any solid skin barrier
• A hydrocolloid solid skin barrier
• Hollister’s Flextend
• A skin sealant

You would recommend a skin sealant, including products like Bard’s Protective Barrier and Convatec’s Allkare, which are a fast drying polymer transparent film that can be applied relatively simply with a wipe or a spray. These products are easy to use and less expensive than solid skin barriers, including Hollister’s Flextend and others containing hydrocolloids.

• A prolapsed stoma
• A vitamin B12 deficiency
• Nocturnal enuresis
• GI stone formation

Some of the complications associated with a colostomy include a prolapsed stoma, infection, dehiscence, an ischemic ileostomy, a peristomal hernia, stoma stenosis, stomal retraction, necrosis, mucocutaneous separation, stomal trauma, peristomal skin damage as the result of leakage and parastomal hernias.

A vitamin B12 deficiency, nocturnal enuresis and urinary stone formations are complications associated with urinary diversion and not fecal ostomy diversions.

• Bone demineralization: Turning and positioning every 2 hours
• Urinary stasis: The client will consume 1,000 mL of oral fluids per day
• Muscle atrophy: The client will perform range of motion exercises at least 3 times a day
• Hypercalcemia: Maintaining fluid intake of 1,000 mL per day

“The client will perform range of motion exercises at least 3 times a day” is an appropriate expected outcome of care that the nurse provides to prevent this complication.

Urinary stasis and hypercalcemia, both hazards of immobility, can be prevented when the client will consume 2,000 mL of oral fluids per day. Lastly, calcium loss from the bones can be prevented by weight bearing activity, and not turning and positioning in bed.

• 1 on the scale of 1 to 3
• 2 on the scale of 1 to 5
• 3 on the scale of 0 to 5
• 4 on the scale of 0 to 5

You would document this client’s muscular strength as a 3 on a scale of 0 to 5.

Muscular strength is classified on a scale of zero to five, as below.

• Zero: No muscular contraction
• One: No muscular movement, only a quiver is noted
• Two: Muscular movement but only when assisted with gravity
• Three: Muscular movement against gravity but not against resistance
• Four: Muscular movement against resistance
• Five: Full muscular movement and strength

You would document the size of this wound as 24 cm. After the wound is assessed and measured, the wound dimension is calculated by multiplying the length by the width by the depth of the wound. For example when the length of the sound is 3 cm deep, 2 cm long and 4 cm wide, it is calculated with 3 x 2 x 4 = 24 cm.

• Secondary intention healing
• Tertiary intention healing
• Primary prevention healing
• Secondary prevention healing

Secondary intention healing is the most likely type of wound healing for this client because of the risks associated with the deep infection associated with the ruptured appendix and the peritonitis.

Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own. The resulting scar is more obvious than those scars that result from primary intention healing.

Primary intention healing is facilitated with wounds without infection. The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues.

Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Some traumatic wounds are healed with tertiary intention.

Primary, secondary and tertiary prevention strategies are prevention, interventions and restorative or rehabilitation care and not methods of wound healing.

• A barrier film
• An alginate dressing
• Surgical laser debridement
• Autolytic debridement

The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment options. RYB stands for the colors of red, yellow and black. The rules of treatment for these three colors are:

• Red: Covering with a dressing such as a hydrocolloid film, turning and positioning the client and avoiding pressure, friction and shearing
• Yellow: Using an alginate dressing
• Black: Debridement, including surgical laser debridement, mechanical debridement, autolytic debridement, enzymatic debridement and sharp instrument debridement, of the area to remove the black necrotic eschar.
• Moritz Schiff’s theory of pain
• The Intensive Theory of Pain
• Melzack and Wall’s theory of pain
• The Specificity Theory of Pain

Melzack and Wall’s Gate Control Theory of pain supports the belief that some of the factors that open this “gate” to pain are low endorphins and anxiety and that some of the factors that close this “gate” to pain are decreased anxiety and fear. The substantia gelatinosa is the “gate” that facilitates or blocks the transmission of pain.

The Specificity Theory of Moritz Schiff described pain as a sensation that was different from all the other senses in that pain had its own specific nervous system pathways from the spinal cord that traveled to the brain; the  Intensive Theory of pain is based on the belief that pain is an emotional state, rather than a sensory phenomenon; the Peripheral Pattern Theory of pain of Sinclair and Weddell describes pain as the result of an intense stimulus applied to the skin; and the Neuromatrix Theory of Pain supports the fact that pain is a dynamic and multidimensional process with physical, behavioral, perceptual, psychological and social responses and one that can only be described by the person who is experiencing it.

• Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
• Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers
• Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
• Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers

Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers are the PQRSTs of the PQRST method of pain assessment.

The severity of the pain, which can include a quantitative, numerical pain score from 1 to 10, for example, is the S of the PQRST method of pain assessment.

• Assessment data, biochemical data, clinical data and dietary data
• Ancestral cultural data, biochemical data, clinical data and dietary data
• Anthropometric data, biological data, chemical data and dietary data
• Anthropometric data, biochemical data, clinical data and dietary data

Anthropometric data, biochemical data, clinical data and dietary data are the A, B, C and Ds of a complete and comprehensive nutritional assessment.

The elements of these A, B, C and Ds of nutritional assessment include:

• A: Anthropometric Data:  This data includes variables such as height, weight, body mass index and arm measurements such as the mid arm circumference and the triceps skin fold.
• B: Biochemical Data: Laboratory testing data like serum albumin, hemoglobin, urinary creatinine, and serum transferrin.
• C: Clinical Data: The client’s skin condition, level of activity and status of the client’s mucous membranes.
• D: Dietary Data: This data includes the client’s subjective reports of their food and fluid intake over the last 24 hours and the types of foods that are typically eating.
• Constipation: The provision of a high fiber diet
• Urinary pH changes: Encouraging ample oral fluid intake
• Aspiration: Maintaining the client in at least a 30 degree angle
• Aspiration: Maintaining the client in at least a 90 degree angle

Aspiration can be prevented by maintaining the client in at least a 30 degree angle; a 90 degree angle is not only not necessary, this angle places a client at greater risk for the development of a pressure ulcer.

Diarrhea, rather than constipation is a complication of tube feedings; and urinary pH changes are not a commonly occurring complication of tube feedings.

Some of the other complications and preventive measures are:

• Diarrhea: Maintaining a slow rate of infusion whenever possible, changing the ordered rate and formula when necessary
• Abdominal pain: Maintaining a slow rate of infusion whenever possible
• Dehydration: Monitor the client for any signs and symptoms of dehydration, measure intake and output and notify the doctor of any abnormalities
• Nausea and Vomiting: Slowing the rate down, changing the formula and antiemetic medications to stop the vomiting and to prevent any aspiration
• Tube Dislodgment: Secure and monitor the tube
• Locus of control
• Bodily surface area
• Diaphoresis

There are a wide variety of different factors that influence and impact on our clients’ hygiene habits and routines. For example, cultural practices and beliefs, ethnical factors, religious practices and beliefs, the client’s level of growth and development.

Although the locus of control, bodily surface area and diaphoresis in addition to other factors such as economic constraints, the client’s level of energy, the client’s level of cognition, and environmental factors can impact on hygiene, these are not factors that impact on the client’s hygiene and hygiene practices; they do not typically impact on the lifelong developed hygiene and hygiene practices.

• The neonate: 10 to 15 hours a day
• The toddler: 11 to 14 hours a day
• The preschool child: 12 to 15 hours a day
• The school age child: Less than 8 hours a day

The age group that is accurately paired with the normal and recommended hours of sleep each day is the toddler should sleep about 11 to 14 hours per day.

The neonate should sleep 14 to 17 hours per day; the preschool child should sleep 10 to 13 hours per day; and the school age child should sleep 9 to 11 hours per day.

Physiological Integrity: Pharmacological & Parenteral Therapies Practice Questions

• Stop the intravenous flow
• Slow down the intravenous flow
• Notify the doctor

Your first priority intervention is to immediately stop the flow of the intravenous antibiotic because it is highly likely that the signs of anaphylaxis have occurred as the result of the client’s adverse effect to this antibiotic.

The next thing that you would do is assess the client to determine their physical status and to provide necessary emergency measures, including CPR, if it is indicated. Later, you would notify the doctor about this adverse reaction.

• Mix a small amount of the medication in a small amount of the intravenous fluid and then examine this mixture for color changes
• Refer to a compatibility chart
• Call the doctor and ask if the medication is compatible with the particular intravenous fluid
• Mix a small amount of the medication in a small amount of the intravenous fluid and then examine this mixture for any precipitates

The best way to determine whether or not a medication is compatible for a particular intravenous fluid is to refer to a compatibility chart.

Although, at times, incompatibility can be evidenced with changes such as those related to color changes and the formation of a cloudy solution or obvious precipitate, at other times incompatibility may not be noticeable. For this reason, nurses must refer to a compatibility or incompatibility chart before they mix medications or medications and solutions.

Lastly, there is no need to call the doctor for compatibilities when you have, and should use, a compatibility chart.

• Prevent polypharmacy
• Conserve financial resources
• Prevent interactions
• Prevent allergies

The medication reconciliation process to insure that the nurse is aware of all medications that the client is taking, some of which may have been ordered by a physician other than the client’s primary care doctor and some of which are over the counter or alternative therapies that the client has added. The complete and current list of medications is then reviewed by the nurse and possible interactions are identified and addressed with the client.

Although this medication reconciliation process can also save costs by eliminating unnecessary medications, particularly when the client is taking multiple medications (polypharmacy), this is not a primary purpose. Lastly, medications that the client is allergic to should never be given, therefore, these medications should not appear during the medication reconciliation process; they should never have been given to or taken by the client.

• The fact that drugs classified as categories C, D and X are contraindicated for women who are pregnant.
• The fact that drugs classified as categories A, B and C are contraindicated for women who are pregnant.
• The fact that drugs classified as categories C, D and E are contraindicated for women who are pregnant.
• The fact that drugs classified as categories C, D and Z are contraindicated for women who are pregnant.

Drugs classified as categories C, D and X are contraindicated for women who are pregnant because of the risks associated with these categories in terms of the developing fetus when these medications cross the placental barrier.

• The nurse must be knowledgeable about the fact that this client has A and B agglutinins and lacks the Rh factor
• The nurse must be knowledgeable about the fact that this client has B and O agglutinins and lacks the Rh factor
• The nurse must be knowledgeable about the fact that this client has B agglutinins and lacks the Rh factor
• The nurse must be knowledgeable about the fact that this client has A agglutinins and lacks the Rh factor

The nurse must be knowledgeable about the fact that this client has A agglutinins and they lack the Rh factor.

Type A blood has B agglutinins; type B blood has A agglutinins, type AB blood has no antibodies, or agglutinins, and type O blood has both A and B agglutinins.

People also have a rhesus, or Rh, factor antigen or the lack of it. Clients with an Rh positive blood, which is the vast majority of people, have Rh positive blood and people without the Rh factor antigen have Rh negative blood.

• Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
• Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
• Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
• Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration

Hemolysis can be prevented by typing and cross matching the blood and checking for ABO compatibility prior to administration. This incompatibility can occur as the result of a laboratory error in terms of typing and cross matching and a practitioner error in terms of checking the blood and matching it to the client’s blood type.

Febrile reactions are the most commonly occurring reaction to blood and blood products administration. Although a febrile reaction can occur with all blood transfusions, it is most frequently associated with packed red blood cells and this reaction is not accompanied with hemolysis nor is it associated with its occurrence.

• You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
• You will need the help of another nurse prior to the administration of these packed red blood cells.
• The unit of packed red blood cells should start no more than 1 hour after it is picked up.
• You must remain with and monitor the client for at least 30 minutes after the transfusion begins.

You will need the help of another nurse prior to the administration of these packed red blood cells. Two nurses must check the blood, the doctor’s order, the ABO compatibility and the client’s identity using at least two unique identifiers prior to the administration of this blood.

You must insure that the client has a patent intravenous catheter that is at least 18 gauge and not 20 gauge; you will be using normal saline and a Y infusion set for the administration of the blood because Ringer’s lactate and other intravenous solutions are not compatible with blood; blood should not remain in the client care area for more than 30 minutes so it is important that the nurse is prepared to begin the transfusion shortly after the blood is delivered to the patient care area; and, lastly, the nurse should remain with and monitor the client for at least 15 minutes  after the transfusion begins at a slow rate since most serious blood reactions and complications occur shortly after the transfusion begins.

• A percutaneous, non tunneled subclavian catheter
• A peripheral intravenous catheter that is 20 gauge
• A multi lumen implanted tunneled and cuffed central venous catheter
• A peripherally inserted central venous catheter

You would most likely anticipate that this client will be given a multi lumen implanted tunneled and cuffed central venous catheter because this multi trauma client is in need of multiple intravenous therapies such as blood, medications and total parenteral nutrition over an extended period of time.

A percutaneous, non tunneled subclavian catheter would not be the device of preference because percutaneous, non tunneled subclavian catheters are used when short term treatments are anticipated; a peripheral intravenous catheter that is at least 18 gauge is necessary for the administration of blood; and a peripherally inserted central venous catheter would also not be the venous access device of choice for this seriously ill client who will require long term treatments and care.

• 1.5 tablets
• 1.25 tablets
• 1.33 tablets

You have to determine how many tablets the patient will take if the doctor has ordered 200 mg a day and the tablets are manufactured as 150 mg per tablet.

The mathematical rule for this type of calculation is:

Have         =  Desired Quantity           X

This problem is calculated as shown below.

200 mg: X tablets = 150 mg: 1 tablet

200 mg     =  150 mg

X tablets       1 tab

You will criss cross multiply the known numbers and then divide this product by the remaining number to solve for X, as below.

200 x 1 = 150 X

200/150 = 1.33 tabs rounded off to 1 1/3 tabs

You have to determine how many mLs the patient will take if the doctor has ordered 10 mg twice a day and there are 12 mg in each mL.

10 mg: X mL  = 12 mg: 1 mL

10 mg     =  12 mg X mL          1 mL

10 x 1 = 10 X

10/12 = 0.833 mL rounded off to 0.8 mL

You have to determine how many mLs the patient will take if the doctor has ordered 6,500 units of heparin subcutaneously and there are 4,500 units in one mL.

6,500 units: X mL = 4,500 units: 1 mL

6,500 units     =  4,500 units X mL                  1 mL

6,500 x 1 = 6,500

6,500/4,500 = 1.44 mL which is rounded off to 1.4 mL

To calculate the number of mg that this pediatric  client will receive in each dose, you will have to calculate the client’s weight in kg and then determine the total mg for the day after which you will divide the daily dosage by 2 because the order is for two equally divided doses each day.

The steps for this calculation are shown below:

This is how to determine the client’s weight in terms of kg:

48 pounds: x kg = 2.2 pounds: 1 kg

48 pounds    =  2.2 pounds x kg                    1 kg

48 x 1 = 48

48/2.2 = 21.81 or 21.81 kg

This is how to determine the client’s total daily dosage when the doctor has ordered has ordered 5 mg/kg/day:

21.81 kg x 5 = 109.05 mg per day

This is how to determine the client’s dose for each of the two divided doses:

109.05/2 = 54.53 mg which is rounded off to 55 mg for each of two divided doses.

The first step of this calculation is to calculate the number of mLs, or cc s, per hour and then  determine the number of drops per minute. This calculation is done as follows:

1000 ml  = 125 mL per hour 8 hrs

The next step is done using this rule that reflects the fact that there are 60 minutes per hour in order to determine the number of mLs per minute .

1 hour   =  The ordered mL per hour 125 mLs X min                        60 min

1 hour   =  125  mL  X min      60 min

60 x 1 = 60

88/60 =  2.08 mL per minute

Finally, the number of drops per minute is calculated by using the intravenous infusion set’s drop factor  by using this rule.

Volume per minute x Drop factor

2.08 x 20 = 41.6 gtts per minute which is rounded off to 42 gtts per minute

With this type of calculation, the amount of normal saline that will be added to a powder in a vial to reconstitute the medication is important, instead, it is the amount of medication that results after the addition of the normal saline. For example, this reconstituted medication yields it is the yield of 12 mg in an mL that is relevant. It is this that will be used in the calculation.

This calculation is done as shown below:

12 mg  = 25 mg 1 mL      X mL

25 x 1 = 25

25/12 = 2.08 mL which is 2.1 mL rounded off

When the doctor has ordered 1200 mLs of intravenous fluid every 8 hours, you would calculate the number of mLs per hour, as below.

1200/8 = 150 mLs per hour

From 8 am to 12 noon there are 4 hours so:

150 mLs x 4 = 600 mLs

Because you had 600 mLs at 8 am, you should be prepared to hand another intravenous bag because this 600 mLs should all be infused at 12 noon.

• Question the order because Benadryl is an antihistamine and not a sleeping medication.
• Refuse to give the Benadryl because this medication is a stimulant.
• Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
• Give the Benadryl because sleep inducement is an accepted off label use of this medication.

You would administer this Benadryl because sleep inducement is an accepted off label use of this medication. When a medication is used for any other than these established and approved uses, this usage is referred to as an “off label use”.

• The “right” verification
• The “right” to refuse
• The “right” documentation
• The “right” client education

The “right verification” is not one of the “Ten Rights of Medication Administration”. The verification of the doctor’s order for a medication is to confirm the right paint, medication, dose, route and time or frequency, it, in itself, is not one of the “10 Rights”.

The “Ten Rights of Medication Administration” are the right, or correct:

• Time or frequency
• Client education
• Documentation
• Right to refuse
• Assessment and
• Gluteus maximus muscle.
• Vastus lateralis muscle.
• Deltoid muscle.
• The sternocledomastoid muscle.

The administration of an intramuscular injection to a neonate should be given in the vastus lateralis, rectus femoris and ventrogluteal muscle sites and not the deltoid or the gluteus maximus muscles because these muscles have not yet developed.

The sternocledomastoid muscle is not an intramuscular injection site.

• A subcutaneous injection site
• The PQRST technique
• The Z track technique
• The sublingual site

You would expect to use to use the Z track technique to administer ferrous sulfate.

Ferrous sulfate IM is given using the Z Track technique to avoid the leakage and dark staining of the injection site with this medication.

Ferrous sulfate is not administered with a subcutaneous injection or using the sublingual route. Lastly, the PQRST method is used to assess pain and not used as a guideline for medication administration.

• 1,5,4,2,3,6
• 4,3,2,6,1,5
• 4,2,5,3,1,6
• 1,5,3,6,4,2

The steps for mixing NPH, the long acting insulin, with regular insulin, the short acting insulin in the correct sequential order are:

• Prep the top of the longer acting insulin vial with an alcohol swab.
• Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe. Do NOT withdraw the longer acting insulin yet.
• Prep the top of the shorter acting insulin with an alcohol swab
• Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin syringe.
• Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe.
• And, then lastly, withdraw the ordered dosage of the longer acting insulin using the same insulin syringe.
• Allow the nurse to administer the injection.
• Ask the nurse to use the vastus lateralis muscle instead.
• Ask the nurse to verify the doctor’s order again.
• Stop the nurse from administering the injection.

You would stop the nurse from administering the injection when you observe that the nurse has palpated the gluteus maximum muscle to determine the correct site. Intramuscular injection sites are determined by using boney landmarks and not by palpating the muscle.

You would not allow the nurse to administer the injection and you would not ask the nurse to use the vastus lateralis muscle instead because nothing indicates the need to do so. Lastly, you would verify the doctor’s order prior to entering the room and preparing to administer the injection and not during the time that the intramuscular site is being identified.

• You have failed to have another nurse witness the 0.8 mLs and the 0.2 mLs of waste.
• You have failed to have another nurse witness the 0.8 mLs of waste.
• You have failed to have another nurse witness the 0.2 mLs of waste.
• You have failed ask another nurse to verify the calculation of the dosage.

You have failed to have another nurse witness the 0.8 mLs and the 0.2 mLs.

All controlled substances are documented on the narcotics record as soon as they are removed, and all controlled substances that are wasted for any reason, either in its entirety or only partially, must be witnessed or documented by the wasting nurse and another nurse. Both nurses document this wasting.

It should not be necessary for you to ask another nurse to verify this calculation; the nurse is accountable and responsible for accurate dosage calculations.

The procedure for this medication reconciliation process is:

2. Compile a list of current medications and other preparations 1. Compile a list of newly prescribed medications 4. Compare the two lists and make note of any discrepancies and inconsistencies 5. Employ critical thinking and professional judgments during the comparisons of the two lists 6. Communicate and document the new list of medications to the appropriate healthcare providers

• The client with heart failure who is receiving Ringer’s lactate
• The client with cancer who is receiving bendamustine
• The client who is receiving potassium supplementation intravenously
• The client who is receiving total parenteral nutrition

The client with cancer who is receiving bendamustine is at greatest risk for extravasation. Extravasation occurs when vesicant and other vein irritating drugs infiltrate into the tissue. In severe cases, extravasation can lead to necrosis and the loss of an affected limb. Bendamustine is a vesicant chemotherapy drug.

Extravasation is not associated with the intravenous administration of Ringers lactate or potassium supplementation intravenously because this solution and medication are not vesicants. These intravenous preparations can lead to infiltration but not extravasation.  Lastly, the client who is receiving total parenteral nutrition is at risk for other complications such as infection, but not extravasation.

• Infection: Lowering the limb to promote circulation
• Infiltration: The application of cold to the site
• Extravasation: The aspiration of contents including blood from the IV cannula
• Hematoma: The administration of dexrazonxane

In addition to other interventions, intravenous fluid contents including blood are aspirated from the IV cannula.

Other interventions include immediate cessation of the infusion, elevating the limb, applying warm compresses initially to rid the area of any remaining drug that is in the tissues which is then followed by cool compresses to reduce any swelling, and the administration of an ordered substance specific medication such as dexrazoxane.

One of the interventions for infection include the elevation, not lowering, of the affected limb; infiltration is treated with the application of warm, not cold, compresses and one of the interventions for hematoma is the application of pressure and heat and not the administration of dexrazonxane.

• Assess motor functioning.
• Assess sensory functioning.
• Evaluate responses to a tactile stimulation.
• Evaluate responses to a pain analgesic.

The CRIES scale is used to evaluate the neonate’s response to a pain analgesic; this pain scale is also used to assess pain among neonates.

Observational behavioral pain assessment scales for the pediatric population are used among children less than three years of age. Some of these standardized pediatric pain scales, in addition to the CRIES scale, include the FACES Pain Scale, the Toddler Preschooler Postoperative Pain Scale (TPPPS), the Neonatal Infant Pain Scale (NIPS), the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), the Faces Legs Activity Cry Consolability Pain Scale (FLACC), the Visual Analog Scale (VASobs) the Observation Scale of Behavioral Distress (OSBD), the COMFORT Pain Scale and the Pre-Verbal Early Verbal Pediatric Pain Scale (PEPPS) that is used with toddlers.

• Opioid Agonist: Dilaudid: Constipation
• Opioid Agonist: Naloxone: Constipation
• Opioid Antagonist: Dilaudid: Anaphylaxis
• Opioid Antagonist: OxyContin: Anaphylaxis

Dilaudid is an opioid agonist that can cause constipation.

Other opioid agonists are codeine, OxyContin, Darvon, Dilaudid, Demerol and Percocet. The side effects and adverse reactions to this classification of drugs include constipation, sedation, nausea, dizziness, pruritus, and sedation, respiratory depression and arrest, hepatic damage, an anaphylactic reaction, circulatory collapse and cardiac arrest.

Opioid antagonists also referred to as opioid receptor antagonists, such as naloxone and naltrexone, can have side effects such as hepatic damage, joint pain, insomnia, vomiting, anxiety, headaches and nervousness.

• Your client may be experiencing a fluid overload.
• Your client may be experiencing an embolus.
• Your client may be hyperglycemic.
• Your client may have an inadvertent pneumothorax.

The client may be experiencing an embolus, which is a complication of total parenteral nutrition. Some of the signs and symptoms of an embolus are chest pain, dyspnea, shortness of breath, coughing, and respiratory distress.

Emboli, secondary to total parenteral nutrition occur when air is permitted to enter this closed system during tubing changes and when a new bottle or bag of hyperalimentation is hung. This complication can be prevented by instructing the client to perform the Valsalva maneuver and the nurse’s rapid changing of tubings and solutions when the closed system is opened to the air.

An inadvertent pneumothorax can occur and become symptomatic during the insertion of the TPN catheter and not four days later.

Other side effects of TPN and their signs and symptoms are listed below.

• Infection: The classical signs of infection including a fever, malaise, swelling and redness at the insertion site, diaphoresis, chilling and pain in the area of the TPN catheter insertion site.
• Fluid overload: Hypertension, edema, adventitious breath sounds like crackles and rales, shortness of breath, and bulging neck veins.
• Hyperglycemia: High blood glucose levels, thirst, excessive urinary output, headache, nausea and fatigue.
• Hypoglycemia: Low blood glucose levels, shakiness, clammy and cool skin, blurry vision, diaphoresis and unconsciousness and seizures.
• Clients are at high risk for infection when they are getting TPN because they are immunocompromised.
• Clients are at high risk for hyperglycemia when they are getting TPN because they are diabetic.
• The client should perform the Valsalva maneuver when the nurse changes the TPN tubing.
• The client should perform the Valsalva maneuver when the nurse changes the TPN dressing.

The client should perform the Valsalva maneuver when the nurse changes the TPN tubing to prevent an embolus which can occur when the tubing is opened to the air while it is being changed.

A mask, not the Valsalva maneuver, is indicated for TPN dressing changes.

Lastly, clients are at risk for infection secondary to TPN because these solutions are high in dextrose and because TPN is an invasive sterile procedure; and clients are at high risk for hyperglycemia when they are getting TPN because these solutions are high in dextrose and not because the client is already a diabetic client.

Physiological Integrity: Reduction of Risk Potential Practice Questions

• Respiratory rate: 32 breaths per minute
• Pulse: 110 beats per minute
• Blood pressure: 55/82
• “The respiratory rate is a little too fast but the other vital signs are normal.”
• “The pulse rate is a little too fast but the other vital signs are normal.”
• “The blood pressure is a little low but the other vital signs are normal.”
• “All of these vital signs are normal for a child that is 2 years of age.”

All of these vital signs are normal for the toddler who is 2 years old. The normal vital signs for the toddler are:

• Respiratory rate: From 20 to 40 per minute
• Pulse rate: From 90 to 140 beats per minute
• Blood pressure: Diastolic from 50 to 80 mm Hg and systolic from 80 to 112 mm Hg
• Pulse: 100 beats per minute
• Blood pressure: 85/55

The respiratory rate is a little too fast for this 5 year old preschool client. The normal respiratory rate for this client should be from 22 to 30 per minute.

The normal pulse rate and blood pressure for the preschool child are from 80 to 110 beats per minute and a diastolic from 50 to 78 mm Hg and a systolic from 82 to 110 mm Hg.

• Pulmonary Artery Systolic Pressure: 22 mm Hg
• Pulmonary Artery Wedge Pressure: 22 mm Hg
• Pulmonary Artery Diastolic Pressure: 10 mm Hg
• Central Venous Pressure: 5 mm Hg

You would report the pulmonary artery wedge pressure of 22 mm Hg because the normal pulmonary artery wedge pressure is from 4 to 12 mm Hg.

The other normal hemodynamic values are:

• Pulmonary Artery Systolic Pressure: 15 to 26 mm Hg
• Pulmonary Artery Diastolic Pressure: 5 to 15 mm Hg
• Central Venous Pressure: 1 to 8 mm Hg
• The need to cleanse the perineal area with circular wipes.
• The need to cleanse the perineal area from the “dirtiest” to the “cleanest”.
• The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
• The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.

You would instruct your female client to use a new antiseptic wipe for each wipe from the inner to the outer labia.

A principle of asepsis is the cleansing of areas from the cleanest to the dirtiest and NOT the reverse; therefore, the inner labia are cleansed before the outer labia. The female perineal area is prepped with straight strokes and wipes; and the male wipes with a circular pattern around the urinary meatus.

• Turn the finger down so the blood will drop with gravity.
• Wipe off the first drop of blood using sterile gauze.
• Prick the side of the finger using the lancet.
• Prick the pad of the finger using the lancet.

Pricking the pad of the finger using the lancet is NOT a step in the procedure for obtaining a blood glucose sample for testing. Instead, the side of the finger is pricked with the lancet.

The procedure for checking the client’s blood glucose levels in correct sequential order is as follows:

• Verify and confirm that the code strip corresponds to the meter code.
• Disinfect the client’s finger with an alcohol swab.
•  Turn the finger down so the blood will drop with gravity.
• Collect the next drop on the test strip.
• Hold the gauze on the client’s finger after the specimen has been obtained.
• Read the client’s blood glucose level on the monitor.
• PaO2: 65 mm Hg
• PaCO2: 40 mm Hg
• Arterial blood pH: 7.39

You would report the client’s PaO2 of 65 mm Hg because it is not within normal parameters and it is also a significant change for the client. The normal partial pressure of oxygen (PaO2) is from 75 to 100 mm Hg.

The other blood gases, above, are within normal limits, as follows:

• Partial pressure of carbon dioxide (PaCO2): 38 - 42 mmHg
• Arterial blood pH: 7.38 - 7.42
• Oxygen saturation (SaO2): 94 - 100%
• Triglycerides: 75 mg/dL
• Total cholesterol: 6.5 mmol/L
• High-density lipoprotein (HDL): 60 mg/dL
• Low-density lipoprotein (LDL): 955 mg/dL

You would report a total cholesterol level of 6.5 mmol/L because this value exceeds the high normal for total cholesterol which is 5.5 mmol/L and the normal range is from 3 to 5.5 mmol/L.

The other lipid levels are normal as follows:

• Triglycerides: 50-150 mg/dL
• High-density lipoprotein (HDL): 40-80 mg/dL
• Low-density lipoprotein (LDL): 85-125 mg/dL
• Albumin: 40 g/L
• Amylase: 40 U/L
• Direct bilirubin: 17 µmol/L
• Total bilirubin: 17 µmol/L

You would report a direct bilirubin level of 17 µmol/L because this value exceeds the high normal for direct bilirubin which is 6 µmol/L and the normal range is from 0-6 µmol/L.

The other gastrointestinal related normal laboratory values are as follows:

• Albumin: 35-50 g/L
• Amylase: 30-125 U/L
• Total bilirubin: 2-20 µmol/L
• A 76 year old female client who has a history of alcohol abuse.
• A 76 year old female client who has a history of radon gas exposure.
• A 64 year old male client who has a history of cigarette smoking.
• A 64 year old male client who has hypotension.

A 64 year old male client who has hypotension is at greatest risk for impaired vascular perfusion.

Other risk factors associated with impaired vascular and tissue perfusion are:

• Hypervolemia
• Hypovolemia
• Low hemoglobin
• An immobilized limb
• Decreased cardiac output
• Impaired oxygen transportation
• Hypoventilation

Alcohol abuse, cigarette smoking and exposures to radon place people at risk for cancer, rather than impaired perfusion.

• A 76 year old female client who has a history of diabetes.
• A 64 year old male client who has a history of impaired oxygen transport.

The client who is at greatest risk for the development of cancer is the 76 year old female client who has a history of alcohol abuse. Data indicates that alcohol abuse can lead to cancer of the liver and other cancers.

Diabetes, a history of impaired oxygen transport and hypotension are risk factors associated with poor tissue perfusion, and not cancer.

• The level of pain among school age children.
• The risk for the impairment of skin integrity.
• Levels of muscular strength.
• Levels of mobility.

The Norton Scale measures the client’s risk for the impairment of skin integrity. The Norton Scale and the Braden Scale are standardized tools to screen clients for their risk of skin breakdown, pressure ulcers and an impairment of skin integrity.

Pain levels among school age children are measured with other standardized pain tools for pediatric clients; and levels of muscular strength and mobility are measured also with other standardized tests and not the Norton Scale.

• Impaired tissue perfusion

Impaired tissue perfusion is an intrinsic, or internal, risk factor that places the client at risk for pressure ulcers.

Pressure, shearing and friction are extrinsic, or external, risk factors that places the client at risk for pressure impaired tissue perfusion.

Other intrinsic risk factors associated with skin breakdown include:

• Poor nutritional status
• A decreased level of consciousness including that which occurs with sedating medications
• Fecal and/or urinary incontinence
• Impaired circulation
• Alterations in terms of the fluid balance
• Altered neurological sensory functioning
• Changes in terms of skin turgor
• Boney prominences
• Inflate the cuff if the cuff is deflated.
• Deflate the cuff if the cuff is inflated.
• Remove the inner cannula of the tube.
• Call the doctor about this airway obstruction.

The first thing that you should do when you insert the suction catheter and you reach a point of resistance is to deflate the cuff when it is inflated and the second thing that you should do is to remove the inner cannula and suction out the mucous plug.

You would not call the doctor because there is an airway obstruction; you should correct this problem with the measures above.

• Maintain the client with NPO status for at least 4 hours prior to this procedure.
• Teach the client about the fact that they may experience muscle flaccidity.
• Teach the client about the fact that they may have a headache after the ECT.
• Maintain the client on continuous hemodynamic monitoring after the ECT.

You would teach the client about the fact that they may have a headache after the ECT. Other components of the teaching about the aftermath of the procedure that the client should know about include the fact that the client may have muscle soreness, not muscle flaccidity, confusion, amnesia and hypertension.

The client should be maintained as NPO for at least 6 hours before ECT; and it is not necessary to maintain the client on continuous hemodynamic monitoring after the ECT, however, the client’s vital signs should be monitored.

• Strnagulation
• Skin breakdown
• Skin pallor

The neurological complication can occur when a vest restraint is too tight around the client’s body is numbness and tingling that, unless corrected, can lead to neurological damage.

Strangulation, skin breakdown and skin pallor can also occur when a restraint is too tight, however, these restraint complications are respiratory, integumentary system and circulatory system complications rather than neurological complications.

• The appearance of petechiae
• Aplastic anemia
• The appearance of thrombophlebitis
• Elevated platelets

The appearance of petechiae is a sign of thrombocytopenia which is a low platelet count. Other signs and symptoms include purpura, easy bruising, epistaxis, and spontaneous hemorrhage and bleeding.

Thrombocytopenia can occur as the result of several disorders and therapeutic treatments and interventions including aplastic anemia, HIV infection, a genetic disorder, cancer, particularly cancer that affects the bones, some viral pathogens like those that cause mononucleosis,  as well as from  therapeutic radiation therapy, chemotherapy and some medications such as Depakote.

• Pneumothorax

The complication that you should be aware of during the immediate post-operative period of time after a thoracentesis is a pneumothorax.

The signs and symptoms of pneumothorax and hemothorax include dyspnea, chest pain, shortness of breath and pain. The treatment of a pneumothorax includes the correction of the underlying cause whenever possible and the placement of a chest tube to remove the blood and/or air in the pleural space which will re-expand the affected lung and recreate the negative pressure of the pleural space.

Infection would not be evident during the immediate post-operative period; and, aspiration is not a complication of a thoracentesis.

• The client’s posterior tibia pulse is Grade B
• The client’s posterior tibia pulse is Grade C
• The client’s posterior tibia pulse is 1
• The client’s posterior tibia pulse is 2

You would document this finding as “The client’s posterior tibia pulse is 1”.

The strength, volume and fullness of the peripheral pulses are categorized and documented as follows:

• 0: Absent pulses
• 1: Weak pulse
• 2: Normal pulse
• 3: Increased volume
• 4: A bounding pulse

Grades and grading are not used in reference to pulses.

• The Lazarus Cognitive Appraisal Scale
• The Hamilton Rating Scale
• The McGill Scale
• The Rancho Los Amigos Scale

The tool or scale that you would use for a focused neurological assessment of your client is the Rancho Los Amigos Scale.

Levels of consciousness, which is part of a complete focused neurological assessment, can be determined and measured by using the standardized Glasgow Coma Scale for adults and children or the Rancho Los Amigos Scale. The Rancho Los Amigos Scale determines the patient’s level of awareness and functioning which can range from a 1 to an 8 when a 1 is the complete lack of all responsiveness to all stimulation and an 8 is when a patient is fully alert, oriented, appropriate and purposeful.

The McGill Pain Assessment is used to assess pain levels; the Lazarus Cognitive Appraisal Scale is used to assess levels of stress and coping; and the Hamilton Rating Scale is used to measure and assess depression.

• A lack of zinc
• A lack of vitamin E
• High iron levels
• High phosphorous levels

A lack of zinc, copper, iron and vitamins C and A are risks associated with impaired and delayed wound healing.

Other risk factors that impede wound healing are:

• Advancing age
• Nutritional status
• Some poor lifestyle choices
• Some medications
• Some diseases and disorders
• “The client is having anesthesia awareness which is not good.”
• “This often happens during stage 2 of general anesthesia.”
• "The client needs more general anesthesia.”
• “The client is having a seizure.”

You should respond to this student nurse by stating, “This often happens during stage 2 of general anesthesia.”

Stage 2 of general anesthesia, often referred to as the Excitement Stage, is characterized with uncontrollable muscular activity, irregular respirations, an irregular cardiac rhythm, and, at times, vomiting. This stage does not indicate the need for more general anesthesia.

Anesthesia awareness, which is a rare complication of general anesthesia, is the lack of amnesia during surgery when the client remembers events during surgery and, at times, they remember the pain.

Lastly, there is no evidence in this question that the client is having a seizure.

• Surgical site marking
• Medication reconciliation
• A neutral zone for sharps

Medication reconciliation prevents medication errors and other complications associated with medications and not a way to reduce surgical risks.

Surgical marking, time outs that are done after surgical site marking is done, and a neutral zone for sharps do reduce surgical risks such as wrong site surgery, wrong patient surgeries and sharps injuries.

Physiological Integrity: Physiological Adaptation Practice Questions

• Exclude pregnant visitors from the client’s room.
• Place the client in a negative pressure room.
• Have all visitors wear protective masks and boots.
• All of the above

You would exclude all pregnant visitors from the client’s room in order to protect the pregnant woman’s developing fetus. Brachytherapy is internally placed radioactive material to treat clients who are affected with tumor and cancer of the prostate, lungs, esophagus, cervix, endometrium, rectum, breast, head and neck.

Special radiation precautions are initiated when a client is receiving brachytherapy in order to protect visitors and health care staff from the harmful effects of the radiation. Some of the other special internal radiation precautions include:

• The minimization of the duration of time that health care providers are in the client’s room to deliver care and services to the client
• The placement of the client receiving internal radiation in a private room. A negative pressure room is not indicated for this client.
• The prohibition of the client’s activities outside of their room
• The initiation of complete bed rest for the client until the treatment is discontinued
• The provision of education to the family members and other visitors that includes information about their need to limit the time of their visits to at least less than 1 hour, to stay at least 6 feet away from the client
• The need for health care staff to minimize the amount of time spent in the room, to decline to enter the room if they are pregnant, to retain all supplies and equipment including things like bed linens in the client’s room until they are deemed safe for disposal by a person who is competent to make this decision, and how and when to report concerns about the client’s treatment such as when implanted seeds inadvertently leave the client’s body.
• Oral dryness

Fibrosis is an adverse effect to therapeutic radiation therapy.

Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons, and the heart in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein accumulation within normal irradiated tissue.

Alopecia, and oral dryness which is also referred to as xerostomia, are side effects and complications to radiation, but not adverse effects.

Other side effects, complications and adverse effects associated with therapeutic radiation therapy are:

• Skin damage
• Damage to the mucosa
• Dental caries and oral infections
• Nausea and vomiting
• Bone marrow suppression and immunosuppression
• Radiation pneumonia
• Placing the client in the Trendelenburg position
• Monitoring the color of the stools
• Using a Hoyer lift for patient transfers
• Monitoring the arterial blood gases

You would monitor the color of the stools for the client who is receiving phototherapy. Phototherapy is used to treat psoriasis, but it is most commonly employed for the treatment of neonatal hyperbilirubinemia and jaundice which can occur among both full term and pre term infants.

You would also monitor and document the client’s:

• Skin for changes in color that may indicate an increase or decrease in the amount of bilirubin in the client’s blood
• Laboratory bilirubin levels to determine whether or not the client’s bilirubin levels are decreasing as the result of the phototherapy
• Volume, color and characteristics of the stool because phototherapy can lead to frequent, loose stools as well as a color change to green colored stools
• Hypokalemia: Hypermagnesemia
• Hyponatremia: Dehydration
• Hyperkalemia: Ketoacidosis
• Hypercalcemia: Hypoparathyroidism

Ketoacidosis is a risk factor for hyperkalemia.

The risk factors for the other electrolyte disorders above are listed below.

• Hypokalemia: Diarrhea, vomiting, and diaphoresis as well as some medications like diuretics and laxatives, and with other disorders and diseases such as ketoacidosis. Hypermagnesemia is not a risk factor for hypokalemia.
• Hyponatremia: Thyroid gland disorders, cirrhosis, renal failure, heart failure, pneumonia, diabetes insipidus, Addison’s disease, hypothyroidism, primary polydipsia, severe diarrhea or vomiting cancer, and cerebral disorders. Dehydration is a risk factor associated with hypernatremia, not hyponatremia.
• Hypercalcemia: Hyperparathyroidism, not hyperparathyroidism, some medications such as thiazide diuretics and lithium, some forms of cancer such as breast cancer and cancer of the lungs, with multiple myeloma, Paget’s disease, non weight bearing activity and elevated levels of calcitriol as occurs with sarcoidosis and tuberculosis.
• Hypernatremia: Hepatic failure
• Hypocalcemia: Vitamin A deficiency
• Hypermagnesemia: Cushing’s disease
• Hypomagnesemia: Crohn’s disease

Crohn’s disease is a risk factor for hypomagnesemia.

Other electrolyte disorder risk factors include:

• Hypernatremia: Dehydration, renal failure, hyperglycemia and Cushing’s disease
• Hypocalcemia: Vitamin D deficiency, Crohn’s disease, sepsis and pancreatitis
• Hypermagnesemia: Addison’s disease, renal failure, diabetic ketoacidosis and dehydration
• Phosphate: From 0.81 to 1.45 mmol/L.
• Chloride: From 60 to 110 mEq/L.
• Calcium: From 6.5 - 10.6 mg/dL.
• Potassium: From 3.7 to 7.2 mEq/L.

The normal level of phosphate is from 0.81 to 1.45 mmol/L.

The other normal levels for these electrolytes are:

• Chloride: From 97 to107 mEq/L.
• Calcium: From 8.5 - 10.6 mg/dL.
• Potassium: From 3.7 to 5.2 mEq/L.

• Idioventricular Rhythm
• Bundle Branch Block
• Sinus bradycardia
• Atrial Flutter

Sinus bradycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the number of beats per minute. Sinus bradycardia has a cardiac rate less than 60 beats per minute, the atrial and the ventricular rhythms are regular, the P wave occurs prior to each and every QRS complex, the P waves are uniform in shape, the length of the PR interval is form 0.12 to 0.20 seconds, the QRS complexes are uniform and the length of these QRS complexes are from 0.06 to 0.12 seconds.

• Atrial flutter
• Supraventricular Tachycardia
• Premature Atrial Contractions

Atrial flutter, which is a relatively frequently occurring tachyarrhymia; this cardiac rhythm is characterized with an rapid atrial rate of 250 to 400 beats per minute, a variable ventricular rate, a regular atrial rhythm, a possibly irregular ventricular rhythm, the P waves are not normal, the flutter wave has a saw tooth look (f waves), the PR interval is not measurable, QRS complexes are uniform and the length of these QRS complexes are from 0.06 to 0.12 seconds.

• Torsades de Pointes
• Accelerated Idioventricular Arrhythmia
• First Degree Atrioventricular Heart Block
• Supraventricular tachycardia

Supraventricular tachycardia, simply defined is all tachyarrhythmias with a heart rate of more than 150 beats per minute.

The atrial and ventricular cardiac rates are from 150 to 250 beats per minute, the cardiac rhythm is regular, the p wave may not be visible because it is behind the QRS complex, the PR interval is not discernable,  the QRS complexes look alike, and the length of the QRS complexes ranges from 0.06 to 0.12 seconds.

• Third Degree Heart Block
• Second-Degree Atrioventricular Block, Type II
• Ventricular fibrillation

The two types of ventricular fibrillation that can be seen on an ECG strip are fine ventricular fibrillation and coarse ventricular fibrillation; ventricular fibrillation occurs when there are multiple electrical impulses from several ventricular site. This results in erratic and uncoordinated ventricular and/or atrial contractions.

You would instill 250 mLs of irrigating solution after each suctioning of the nasogastric tube. The typical amount of irrigating solution is from 20 mLs to 300 mLs.

• The compression of the renal medulla.
• Syncope and dizziness of unknown origin.
• Pressure on the vena cava which is a major vein in the body.
• Pressure on the vena cava which is the largest artery in the body.

You should explain that superior vena cava syndrome is pressure on the vena cava which is a major vein, not an artery, in the body that carries blood from the systemic circulation to the right atrium of the heart. This pressure on the superior vena cava prevents the normal return of the body’s circulating blood to the heart.

The signs and symptoms of superior vena cava syndrome include tachypnea, dyspnea, venous stasis, a loss of consciousness, edema, seizures, respiratory and/or cardiac arrest and not syncope of unknown origin. This is a life threatening medical emergency.

• Hypovolemic shock
• Septic shock
• A dissected thoracic aortic aneurysm

You would most likely suspect that this client is affected with a dissected thoracic aneurysm. Thoracic aorta rupture and dissections can present with symptoms that can include shortness of breath, dysphagia, dyspnea, coughing, and pain in the chest, arms, jaw, neck, and/or back.

The signs and symptoms of hypovolemic shock vary according to the stage of the shock; some of the signs and symptoms include hypotension, tachycardia, a lack of tissue perfusion, hyperventilation, decreased cardiac output, decreased urinary output, oliguria, anuria, metabolic acidosis, increased blood viscosity, and multisystem failure.

The signs and symptoms of septic shock include the classical signs of infection in addition to hypotension, confusion, metabolic acidosis, respiratory alkalosis, abnormal breath sounds like crackles and rales, a widened pulse pressure, and decreased cardiac output.

• Part of the intestine slides into another part of the intestine.
• The appendix ruptures.
• An ileostomy stoma retracts below the abdominal surface.
• Lungs are infiltrated.

Intussusception occurs when a part of the intestine slides into another part of the intestine. This medical emergency can lead to poor perfusion to the intestine.

The signs and symptoms of intussusception include knee to chest posturing, abdominal pain, bloody stool, fever, constipation, vomiting and diarrhea.

A ruptured appendix occurs when an infected appendix ruptures; a stoma retraction occurs when an ileostomy stoma retracts below the abdominal surface; and pneumonia occurs when the lungs become infiltrated.

• The administration of a thrombolytic medication
• The administration of hyroxyurea
• Placing the client in the lithotomy position

You would expect to administer hydroxyurea which prevents the sickling of the client’s red blood cells. You would not administer a thrombolytic medication; however, you would likely administer analgesic medications for the pain associated with the sickle cell crisis.

The lithotomy position is used for procedures involving the pelvis, including gynecological examinations; and the Trendelenburg position is used when the client is in shock and with significant hypotension.

• Perform the Valsalva maneuver
• Encourage the person to continue coughing
• Perform the Heimlich maneuver
• Begin CPR and prepare for ACLS measures

You would encourage the person to continue coughing because this person has a partial airway obstruction.

You would perform the Heimlich maneuver when the person has a complete airway obstruction. CPR and ACLS may be necessary later, but not now as based on the fact that the person only has a partial airway obstruction. Lastly, the Valsalva maneuver is done when one exerts pressure against resistance.

• Trichomoniasis
• Staphylococcus aureus
• Neisseria gonorrhoeae

Pelvic inflammatory disease is most often caused by the Neisseria gonorrhoeae and Chlamydia trachomatis pathogens; and it most often occurs as the result of untreated salpingitis, pelvic peritonitis, a tubo ovarian abscess and/or endometritis.

Unlike Neisseria gonorrhoeae, trichomoniasis and infections caused by E. coli and Staphylococcus aureus are not associated with the onset of pelvic inflammatory disease which can lead to infertility, increased risk for ectopic pregnancies, sepsis, septic shock and death when left untreated.

• Adaptive immunity
• Passive natural immunity
• Active natural immunity
• Active artificial immunity

The type of immunity occurs when a person has an infectious, communicable disease like the measles is active natural immunity.

Active immunity occurs as the result of our bodily response to the presence of an antigen, with the development of antibodies. Active immunity can be both natural and artificial. Natural active immunity occurs when the body produces antibodies after the client is infected with a pathogen; and artificial active immunity occurs when the body produces antibodies to an immunization vaccine such as those for pneumonia and a wide variety of childhood infectious diseases.

Adaptive immunity is the acquisition of antibodies or activated T cells in the body. Passive immunity occurs when an antibody is introduced into the body by either natural or artificial means. Passive natural immunity occurs when the fetus and neonate receive immunity as a natural process through the placenta; and passive artificial immunity occurs when the client receives an injection of immune globulin.

• The incubation stage
• The prodromal stage

The prodromal stage, or phase, of the infection process is characterized with general malaise, joint and muscular aches and pains, anorexia, and the presence of a headache. The prodromal stage begins with the onset of symptoms and this stage is characterized with the replication and reproduction of the pathogen.

The incubation stage is asymptomatic; the illness stage is the period of time that begins with continuation of the signs and symptoms and it continues until the symptoms are no longer as serious as they were before; and the convalescence stage is the period of recovery during which time the symptoms completely disappear.

• They are not as effective as regular defibrillators.
• They are replacing regular defibrillators in acute care settings.
• Only BLS certified people in the community should use them.
• They can be easily used by people with no healthcare experience.

Automated external defibrillators can be easily used by people with no healthcare experience. Automated external defibrillators are simple to use and there is no need to be able to recognize cardiac arrhythmias or interpret cardiac rhythm strips. Automated external defibrillations are intended to be used by the general public without any healthcare or nursing knowledge of experience; therefore, they are not restricted to only those BLS certified.

Although they are highly effective, they are not replacing the standard defibrillators in the acute care setting.

• Episiotomy extension related to a forceps delivery
• Respiratory depression related to NSAIDs
• Hemothorax related to a latex allergy

Maternal trauma, lacerations, pelvic floor damage, bleeding and an inadvertent extension of the episiotomy to the anus when a forceps delivery of a new born is done.

Respiratory depression can occur as the result of narcotic analgesics such as morphine, and not NSAIDs; pneumothorax and hemothorax can occur as the result of an inadvertent perforation during invasive procedures such as the placement of a total parenteral nutrition catheter and a thoracentesis; and the signs and symptoms of a latex allergy include tachycardia, hypotension, dyspnea, chest pain tremors, and anaphylactic shock, not respiratory depression.

How To ACE Nursing Fundamentals (+ Critical Thinking Tips!)

Skills , Study Tips and Getting Organized , Test Taking Tips , Uncategorized

Are you worried about nursing school and not sure how to tackle it?

This video will walk you through, step-by-step, how to ACE nursing fundamentals.

The study tips I will share will help you figure out exactly what you need to focus on to save time studying!

You are going to LOVE these nursing study tips to help you ACE this term in nursing school!

Here’s a quick breakdown of the Nursing School Critical Thinking Model (DRC):

D:  Definition/Description What is it? What’s the description of it?

R: Reason/Rationale Why does it happen? Why does it matter?

C: Connection How does it connect to everything else you’re learning?

Oxygen Administration:

D: Giving supplemental oxygen to your patient. Can be at various concentrations and flow rates based on patient needs.

R: Oxygen is given when the patient can’t get enough oxygen themselves. Possibly because they aren’t able to get oxygen in (ventilation), or they can’t circulate it through their body (perfusion).

C: Nursing Assessment: assess mucous membranes, lips and skin, check respiratory rate, look for labored or trouble breathing, listen to lungs.

RELATED VIDEOS: 

How To PASS Nursing School

How I Got Straight A’s in Nursing School

How To Take Notes

How I Made Nursing School Easier

VIDEO TRANSCRIPT: 

Are you freaked out about nursing school and not sure what to expect or how to pass? In this video, I’m going to walk you through my step-by-step process for how to ace your nursing fundamentals class. I’m not kidding you, these tips I’m going to share will help you figure out exactly WHAT to focus your study time on, how to learn it faster, and how to critically think along the way. This might just be the most important video you ever watch in nursing school, so be sure to stick around until the end, because I’m about to blow your mind. Now like this video, hit that subscribe button, click the notification bell, and let’s dive in.

So if you remember from THIS video, I shared my top tips for how I got straight A’s in nursing school. But being honest, that wasn’t an easy road. There was a LOT of trial and error that went into figuring out exactly how to study. I came home much every day with a headache, and felt like quitting pretty much all the time in that first term of nursing school. I cried all those tears, so you don’t have to.

I’ve spent a lot of time thinking about WHY I got straight A’s in nursing school, when other students struggled to make it. It’s not that I’m special, gifted, or super talented. I know my husband can give you a whole LIST of things I’m terrible at. Starting with keeping ANY plant alive for an extended period of time…

And those are just a few of the casualties we’ve had over the years…

I am not special. But here’s what I DO know.

I followed a particular critical thinking model, even before I created it and recognized what it was. This is a Model that I created to help walk you through, step-by-step, how to critically think in nursing school. In a few minutes, I’m going to walk you through this Model for how to study in nursing school so that you can ACE your fundamentals class.

But first, I want to put your mind at ease and walk through exactly what you can expect in your fundamentals class. I’ve received a LOT of questions about this over the past few weeks from our NursingSOS Members, and I know you’re probably a little freaked out about it too. So if you’re heading into nursing fundamentals, listen up.

Here’s how it will go: you’ll have your main lecture class where you’ll learn all of the basic concepts. The main thing you’ll learn about is the nursing assessment and the nursing process. I have a deep dive video on the nursing process HERE for you to check out after this video.

So along with the nursing process, you’ll learn about things like fluid and electrolyte balance, how to take vital signs, infection control practices, how to write care plans and how to document in a patient’s chart.

Don’t worry, we cover many of those topics here on our YouTube channel. I’ll put all the links in the description for you to check out.

Now along with this lecture class, you’ll also most likely have a skills lab class and a clinical class that go along with it for you to be able to practice all of these things. During skills lab, you’ll probably get to use mannequins and supplies in your school’s simulation lab so it’s like you’re taking care of real patient’s, without the fear of a real patient judging you or putting you at risk to hurt someone. It’s important to practice your skills FIRST before doing them in real life. You’ll practice your nursing assessment, learn how to give medications, and maybe practice some basic skills like giving vaccines.

And then during your clinical class, you’ll finally be able to practice all of your assessment skills on a REAL LIVE PERSON. How exciting!!! So don’t worry, friend, take a breath, trust yourself, and do the best you can.

It took me the better part of a clinical day to assess my first patient in nursing school, because I kept forgetting things and having to go back into her room and ask her more questions. Man, that was rough. So don’t worry, if you’re super nervous, you are NOT alone. I was right there with you!

So that is generally what you can expect for your nursing fundamentals. Make sure you practice as much as you can in the skills lab so that you’re prepared for clinical.

Now, let’s talk about how to study in your nursing fundamentals class. I’ve created a Critical Thinking Model that you can use again and again for every topic you’re studying. It will walk you through, step-by-step, how to study in nursing school.

Following this Model will be the difference between getting a C on an exam and getting an A. So pay attention, take notes, and let’s change your life.

The Critical Thinking Model goes like this: DRC. The “D” stands for definition or description. The “R” stands for reason or rationale, and the “C” stands for connection.

So let’s write this out and go through and example to help it all come together. Because seriously, friend, this is the KEY to success in nursing school. Follow this Model, and you will be GOLDEN.

The “D” stands for description or definition. What is it? What is it that you need to know about? What’s the description of it?

This is the high level stuff. Don’t worry, we’ll get to the critical thinking and the deep stuff in a minute. So stay with me.

So let’s take an example of giving oxygen to a patient. Giving oxygen and oxygen administration is absolutely something you’ll study during your fundamentals class. You HAVE to know it for nursing school and your clinicals.

So the definition and description of oxygen administration is that you are actually GIVING oxygen to your patient. You may give it at different levels or concentrations and through different ways. And if you want, you can write all of those down here as well in this category.

Now the second part of this process is the R, which stands for reasoning or rationale. This is where you’ll write about the WHY. Why does it happen, or why does it matter? This is the reasoning behind it. And in this section, I really want you to dig deep and focus on the underlying reason. This is the first step of critical thinking here. I’ll walk you through the next step in a minute, so stay with me, we’ll get there.

So in our example of giving oxygen, WHY do we give oxygen to a patient? Well, we give oxygen if a patient isn’t able to oxygenate themselves, either they aren’t able to get enough oxygen in, or they aren’t able to circulate it as well. So here I want you to dive into the pathophysiology behind it.

Listen, friend. If there is ONE reason that I got straight A’s in nursing school, it’s this: I dug deep. Constantly. I didn’t just learn the surface level stuff like everyone else. I used this model and practiced my critical thinking skills over and over again. And THAT is what made me successful. Because when I got to my exam and it gave me a case scenario about oxygen administration, I didn’t just memorize the surface level stuff that the rest of my class focused on. I was way more prepared because I did the critical thinking and learned WHY it matters.

And that’s what I want you to do, too. To really dig deep and ask yourself WHY. Why do we give oxygen, why does it matter, and why is it important.

So that’s step number 2: reasoning or rationale. Why do we do it?

And now the 3rd step is the ultra critical thinking part, and this is the C: Connection. This is where you’ll write how it connects to the other things you’re learning. This is the HOW: How does it connect to everything else?

This is where you’ll really shine at your critical thinking skills, and where it will really start to show to your instructors that you know you stuff: when you can connect the dots and put it all together.

So in our example of giving oxygen, how does that connect to other things you’re learning about? So in your fundamentals class, you’ll be learning about the nursing assessment, and you’ll also learn about oxygenation and perfusion: how the body gets oxygen and how it circulates through the body to keep us alive.

If you want a deep dive into the nursing process and what the nursing assessment is, be sure to check THIS video out after you finish this video.

So this is the final part of critical thinking, being able to connect it all together with everything that you’re learning about. Don’t worry, I’m not going to leave you guessing on how to do this. Let’s keep our same example and walk through it together.

So when you give oxygen to a patient, there are a LOT of things you need to assess for before, during and after. You’ll look at things like their lips and mucous membranes to see if they have a blue tint to them, which could indicate a lack of oxygen. You’ll look at how they’re breathing and listen to their lungs. If they’re having difficulty breathing they may need to be on oxygen to increase their blood oxygen level. So walk through each of the nursing assessment components that relate to giving oxygen. How does giving oxygen affect the body?

You’ll also learn about oxygenation and perfusion in your fundamentals class, so how does giving oxygen affect that? Well, giving a patient oxygen will hopefully increase the amount of oxygen in their blood, it will get more oxygen to their brain and other vital organs to keep them happy.

Are you seeing how all of this connects together? This Critical Thinking Model is VITAL to follow in nursing school. Like I said before, practicing this will be the difference between getting an A and getting a B or a C on your exam.

Now I have a series of critical thinking questions for you to follow as you study as well. These will really help guide your learning and help you focus your studying even more. I do a deep dive into these question in THIS video here, and I’ve also got a free cheat sheet that outlines them too. So be sure to download that, the link is in the description below.

Phew, friend, I know that was a LOT of information right here. I really wanted to do a deep dive video for you to give you everything you needed to succeed in your Fundamentals Class.

So if you found this deep dive training SUPER helpful, write LOVE in the comments to let me know, and tell me the date your start your nursing program, or if you’re already in nursing school, tell me the month and year you’ll be graduating. I am super pumped for you and your nursing school journey, and I feel so blessed to have the opportunity to help you through it.

And of course, if you want more help with Nursing Fundamentals, make sure to join the NursingSOS Membership Community where we are currently releasing a brand new fundamentals course. I’m so excited! You are going to LOVE it!

Now click on the next video to help you keep rocking nursing school, and go become the nurse that God created only YOU to be. I’ll see you over there friend. Take care!

NursingSOS Membership Community

Enrollment open until friday, get better grades and have more free time, pass nursing school or get your money back.

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Chapter 4 Nursing Process

4.1. nursing process introduction, learning objectives.

• Use the nursing process to provide patient care
• Identify nursing diagnoses from evidence-based sources
• Describe the development of a care plan
• Prioritize patient care
• Describe documentation for each step of the nursing process
• Differentiate between the role of the PN and RN

Have you ever wondered how a nurse can receive a quick handoff report from another nurse and immediately begin providing care for a patient they previously knew nothing about? How do they know what to do? How do they prioritize and make a plan?

Nurses do this activity every shift. They know how to find pertinent information and use the nursing process as a critical thinking model to guide patient care. The nursing process becomes a road map for the actions and interventions that nurses implement to optimize their patients’ well-being and health. This chapter will explain how to use the  nursing process  as standards of professional nursing practice to provide safe, patient-centered care.

4.2. BASIC CONCEPTS

Before learning how to use the nursing process, it is important to understand some basic concepts related to critical thinking and nursing practice. Let’s take a deeper look at how nurses think.

Critical Thinking and Clinical Reasoning

Nurses make decisions while providing patient care by using critical thinking and clinical reasoning.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [ 1 ] Using critical thinking means that nurses take extra steps to maintain patient safety and don’t just “follow orders.” It also means the accuracy of patient information is validated and plans for caring for patients are based on their needs, current clinical practice, and research.

“Critical thinkers” possess certain attitudes that foster rational thinking. These attitudes are as follows:

• Independence of thought: Thinking on your own
• Fair-mindedness:  Treating every viewpoint in an unbiased, unprejudiced way
• Insight into egocentricity and sociocentricity:  Thinking of the greater good and not just thinking of yourself. Knowing when you are thinking of yourself (egocentricity) and when you are thinking or acting for the greater good (sociocentricity)
• Intellectual humility:  Recognizing your intellectual limitations and abilities
• Nonjudgmental:  Using professional ethical standards and not basing your judgments on your own personal or moral standards
• Integrity:  Being honest and demonstrating strong moral principles
• Perseverance:  Persisting in doing something despite it being difficult
• Confidence:  Believing in yourself to complete a task or activity
• Interest in exploring thoughts and feelings:  Wanting to explore different ways of knowing
• Curiosity:  Asking “why” and wanting to know more

Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [ 2 ]  To make sound judgments about patient care, nurses must generate alternatives, weigh them against the evidence, and choose the best course of action. The ability to clinically reason develops over time and is based on knowledge and experience. [ 3 ]

Inductive and Deductive Reasoning and Clinical Judgment

Inductive and deductive reasoning are important critical thinking skills. They help the nurse use clinical judgment when implementing the nursing process.

Inductive reasoning  involves noticing cues, making generalizations, and creating hypotheses.  Cues  are data that fall outside of expected findings that give the nurse a hint or indication of a patient’s potential problem or condition. The nurse organizes these cues into patterns and creates a generalization. A  generalization  is a judgment formed from a set of facts, cues, and observations and is similar to gathering pieces of a jigsaw puzzle into patterns until the whole picture becomes more clear. Based on generalizations created from patterns of data, the nurse creates a hypothesis regarding a patient problem. A  hypothesis  is a proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. If a “why” is identified, then a solution can begin to be explored.

No one can draw conclusions without first noticing cues. Paying close attention to a patient, the environment, and interactions with family members is critical for inductive reasoning. As you work to improve your inductive reasoning, begin by first noticing details about the things around you. A nurse is similar to the detective looking for cues in Figure 4.1 . [ 4 ]  Be mindful of your five primary senses: the things that you hear, feel, smell, taste, and see. Nurses need strong inductive reasoning patterns and be able to take action quickly, especially in emergency situations. They can see how certain objects or events form a pattern (i.e., generalization) that indicates a common problem (i.e., hypothesis).

Inductive Reasoning Includes Looking for Cues

Example:  A nurse assesses a patient and finds the surgical incision site is red, warm, and tender to the touch. The nurse recognizes these cues form a pattern of signs of infection and creates a hypothesis that the incision has become infected. The provider is notified of the patient’s change in condition, and a new prescription is received for an antibiotic. This is an example of the use of inductive reasoning in nursing practice.

Deductive reasoning  is another type of critical thinking that is referred to as “top-down thinking.” Deductive reasoning relies on using a general standard or rule to create a strategy. Nurses use standards set by their state’s Nurse Practice Act, federal regulations, the American Nursing Association, professional organizations, and their employer to make decisions about patient care and solve problems.

Example:  Based on research findings, hospital leaders determine patients recover more quickly if they receive adequate rest. The hospital creates a policy for quiet zones at night by initiating no overhead paging, promoting low-speaking voices by staff, and reducing lighting in the hallways. (See Figure 4.2 ). [ 5 ]  The nurse further implements this policy by organizing care for patients that promotes periods of uninterrupted rest at night. This is an example of deductive thinking because the intervention is applied to all patients regardless if they have difficulty sleeping or not.

Deductive Reasoning Example: Implementing Interventions for a Quiet Zone Policy

Clinical judgment  is the result of critical thinking and clinical reasoning using inductive and deductive reasoning. Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, “The observed outcome of critical thinking and decision-making. It uses nursing knowledge to observe and assess presenting situations, identify a prioritized patient concern, and generate the best possible evidence-based solutions in order to deliver safe patient care.”  [ 6 ]  The NCSBN administers the national licensure exam (NCLEX) that measures nursing clinical judgment and decision-making ability of prospective entry-level nurses to assure safe and competent nursing care by licensed nurses.

Evidence-based practice (EBP)  is defined by the American Nurses Association (ANA) as, “A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.” [ 7 ]

Nursing Process

The nursing process is a critical thinking model based on a systematic approach to patient-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing patient care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently. [ 8 ]  The mnemonic  ADOPIE  is an easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process:  A ssessment,  D iagnosis,  O utcomes Identification,  P lanning,  I mplementation, and  E valuation.

The nursing process is a continuous, cyclic process that is constantly adapting to the patient’s current health status. See Figure 4.3 [ 9 ]  for an illustration of the nursing process.

The Nursing Process

Review Scenario A in the following box for an example of a nurse using the nursing process while providing patient care.

Patient Scenario A: Using the Nursing Process [ 10 ]

A hospitalized patient has a prescription to receive Lasix 80mg IV every morning for a medical diagnosis of heart failure. During the morning assessment, the nurse notes that the patient has a blood pressure of 98/60, heart rate of 100, respirations of 18, and a temperature of 98.7F. The nurse reviews the medical record for the patient’s vital signs baseline and observes the blood pressure trend is around 110/70 and the heart rate in the 80s. The nurse recognizes these cues form a pattern related to fluid imbalance and hypothesizes that the patient may be dehydrated. The nurse gathers additional information and notes the patient’s weight has decreased 4 pounds since yesterday. The nurse talks with the patient and validates the hypothesis when the patient reports that their mouth feels like cotton and they feel light-headed. By using critical thinking and clinical judgment, the nurse diagnoses the patient with the nursing diagnosis Fluid Volume Deficit and establishes outcomes for reestablishing fluid balance. The nurse withholds the administration of IV Lasix and contacts the health care provider to discuss the patient’s current fluid status. After contacting the provider, the nurse initiates additional nursing interventions to promote oral intake and closely monitor hydration status. By the end of the shift, the nurse evaluates the patient status and determines that fluid balance has been restored.

In Scenario A, the nurse is using clinical judgment and not just “following orders” to administer the Lasix as scheduled. The nurse assesses the patient, recognizes cues, creates a generalization and hypothesis regarding the fluid status, plans and implements nursing interventions, and evaluates the outcome. Additionally, the nurse promotes patient safety by contacting the provider before administering a medication that could cause harm to the patient at this time.

The ANA’s Standards of Professional Nursing Practice associated with each component of the nursing process are described below.

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” [ 11 ]  A registered nurse uses a systematic method to collect and analyze patient data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, a nurse’s assessment of a hospitalized patient in pain includes the patient’s response to pain, such as the inability to get out of bed, refusal to eat, withdrawal from family members, or anger directed at hospital staff. [ 12 ]

The “Assessment” component of the nursing process is further described in the “ Assessment ” section of this chapter.

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.” [ 13 ]  A nursing diagnosis is the nurse’s clinical judgment about the  client's  response to actual or potential health conditions or needs. Nursing diagnoses are the bases for the nurse’s care plan and are different than medical diagnoses. [ 14 ]

The “Diagnosis” component of the nursing process is further described in the “ Diagnosis ” section of this chapter.

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” [ 15 ]  The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the patient based on their assessment data and nursing diagnoses.

The “Outcomes Identification” component of the nursing process is further described in the “ Outcomes Identification ” section of this chapter.

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” [ 16 ]  Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each patient’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the patient’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care. [ 17 ]

The “Planning” component of the nursing process is further described in the “ Planning ” section of this chapter.

NURSING CARE PLANS

Creating nursing care plans is a part of the “Planning” step of the nursing process. A  nursing care plan  is a type of documentation that demonstrates the individualized planning and delivery of nursing care for each specific patient using the nursing process. Registered nurses (RNs) create nursing care plans so that the care provided to the patient across shifts is consistent among health care personnel. Some interventions can be delegated to Licensed Practical Nurses (LPNs) or trained Unlicensed Assistive Personnel (UAPs) with the RN’s supervision. Developing nursing care plans and implementing appropriate delegation are further discussed under the “ Planning ” and “ Implementing ” sections of this chapter.

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.” [ 18 ]  Nursing interventions are implemented or delegated with supervision according to the care plan to assure continuity of care across multiple nurses and health professionals caring for the patient. Interventions are also documented in the patient’s electronic medical record as they are completed. [ 19 ]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment. [ 20 ]

The “Implementation” component of the nursing process is further described in the “ Implementation ” section of this chapter.

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 21 ]  During evaluation, nurses assess the patient and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed. [ 22 ]

The “Evaluation” component of the nursing process is further described in the “ Evaluation ” section of this chapter.

Benefits of Using the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the health care team. The benefits of using the nursing process include the following:

• Promotes quality patient care
• Decreases omissions and duplications
• Provides a guide for all staff involved to provide consistent and responsive care
• Encourages collaborative management of a patient’s health care problems
• Improves patient safety
• Improves patient satisfaction
• Identifies a patient’s goals and strategies to attain them
• Increases the likelihood of achieving positive patient outcomes
• Saves time, energy, and frustration by creating a care plan or path to follow

By using these components of the nursing process as a critical thinking model, nurses plan interventions customized to the patient’s needs, plan outcomes and interventions, and determine whether those actions are effective in meeting the patient’s needs. In the remaining sections of this chapter, we will take an in-depth look at each of these components of the nursing process. Using the nursing process and implementing evidence-based practices are referred to as the “science of nursing.” Let’s review concepts related to the “art of nursing” while providing holistic care in a caring manner using the nursing process.

Holistic Nursing Care

The American Nurses Association (ANA) recently updated the definition of  nursing  as, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.” [ 23 ]

The ANA further describes nursing is a learned profession built on a core body of knowledge that integrates both the art and science of nursing. The  art of nursing  is defined as, “Unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.” [ 24 ]

Nurses care for individuals holistically, including their emotional, spiritual, psychosocial, cultural, and physical needs. They consider problems, issues, and needs that the person experiences as a part of a family and a community as they use the nursing process. Review a scenario illustrating holistic nursing care provided to a patient and their family in the following box.

Holistic Nursing Care Scenario

A single mother brings her child to the emergency room for ear pain and a fever. The physician diagnoses the child with an ear infection and prescribes an antibiotic. The mother is advised to make a follow-up appointment with their primary provider in two weeks. While providing discharge teaching, the nurse discovers that the family is unable to afford the expensive antibiotic prescribed and cannot find a primary care provider in their community they can reach by a bus route. The nurse asks a social worker to speak with the mother about affordable health insurance options and available providers in her community and follows up with the prescribing physician to obtain a prescription for a less expensive generic antibiotic. In this manner, the nurse provides holistic care and advocates for improved health for the child and their family.

Review how to provide culturally responsive care and reduce health disparities in the “ Diverse Patients ” chapter.

Caring and the nursing process.

The American Nurses Association (ANA) states, “The act of caring is foundational to the practice of nursing.” [ 25 ]  Successful use of the nursing process requires the development of a care relationship with the patient. A  care relationship  is a mutual relationship that requires the development of trust between both parties. This trust is often referred to as the development of  rapport  and underlies the art of nursing. While establishing a caring relationship, the whole person is assessed, including the individual’s beliefs, values, and attitudes, while also acknowledging the vulnerability and dignity of the patient and family. Assessing and caring for the whole person takes into account the physical, mental, emotional, and spiritual aspects of being a human being. [ 26 ] Caring interventions can be demonstrated in simple gestures such as active listening, making eye contact, touching, and verbal reassurances while also respecting and being sensitive to the care recipient’s cultural beliefs and meanings associated with caring behaviors. [ 27 ]  See Figure 4.4 [ 28 ]  for an image of a nurse using touch as a therapeutic communication technique to communicate caring.

Touch as a Therapeutic Communication Technique

Review how to communicate with patients using therapeutic communication techniques like active listening in the “ Communication ” chapter.

Dr. Jean Watson is a nurse theorist who has published many works on the art and science of caring in the nursing profession. Her theory of human caring sought to balance the cure orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and the public. Dr. Watson’s caring philosophy encourages nurses to be authentically present with their patients while creating a healing environment. [ 29 ]

Read more about Dr. Watson’s theory of caring at the  Watson Caring Science Institute .

Now that we have discussed basic concepts related to the nursing process, let’s look more deeply at each component of the nursing process in the following sections.

4.3. ASSESSMENT

Assessment  is the first step of the nursing process (and the first  Standard of Practice  set by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.” This includes collecting “pertinent data related to the health and quality of life in a systematic, ongoing manner, with compassion and respect for the wholeness, inherent dignity, worth, and unique attributes of every person, including but not limited to, demographics, environmental and occupational exposures, social determinants of health, health disparities, physical, functional, psychosocial, emotional, cognitive, spiritual/transpersonal, sexual, sociocultural, age-related, environmental, and lifestyle/economic assessments.” [ 1 ]

Nurses assess patients to gather clues, make generalizations, and diagnose human responses to health conditions and life processes. Patient data is considered either subjective or objective, and it can be collected from multiple sources.

Subjective Assessment Data

Subjective data  is information obtained from the patient and/or family members and offers important cues from their perspectives. When documenting subjective data stated by a patient, it should be in quotation marks and start with verbiage such as,  The patient reports.  It is vital for the nurse to establish rapport with a patient to obtain accurate, valuable subjective data regarding the mental, emotional, and spiritual aspects of their condition.

There are two types of subjective information, primary and secondary.  Primary data  is information provided directly by the patient. Patients are the best source of information about their bodies and feelings, and the nurse who actively listens to a patient will often learn valuable information while also promoting a sense of well-being. Information collected from a family member, chart, or other sources is known as  secondary data . Family members can provide important information, especially for individuals with memory impairments, infants, children, or when patients are unable to speak for themselves.

See Figure 4.5 [ 2 ]  for an illustration of a nurse obtaining subjective data and establishing rapport after obtaining permission from the patient to sit on the bed.

Example.  An example of documented subjective data obtained from a patient assessment is,  “The patient reports, ‘My pain is a level 2 on a 1-10 scale.’”

Objective Assessment Data

Objective data  is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results. See Figure 4.6 [ 3 ]  for an image of a nurse performing a physical examination.

Physical Examination

Example.  An example of documented objective data is,  “The patient’s radial pulse is 58 and regular, and their skin feels warm and dry.”

Sources of Assessment Data

There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results.

Interviewing

Interviewing includes asking the patient questions, listening, and observing verbal and nonverbal communication. Reviewing the chart prior to interviewing the patient may eliminate redundancy in the interview process and allows the nurse to hone in on the most significant areas of concern or need for clarification. However, if information in the chart does not make sense or is incomplete, the nurse should use the interview process to verify data with the patient.

After performing patient identification, the best way to initiate a caring relationship is to introduce yourself to the patient and explain your role. Share the purpose of your interview and the approximate time it will take. When beginning an interview, it may be helpful to start with questions related to the patient’s  medical diagnoses  to gather information about how they have affected the patient’s functioning, relationships, and lifestyle. Listen carefully and ask for clarification when something isn’t clear to you. Patients may not volunteer important information because they don’t realize it is important for their care. By using critical thinking and active listening, you may discover valuable cues that are important to provide safe, quality nursing care. Sometimes nursing students can feel uncomfortable having difficult conversations or asking personal questions due to generational or other cultural differences. Don’t shy away from asking about information that is important to know for safe patient care. Most patients will be grateful that you cared enough to ask and listen.

Be alert and attentive to how the patient answers questions, as well as when they do not answer a question. Nonverbal communication and body language can be cues to important information that requires further investigation. A keen sense of observation is important. To avoid making inappropriate  inferences , the nurse should validate any cues. For example, a nurse may make an inference that a patient is depressed when the patient avoids making eye contact during an interview. However, upon further questioning, the nurse may discover that the patient’s cultural background believes direct eye contact to be disrespectful and this is why they are avoiding eye contact. To read more information about communicating with patients, review the “ Communication ” chapter of this book.

A  physical examination  is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a patient’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid is present. Detailed physical examination procedures of various body systems can be found in the Open RN  Nursing Skills  textbook with a head-to-toe checklist in  Appendix C . Physical examination also includes the collection and analysis of vital signs.

Registered Nurses (RNs)  complete the initial physical examination and analyze the findings as part of the nursing process. Collection of follow-up physical examination data can be delegated to  Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs) , or measurements such as vital signs and weight may be delegated to trained  Unlicensed Assistive Personnel (UAP)  when appropriate to do so. However, the RN remains responsible for supervising these tasks, analyzing the findings, and ensuring they are documented .

A physical examination can be performed as a comprehensive, head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the patient’s  Electronic Medical Record (EMR) , an electronic version of the patient’s medical chart.

Reviewing Laboratory and Diagnostic Test Results

Reviewing laboratory and diagnostic test results provides relevant and useful information related to the needs of the patient. Understanding how normal and abnormal results affect patient care is important when implementing the nursing care plan and administering provider prescriptions. If results cause concern, it is the nurse’s responsibility to notify the provider and verify the appropriateness of prescriptions based on the patient’s current status before implementing them.

Types of Assessments

Several types of nursing assessment are used in clinical practice:

• Primary Survey:  Used during every patient encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.
• Admission Assessment:  A comprehensive assessment completed when a patient is admitted to a facility that involves assessing a large amount of information using an organized approach.
• Ongoing Assessment:  In acute care agencies such as hospitals, a head-to-toe assessment is completed and documented at least once every shift. Any changes in patient condition are reported to the health care provider.
• Focused Assessment:  Focused assessments are used to reevaluate the status of a previously diagnosed problem.
• Time-lapsed Reassessment:  Time-lapsed reassessments are used in long-term care facilities when three or more months have elapsed since the previous assessment to evaluate progress on previously identified outcomes. [ 4 ]

Putting It Together

Review Scenario C in the following box to apply concepts of assessment to a patient scenario.

Scenario C [5]

Ms. J. is a 74-year-old woman who is admitted directly to the medical unit after visiting her physician because of shortness of breath, increased swelling in her ankles and calves, and fatigue. Her medical history includes hypertension (30 years), coronary artery disease (18 years), heart failure (2 years), and type 2 diabetes (14 years). She takes 81 mg of aspirin every day, metoprolol 50 mg twice a day, furosemide 40 mg every day, and metformin 2,000 mg every day.

Ms. J.’s vital sign values on admission were as follows:

• Blood Pressure: 162/96 mm Hg
• Heart Rate: 88 beats/min
• Oxygen Saturation: 91% on room air
• Respiratory Rate: 28 breaths/minute
• Temperature: 97.8 degrees F orally

Her weight is up 10 pounds since the last office visit three weeks prior. The patient states, “I am so short of breath” and “My ankles are so swollen I have to wear my house slippers.” Ms. J. also shares, “I am so tired and weak that I can’t get out of the house to shop for groceries,” and “Sometimes I’m afraid to get out of bed because I get so dizzy.” She confides, “I would like to learn more about my health so I can take better care of myself.”

The physical assessment findings of Ms. J. are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet. Laboratory results indicate a decreased serum potassium level of 3.4 mEq/L.

As the nurse completes the physical assessment, the patient’s daughter enters the room. She confides, “We are so worried about mom living at home by herself when she is so tired all the time!”

Critical Thinking Questions

Identify subjective data.

Identify objective data.

Provide an example of secondary data.

Answers are located in the Answer Key at the end of the book.

4.4. DIAGNOSIS

Diagnosis  is the second step of the nursing process (and the second Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan. [ 1 ]

Analyzing Assessment Data

After collection of assessment data, the registered nurse analyzes the data to form generalizations and create hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering of information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and drive the nursing care plan. [ 2 ]

Performing Data Analysis

After nurses collect assessment data from a patient, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that patient according to their age, development, and baseline status. From there, nurses determine what data are “clinically relevant” as they prioritize their nursing care. [ 3 ]

Example.  In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this patient. These findings are considered “relevant cues.”

Clustering Information/Seeing Patterns/Making Hypotheses

After analyzing the data and determining relevant cues, the nurse  clusters  data into patterns. Assessment frameworks such as Gordon’s  Functional Health Patterns  assist nurses in clustering information according to evidence-based patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns. [ 4 ]  Concepts related to many of these patterns will be discussed in chapters later in this book.

Example.  Refer to Scenario C of the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, a medical history of heart failure, and currently prescribed a diuretic medication. These cues are clustered into a generalization/pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. The nurse makes a hypothesis that the patient has excess fluid volume present.

Gordon’s Functional Health Patterns [ 5 ]

Health Perception-Health Management:  A patient’s perception of their health and well-being and how it is managed

Nutritional-Metabolic:  Food and fluid consumption relative to metabolic need

Elimination:  Excretory function, including bowel, bladder, and skin

Activity-Exercise:  Exercise and daily activities

Sleep-Rest:  Sleep, rest, and daily activities

Cognitive-Perceptual:  Perception and cognition

Self-perception and Self-concept:  Self-concept and perception of self-worth, self-competency, body image, and mood state

Role-Relationship:  Role engagements and relationships

Sexuality-Reproductive:  Reproduction and satisfaction or dissatisfaction with sexuality

Coping-Stress Tolerance:  Coping and effectiveness in terms of stress tolerance

Value-Belief:  Values, beliefs (including spiritual beliefs), and goals that guide choices and decisions

Identifying Nursing Diagnoses

After the nurse has analyzed and clustered the data from the patient assessment, the next step is to begin to answer the question, “What are my patient’s human responses (i.e., nursing diagnoses)?” A  nursing diagnosis  is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.” [ 6 ]  Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis.

Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings. [ 7 ]  Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence. A list of commonly used NANDA-I diagnoses are listed in  Appendix A . For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.

NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and include health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.

Knowledge regarding specific NANDA-I nursing diagnoses is not assessed on the NCLEX. However, analyzing cues and creating hypotheses are part of the measurement model used to assess a candidate’s clinical judgment. Read more about the NCLEX and Next Generation NCLEX in the “ Scope of Practice ” chapter.

Nursing diagnoses vs. medical diagnoses.

You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on the  human response  to health conditions and life processes and are made independently by RNs. Patients with the same medical diagnosis will often  respond  differently to that diagnosis and thus have different nursing diagnoses. For example, two patients have the same medical diagnosis of heart failure. However, one patient may be interested in learning more information about the condition and the medications used to treat it, whereas another patient may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the patient’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each patient.

Example.  A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis, but it can be considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will be related to the patient’s response to heart failure.

Additional Definitions Used in NANDA-I Nursing Diagnoses

The following definitions of patient, age, and time are used in association with NANDA-I nursing diagnoses:

The NANDA-I definition of a “patient” includes:

• Individual:  a single human being distinct from others (i.e., a person).
• Caregiver:  a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
• Family:  two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
• Group:  a number of people with shared characteristics generally referred to as an ethnic group.
• Community:  a group of people living in the same locale under the same governance. Examples include neighborhoods and cities. [ 8 ]

The age of the person who is the subject of the diagnosis is defined by the following terms: [ 9 ]

• Fetus:  an unborn human more than eight weeks after conception, until birth.
• Neonate:  a person less than 28 days of age.
• Infant:  a person greater than 28 days and less than 1 year of age.
• Child:  a person aged 1 to 9 years
• Adolescent:  a person aged 10 to 19 years
• Adult:  a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
• Older adult:  a person greater than 65 years of age.

The duration of the diagnosis is defined by the following terms: [ 10 ]

• Acute:  lasting less than 3 months.
• Chronic:  lasting greater than 3 months.
• Intermittent:  stopping or starting again at intervals
• Continuous:  uninterrupted, going on without stop.

New Terms Used in 2018-2020 NANDA-I Diagnoses

The 2018-2020 edition of  Nursing Diagnoses  includes two new terms to assist in creating nursing diagnoses: at-risk populations and associated conditions. [ 11 ]

At-Risk Populations  are groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.

Associated Conditions  are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis [ 12 ]

Types of Nursing Diagnoses

There are four types of NANDA-I nursing diagnoses: [ 13 ]

• Problem-Focused
• Health Promotion – Wellness

A  problem-focused nursing diagnosis  is a “clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community.” [ 14 ]  To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present.  Related factors  (also called etiology) are causes that contribute to the diagnosis.  Defining characteristics  are cues, signs, and symptoms that cluster into patterns. [ 15 ]

A  health promotion-wellness nursing diagnosis  is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient’s readiness to enhance specific health behaviors. [ 16 ] A health promotion-wellness diagnosis is used when the patient is willing to improve a lack of knowledge, coping, or other identified need.

A  risk nursing diagnosis  is “a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.” [ 17 ]  A risk nursing diagnosis must be supported by risk factors that contribute to the increased vulnerability. A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. Problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a patient. [ 18 ]

A  syndrome diagnosis  is a “clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.” [ 19 ]

Establishing Nursing Diagnosis Statements

When using NANDA-I nursing diagnoses, NANDA-I recommends the structure of a nursing diagnosis should be a statement that includes the  nursing diagnosis  and  related factors  as exhibited by  defining characteristics . The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the patient’s assessment. [ 20 ]

To create a nursing diagnosis statement, the registered nurse completes the following steps. After analyzing the patient’s subjective and objective data and clustering the data into patterns, the nurse generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis.  Defining characteristics  is the terminology used for observable signs and symptoms related to a nursing diagnosis. [ 21 ]  Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis. For example, objective and subjective data such as weight, height, and dietary intake can be clustered together as defining characteristics for the nursing diagnosis of nutritional status.

When creating a nursing diagnosis statement, the nurse also identifies the cause of the problem for that specific patient.  Related factors  is the terminology used for the underlying causes (etiology) of a patient’s problem or situation. Related factors should not be a medical diagnosis, but instead should be attributed to the underlying pathophysiology that the nurse can treat. When possible, the nursing interventions planned for each nursing diagnosis should attempt to modify or remove these related factors that are the underlying cause of the nursing diagnosis. [ 22 ]

Creating nursing diagnosis statements has traditionally been referred to as “using PES format.” The  PES  mnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:

Problem (P)  – the patient  p roblem (i.e., the nursing diagnosis)

Etiology (E)  – related factors (i.e., the  e tiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”

Signs and Symptoms (S)  – defining characteristics manifested by the patient (i.e., the  s igns and  s ymptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the patient; phrased with “as manifested by” or “as evidenced by.”

Examples of different types of nursing diagnoses are further explained below.

Problem-Focused Nursing Diagnosis

A problem-focused nursing diagnosis contains all three components of the  PES format :

Problem (P)  – statement of the patient response (nursing diagnosis)

Etiology (E)  – related factors contributing to the nursing diagnosis

Signs and Symptoms (S)  – defining characteristics manifested by that patient

SAMPLE PROBLEM-FOCUSED NURSING DIAGNOSIS STATEMENT

Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing Diagnosis  Excess Fluid Volume . The NANDA-I definition of  Excess Fluid Volume  is “surplus intake and/or retention of fluid.” The related factor (etiology) of the problem is that the patient has excessive fluid intake. [ 23 ]

The components of a  problem-focused nursing diagnosis  statement for Ms. J. would be:

Fluid Volume Excess

Related to excessive fluid intake

As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 10 pounds, and the patient reports, “ My ankles are so swollen .”

A correctly written problem-focused nursing diagnosis statement for Ms. J. would look like this:

Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”

Health-Promotion Nursing Diagnosis

A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance”: [ 24 ]

Signs and Symptoms (S)  – the patient’s expressed desire to enhance

SAMPLE HEALTH-PROMOTION NURSING DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she would like to “learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I nursing diagnosis  Readiness for Enhanced Health Management , which is defined as “a pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.” [ 25 ]

The components of a  health-promotion nursing diagnosis  for Ms. J. would be:

Problem (P):  Readiness for Enhanced Health Management

Symptoms (S):  Expressed desire to “learn more about my health so I can take better care of myself.”

A correctly written health-promotion nursing diagnosis statement for Ms. J. would look like this:

Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis

A risk nursing diagnosis should be supported by evidence of the patient’s risk factors for developing that problem. Different experts recommend different phrasing. NANDA-I 2018-2020 recommends using the phrase “as evidenced by” to refer to the risk factors for developing that problem. [ 26 ]

A risk diagnosis consists of the following:

As Evidenced By  – Risk factors for developing the problem

SAMPLE RISK DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to vulnerability from the dizziness and weakness she is experiencing. The NANDA-I definition of  Risk for Falls  is “increased susceptibility to falling, which may cause physical harm and compromise health.” [ 27 ]

The components of a  risk diagnosis  statement for Ms. J. would be:

Problem (P)  – Risk for Falls

As Evidenced By  – Dizziness and decreased lower extremity strength

A correctly written risk nursing diagnosis statement for Ms. J. would look like this:

Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Syndrome Diagnosis

A syndrome is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition, but are not required. [ 28 ]

A syndrome statement consists of these items:

Problem (P)  – the syndrome

Signs and Symptoms (S)  – the defining characteristics are two or more similar nursing diagnoses

SAMPLE SYNDROME DIAGNOSIS STATEMENT

Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses that can be categorized as a  syndrome . For example,  Activity Intolerance  is defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.”  Social Isolation  is defined as “aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.” These diagnoses can be included under the the NANDA-I syndrome named  Risk for Frail Elderly Syndrome.  This syndrome is defined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.” [ 29 ]

The components of a  syndrome nursing diagnosis  for Ms. J. would be:

– Risk for Frail Elderly Syndrome

– The nursing diagnoses of  Activity Intolerance  and  Social Isolation

Additional related factor: Fear of falling

A correctly written syndrome diagnosis statement for Ms. J. would look like this:

Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling

Prioritization

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the patient. Nurses prioritize their actions while providing patient care multiple times every day.  Prioritization  is the process that identifies the most significant nursing problems, as well as the most important interventions, in the nursing care plan.

It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns. In critical situations, the steps of the nursing process are performed through rapid clinical judgment. Nurses must recognize cues signaling a change in patient condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members. Most patient situations fall somewhere between a crisis and routine care.

There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7 [30]  on  The How To of Prioritization .

The How To of Prioritization

Maslow’s Hierarchy of Needs  is used to categorize the most urgent patient needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8 [31]  for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.

Maslow’s Hierarchy of Needs

In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the patient’s condition is an acute or chronic problem. Acute, uncompensated conditions generally require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the patient vulnerability and risk factors.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.:  Fluid Volume Excess, Enhanced Readiness for Health Promotion, Risk for Falls , and  Risk for Frail Elderly Syndrome . The top priority diagnosis is  Fluid Volume Excess  because it affects the physiological needs of breathing, homeostasis, and excretion. However, the  Risk for Falls  diagnosis comes in a close second because of safety implications and potential injury that could occur if the patient fell.

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NANDA International. (n.d.).  Glossary of terms .  https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

NANDA International. (n.d.).  Glossary of terms.   https://nanda ​.org/nanda-i-resources ​/glossary-of-terms/   ↵

“The How To of Prioritization” by Valerie Palarski for  Chippewa Valley Technical College  is licensed under  CC BY 4.0   ↵

“ Maslow's hierarchy of needs.svg ” by  J. Finkelstein  is licensed under  CC BY-SA 3.0   ↵

4.5. OUTCOME IDENTIFICATION

Outcome Identification  is the third step of the nursing process (and the third Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The RN collaborates with the health care consumer, interprofessional team, and others to identify expected outcomes integrating the health care consumer’s culture, values, and ethical considerations. Expected outcomes are documented as measurable goals with a time frame for attainment. [ 1 ]

An  outcome  is a “measurable behavior demonstrated by the patient responsive to nursing interventions.” [ 2 ]  Outcomes should be identified before nursing interventions are planned. After nursing interventions are implemented, the nurse will evaluate if the outcomes were met in the time frame indicated for that patient.

Outcome identification includes setting short- and long-term goals and then creating specific expected outcome statements for each nursing diagnosis.

Short-Term and Long-Term Goals

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.

The nursing care plan is a road map used to guide patient care so that all health care providers are moving toward the same patient goals.  Goals  are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided. For example, in a critical care area, a short-term goal might be set to be achieved within an 8-hour nursing shift, and a long-term goal might be in 24 hours. In contrast, in an outpatient setting, a short-term goal might be set to be achieved within one month and a long-term goal might be within six months.

A nursing goal is the overall direction in which the patient must progress to improve the problem/nursing diagnosis and is often the opposite of the problem.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. had a priority nursing diagnosis of  Fluid Volume Excess.  A broad goal would be, “ Ms. J. will achieve a state of fluid balance. ”

Expected Outcomes

Goals are broad, general statements, but outcomes are specific and measurable.  Expected outcomes  are statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions. Nurses may create expected outcomes independently or refer to classification systems for assistance. Just as NANDA-I creates and revises standardized nursing diagnoses, a similar classification and standardization process exists for expected nursing outcomes. The Nursing Outcomes Classification (NOC) is a list of over 330 nursing outcomes designed to coordinate with established NANDA-I diagnoses. [ 3 ]

Patient-Centered

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving.

Outcome statements should contain five components easily remembered using the “SMART” mnemonic: [ 4 ]

• M easurable
• A ttainable/Action oriented
• R elevant/Realistic

See Figure 4.9 [ 5 ]  for an image of the SMART components of outcome statements. Each of these components is further described in the following subsections.

SMART Components of Outcome Statements

Outcome statements should state precisely what is to be accomplished. See the following examples:

• Not specific:  “The patient will increase the amount of exercise.”
• Specific:  “The patient will participate in a bicycling exercise session daily for 30 minutes.”

Additionally, only one action should be included in each expected outcome. See the following examples:

• “The patient will walk 50 feet three times a day with standby assistance of one and will shower in the morning until discharge”  is actually two goals written as one. The outcome of ambulation should be separate from showering for precise evaluation. For instance, the patient could shower but not ambulate, which would make this outcome statement very difficult to effectively evaluate.
• Suggested revision is to create two outcomes statements so each can be measured: The patient will walk 50 feet three times a day with standby assistance of one until discharge. The patient will shower every morning until discharge.

Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met. It is important to use objective data to measure outcomes. If terms like “acceptable” or “normal” are used in an outcome statement, it is difficult to determine whether the outcome is attained. Refer to Figure 4.10 [ 6 ]  for examples of verbs that are measurable and not measurable in outcome statements.

Figure 4.10

Measurable Outcomes

See the following examples:

• Not measurable:  “The patient will drink adequate fluid amounts every shift.”
• Measurable:  “The patient will drink 24 ounces of fluids during every day shift (0600-1400).”

Action-Oriented and Attainable

Outcome statements should be written so that there is a clear action to be taken by the patient or significant others. This means that the outcome statement should include a verb. Refer to Figure 4.11 [ 7 ]  for examples of action verbs.

Figure 4.11

Action Verbs

• Not action-oriented:  “The patient will get increased physical activity.”
• Action-oriented:  “The patient will list three types of aerobic activity that he would enjoy completing every week.”

Realistic and Relevant

Realistic outcomes consider the patient’s physical and mental condition; their cultural and spiritual values, beliefs, and preferences; and their socioeconomic status in terms of their ability to attain these outcomes. Consideration should be also given to disease processes and the effects of conditions such as pain and decreased mobility on the patient’s ability to reach expected outcomes. Other barriers to outcome attainment may be related to health literacy or lack of available resources. Outcomes should always be reevaluated and revised for attainability as needed. If an outcome is not attained, it is commonly because the original time frame was too ambitious or the outcome was not realistic for the patient.

• Not realistic:  “The patient will jog one mile every day when starting the exercise program.”
• Realistic:  “The patient will walk ½ mile three times a week for two weeks.”

Time Limited

Outcome statements should include a time frame for evaluation. The time frame depends on the intervention and the patient’s current condition. Some outcomes may need to be evaluated every shift, whereas other outcomes may be evaluated daily, weekly, or monthly. During the evaluation phase of the nursing process, the outcomes will be assessed according to the time frame specified for evaluation. If it has not been met, the nursing care plan should be revised.

• Not time limited: “The patient will stop smoking cigarettes.”
• Time limited:  “The patient will complete the smoking cessation plan by December 12, 2021.”

In Scenario C in Box 4.3, Ms. J.’s priority nursing diagnosis statement was  Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 10 pounds, and the patient reports, “My ankles are so swollen.”  An example of an expected outcome meeting SMART criteria for Ms. J. is,  “The patient will have clear bilateral lung sounds within the next 24 hours.”

4.6. PLANNING

Planning  is the fourth step of the nursing process (and the fourth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.” The RN develops an individualized, holistic, evidence-based plan in partnership with the health care consumer, family, significant others, and interprofessional team. Elements of the plan are prioritized. The plan is modified according to the ongoing assessment of the health care consumer’s response and other indicators. The plan is documented using standardized language or terminology. [ 1 ]

After expected outcomes are identified, the nurse begins planning nursing interventions to implement.  Nursing interventions  are evidence-based actions that the nurse performs to achieve patient outcomes. Just as a provider makes medical diagnoses and writes prescriptions to improve the patient’s medical condition, a nurse formulates nursing diagnoses and plans nursing interventions to resolve patient problems. Nursing interventions should focus on eliminating or reducing the related factors (etiology) of the nursing diagnoses when possible. [ 2 ]  Nursing interventions, goals, and expected outcomes are written in the nursing care plan for continuity of care across shifts, nurses, and health professionals.

Planning Nursing Interventions

You might be asking yourself, “How do I know what evidence-based nursing interventions to include in the nursing care plan?” There are several sources that nurses and nursing students can use to select nursing interventions. Many agencies have care planning tools and references included in the electronic health record that are easily documented in the patient chart. Nurses can also refer to other care planning books our sources such as the Nursing Interventions Classification (NIC) system. Based on research and input from the nursing profession, NIC categorizes and describes nursing interventions that are constantly evaluated and updated. Interventions included in NIC are considered evidence-based nursing practices. The nurse is responsible for using clinical judgment to make decisions about which interventions are best suited to meet an individualized patient’s needs. [ 3 ]

Direct and Indirect Care

Nursing interventions are considered direct care or indirect care.  Direct care  refers to interventions that are carried out by having personal contact with patients. Examples of direct care interventions are wound care, repositioning, and ambulation.  Indirect care  interventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.

Classification of Nursing Interventions

There are three types of nursing interventions: independent, dependent, and collaborative. (See Figure 4.12 [ 4 ]  for an image of a nurse collaborating with the health care team when planning interventions.)

Figure 4.12

Collaborative nursing interventions, independent nursing interventions.

Any intervention that the nurse can independently provide without obtaining a prescription is considered an  independent nursing intervention . An example of an independent nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume. Another example of independent nursing interventions is the therapeutic communication that a nurse uses to assist patients to cope with a new medical diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of an evidence-based independent nursing intervention is,  “The nurse will reposition the patient with dependent edema frequently, as appropriate.” [ 5 ]  The nurse would individualize this evidence-based intervention to the patient and agency policy by stating,  “The nurse will reposition the patient every 2 hours.”

Dependent Nursing Interventions

Dependent nursing interventions  require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 6 ]  A  primary health care provider  is a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication is a dependent nursing intervention. The nurse incorporates dependent interventions into the patient’s overall care plan by associating each intervention with the appropriate nursing diagnosis.

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a dependent nursing intervention is,  “The nurse will administer scheduled diuretics as prescribed.”

Collaborative nursing interventions  are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint. [ 7 ]

Example.  Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. was diagnosed with  Fluid Volume Excess . An example of a collaborative nursing intervention is consulting with a respiratory therapist when the patient has deteriorating oxygen saturation levels. The respiratory therapist plans oxygen therapy and obtains a prescription from the provider. The nurse would document “ The nurse will manage oxygen therapy in collaboration with the respiratory therapist ” in the care plan.

Individualization of Interventions

It is vital for the planned interventions to be individualized to the patient to be successful. For example, adding prune juice to the breakfast meal of a patient with constipation will only work if the patient likes to drink the prune juice. If the patient does not like prune juice, then this intervention should not be included in the care plan. Collaboration with the patient, family members, significant others, and the interprofessional team is essential for selecting effective interventions. The number of interventions included in a nursing care plan is not a hard and fast rule, but enough quality, individualized interventions should be planned to meet the identified outcomes for that patient.

Creating Nursing Care Plans

Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans are legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. CMS guidelines state, “Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best and patient representatives can be present, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision-making. A resident has the right to select or refuse specific treatment options before the care plan is instituted.” [ 8 ]  The Joint Commission conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care. [ 9 ]

Many facilities have established standardized nursing care plans with lists of possible interventions that can be customized for each specific patient. Other facilities require the nurse to develop each care plan independently. Whatever the format, nursing care plans should be individualized to meet the specific and unique needs of each patient. See Figure 4.13 [ 10 ]  for an image of a standardized care plan.

Figure 4.13

Standardized Care Plan

Nursing care plans created in nursing school can also be in various formats such as concept maps or tables. Some are fun and creative, while others are more formal.  Appendix B  contains a template that can be used for creating nursing care plans.

4.7. IMPLEMENTATION OF INTERVENTIONS

Implementation  is the fifth step of the nursing process (and the fifth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse implements the identified plan.” The RN may delegate planned interventions after considering the circumstance, person, task, communication, supervision, and evaluation, as well as the state Nurse Practice Act, federal regulation, and agency policy. [ 1 ]

Implementation of interventions requires the RN to use critical thinking and clinical judgment. After the initial plan of care is developed, continual reassessment of the patient is necessary to detect any changes in the patient’s condition requiring modification of the plan. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.

During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses patient safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed.

Prioritizing Implementation of Interventions

Prioritizing implementation of interventions follows a similar method as to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions. When possible, least invasive actions are usually preferred due to the risk of injury from invasive options. Read more about methods for prioritization under the “ Diagnosis ” subsection of this chapter.

The potential impact on future events, especially if a task is not completed at a certain time, is also included when prioritizing nursing interventions. For example, if a patient is scheduled to undergo a surgical procedure later in the day, the nurse prioritizes initiating a NPO (nothing by mouth) prescription prior to completing pre-op patient education about the procedure. The rationale for this decision is that if the patient ate food or drank water, the surgery time would be delayed. Knowing and understanding the patient’s purpose for care, current situation, and expected outcomes are necessary to accurately prioritize interventions.

Patient Safety

It is essential to consider patient safety when implementing interventions. At times, patients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a patient states,  “The nurse will ambulate the patient 100 feet three times daily.”  However, during assessment this morning, the patient reports feeling dizzy today, and their blood pressure is 90/60. Using critical thinking and clinical judgment, the nurse decides to not implement the planned intervention of ambulating the patient. This decision and supporting assessment findings should be documented in the patient’s chart and also communicated during the shift handoff report, along with appropriate notification of the provider of the patient’s change in condition.

Implementing interventions goes far beyond implementing provider prescriptions and completing tasks identified on the nursing care plan and must focus on patient safety. As front-line providers, nurses are in the position to stop errors before they reach the patient. [ 2 ]

In 2000 the Institute of Medicine (IOM) issued a groundbreaking report titled  To Err Is Human: Building a Safer Health System . The report stated that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors.  To Err Is Human  broke the silence that previously surrounded the consequences of medical errors and set a national agenda for reducing medical errors and improving patient safety through the design of a safer health system. [ 3 ]  In 2007 the IOM published a follow-up report titled  Preventing Medication Errors  and reported that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. This report emphasized actions that health care systems could take to improve medication safety. [ 4 ]

Read additional information about specific actions that nurses can take to prevent medication errors; go to the “Preventing Medication Errors” section of the “ Legal/Ethical”  chapter of the Open RN  Nursing Pharmacology  textbook.

In an article released by the Robert Wood Johnson Foundation, errors involving nurses that endanger patient safety cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall, and more. Some errors can be traced to shifts that are too long that leave nurses fatigued, some result from flawed systems that do not allow for adequate safety checks, and others are caused by interruptions to nurses while they are trying to administer medications or provide other care. [ 5 ]

The Quality and Safety Education for Nurses (QSEN) project began in 2005 to assist in preparing future nurses to continuously improve the quality and safety of the health care systems in which they work. The vision of the QSEN project is to “inspire health care professionals to put quality and safety as core values to guide their work.” [ 6 ]  Nurses and nursing students are expected to participate in quality improvement (QI) initiatives by identifying gaps where change is needed and assisting in implementing initiatives to resolve these gaps.  Quality improvement  is defined as, “The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 7 ]

Delegation of Interventions

While implementing interventions, RNs may elect to delegate nursing tasks.  Delegation  is defined by the American Nurses Association as, “The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel or licensed practical nurses (LPNs) while retaining accountability for the outcome.” [ 8 ]  RNs are accountable for determining the appropriateness of the delegated task according to condition of the patient and the circumstance; the communication provided to an appropriately trained LPN or UAP; the level of supervision provided; and the evaluation and documentation of the task completed. The RN must also be aware of the state Nurse Practice Act, federal regulations, and agency policy before delegating. The RN cannot delegate responsibilities requiring clinical judgment. [ 9 ]  See the following box for information regarding legal requirements associated with delegation according to the Wisconsin Nurse Practice Act.

Delegation According to the Wisconsin Nurse Practice Act

During the supervision and direction of delegated acts a Registered Nurse shall do all of the following:

Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.

Provide direction and assistance to those supervised.

Observe and monitor the activities of those supervised.

Evaluate the effectiveness of acts performed under supervision. [ 10 ]

The standard of practice for Licensed Practical Nurses in Wisconsin states, “In the performance of acts in basic patient situations, the LPN. shall, under the general supervision of an RN or the direction of a provider:

Accept only patient care assignments which the LPN is competent to perform.

Provide basic nursing care. Basic nursing care is defined as care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.

Record nursing care given and report to the appropriate person changes in the condition of a patient.

Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.

Perform the following other acts when applicable:

Assist with the collection of data.

Assist with the development and revision of a nursing care plan.

Reinforce the teaching provided by an RN provider and provide basic health care instruction.

Participate with other health team members in meeting basic patient needs.” [ 11 ]

Read additional details about the scope of practice of registered nurses (RNs) and licensed practical nurses (LPNs) in Wisconsin’s Nurse Practice Act in  Chapter N 6 Standards of Practice .

Read more about the American Nurses Association’s  Principles of Delegation.

Table 4.7 outlines general guidelines for delegating nursing tasks in the state of Wisconsin according to the role of the health care team member.

General Guidelines for Delegating Nursing Tasks

Documentation of Interventions

As interventions are performed, they must be documented in the patient’s record in a timely manner. As previously discussed in the “Ethical and Legal Issues” subsection of the “ Basic Concepts ” section, lack of documentation is considered a failure to communicate and a basis for legal action. A basic rule of thumb is if an intervention is not documented, it is considered not done in a court of law. It is also important to document administration of medication and other interventions in a timely manner to prevent errors that can occur due to delayed documentation time.

Coordination of Care and Health Teaching/Health Promotion

ANA’s Standard of Professional Practice for Implementation also includes the standards  5A   Coordination of Care  and  5B   Health Teaching and Health Promotion . [ 12 ]   Coordination of Care  includes competencies such as organizing the components of the plan, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and holistic care by the interprofessional team.  Health Teaching and Health Promotion  is defined as, “Employing strategies to teach and promote health and wellness.” [ 13 ]  Patient education is an important component of nursing care and should be included during every patient encounter. For example, patient education may include teaching about side effects while administering medications or teaching patients how to self-manage their conditions at home.

Refer to Scenario C in the “Assessment” section of this chapter. The nurse implemented the nursing care plan documented in Appendix C. Interventions related to breathing were prioritized. Administration of the diuretic medication was completed first, and lung sounds were monitored frequently for the remainder of the shift. Weighing the patient before breakfast was delegated to the CNA. The patient was educated about her medications and methods to use to reduce peripheral edema at home. All interventions were documented in the electronic medical record (EMR).

4.8. EVALUATION

Evaluation  is the sixth step of the nursing process (and the sixth Standard of Practice set by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [ 1 ]  Both the patient status and the effectiveness of the nursing care must be continuously evaluated and the care plan modified as needed. [ 2 ]

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the patient’s medical record.

Ideally, when the planned interventions are implemented, the patient will respond positively and the expected outcomes are achieved. However, when interventions do not assist in progressing the patient toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the patient. These questions can be used as a guide when revising the nursing care plan:

• Did anything unanticipated occur?
• Has the patient’s condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this patient at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

Refer to Scenario C in the “Assessment” section of this chapter and Appendix C . The nurse evaluates the patient’s progress toward achieving the expected outcomes.

For the nursing diagnosis  Fluid Volume Excess , the nurse evaluated the four expected outcomes to determine if they were met during the time frames indicated:

The patient will report decreased dyspnea within the next 8 hours.

The patient will have clear lung sounds within the next 24 hours.

The patient will have decreased edema within the next 24 hours.

The patient’s weight will return to baseline by discharge.

Evaluation of the patient condition on Day 1 included the following data: “ The patient reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves .” Based on this data, the nurse evaluated the expected outcomes as “ Partially Met ” and revised the care plan with two new interventions:

Request prescription for TED hose from provider.

Elevate patient’s legs when sitting in chair.

For the second nursing diagnosis,  Risk for Falls , the nurse evaluated the outcome criteria as “ Met ” based on the evaluation, “ The patient verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred. ”

The nurse will continue to reassess the patient’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the patient’s medical record.

4.9. SUMMARY OF THE NURSING PROCESS

You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.

Video Review of Creating a Sample Care Plan [ 1 ]

4.10. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Instructions: Apply what you’ve learned in this chapter by creating a nursing care plan using the following scenario. Use the template in   Appendix B   as a guide.

The client, Mark S., is a 57-year-old male who was admitted to the hospital with “severe” abdominal pain that was unable to be managed in the Emergency Department. The physician has informed Mark that he will need to undergo some diagnostic tests. The tests are scheduled for the morning.

After receiving the news about his condition and the need for diagnostic tests, Mark begins to pace the floor. He continues to pace constantly. He keeps asking the nurse the same question (“How long will the tests take?”) about his tests over and over again. The patient also remarked, “I’m so uptight I will never be able to sleep tonight.” The nurse observes that the client avoids eye contact during their interactions and that he continually fidgets with the call light. His eyes keep darting around the room. He appears tense and has a strained expression on his face. He states, “My mouth is so dry.” The nurse observes his vital signs to be: T 98, P 104, R 30, BP 180/96. The nurse notes that his skin feels sweaty (diaphoretic) and cool to the touch.

Critical Thinking Activity:

Group (cluster) the subjective and objective data.

Create a problem-focused nursing diagnosis (hypothesis).

Develop a broad goal and then identify an expected outcome in “SMART” format.

Outline three interventions for the nursing diagnosis to meet the goal. Cite an evidence-based source.

Imagine that you implemented the interventions that you identified. Evaluate the degree to which the expected outcome was achieved: Met – Partially Met – Not Met.

• IV GLOSSARY

The act or process of pleading for, supporting, or recommending a cause or course of action. [ 1 ]

Unconditionally acceptance of the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care. [ 2 ]

Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences. [ 3 ]

Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. [ 4 ]

Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable. [ 5 ]

A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the patient and family. [ 6 ]

Individual, family, or group, which includes significant others and populations. [ 7 ]

The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care. [ 8 ]

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.  [ 9 ]

Grouping data into similar domains or patterns.

Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP).

While implementing interventions during the nursing process, includes components such as organizing the components of the plan with input from the health care consumer, engaging the patient in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team. [ 10 ]

Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow. [ 11 ]

Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder.

“Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion.

Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the patient/family tells us), touched, or smelled. [ 12 ]

The assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. [ 13 ]

Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant.

Interventions that are carried out by having personal contact with a patient.

An electronic version of the patient’s medical record.

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values. [ 14 ]

Statements of measurable action for the patient within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame.

An evidence-based assessment framework for identifying patient problems and risks during the assessment phase of the nursing process.

A judgment formed from a set of facts, cues, and observations.

Broad statements of purpose that describe the aim of nursing care.

Employing strategies to teach and promote health and wellness. [ 15 ]

Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else.

Interventions performed by the nurse in a setting other than directly with the patient. An example of indirect care is creating a nursing care plan.

A type of reasoning that involves forming generalizations based on specific incidents.

Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations.

Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act.

A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual.

Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity. [ 16 ]

Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission.

A systematic approach to patient-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.”

Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data.

A measurable behavior demonstrated by the patient that is responsive to nursing interventions. [ 17 ]

The format of a nursing diagnosis statement that includes:

Problem (P) – statement of the patient problem (i.e., the nursing diagnosis)

Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis

Signs and Symptoms (S) – defining characteristics manifested by the patient of that nursing diagnosis

Orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. [ 18 ]

Information collected from the patient.

Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client. [ 19 ]

The skillful process of deciding which actions to complete first, second, or third for optimal patient outcomes and to improve patient safety.

The “combined and unceasing efforts of everyone — health care professionals, patients and their families, researchers, payers, planners, and educators — to make the changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning).” [ 20 ]

Developing a relationship of mutual trust and understanding.

A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing.

The underlying cause (etiology) of a nursing diagnosis when creating a PES statement.

Patients have the right to determine what will be done with and to their own person.

Principles and procedures in the discovery of knowledge involving the recognition and formulation of a problem, the collection of data, and the formulation and testing of a hypothesis.

Information collected from sources other than the patient.

Data that the patient or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as  “The patient appears anxious.”

Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. [ 21 ]

Obtaining Subjective Data in a Care Relationship

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 4 Nursing Process.
• PDF version of this title (216M)

In this Page

• NURSING PROCESS INTRODUCTION
• BASIC CONCEPTS
• OUTCOME IDENTIFICATION
• IMPLEMENTATION OF INTERVENTIONS
• SUMMARY OF THE NURSING PROCESS
• LEARNING ACTIVITIES

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