Nursing Process Overview

An example of subjective data for assessment is:

• "I feel like I have a fever"

• Patient appears flushed

• Patient's temperature is 101 degrees F - orally

• Patient is experiencing a high fever

Which of the following does NOT fit within the cluster of impaired mobility

• Dragging left leg when walking

• Using a cane

• Complains of pain in left leg

• Requires assistance to ambulate

Another term for "diagnostic label" is:

• Nursing diagnosis

• Cluster

• Problem

• Etiology

What observation can be made about the following nursing diagnostic label:

Pneumonia related to bacterial infection.......

• Nothing is wrong with it

• Stated correctly

• It is a medical diagnosis

• It is a NANDA dx.

Determining goals, outcomes and interventions is within which step of the Nursing Process?

• Assessment

• Diagnosis

• Planning

• Evaluation

Which intervention represents one that is nurse initiated (Independent ) action

• Administer furosemide 40 mg po every am

• Assist the patient with a bed bath

• Patient's diet: Low sodium

• Change wound dressing daily

Implementation best refers to:

• Deciding on the appropriate interventions

• Carrying out the physicians orders

• Determining if the goal has been met

• Carrying out the planned interventions

The nursing assistant reports that a patient is complaining of SOB (shortness of breath). Which action should the nurse take next?

• Let the patient rest and check on him in 30 minutes

• Instruct the nursing assistant to take a set of vital signes

• Contact the physician immediately

• Assess the patient her/him self

The blood pressure in the left arm per the electronic machine reads as 80/ 40. What is the next action by the RN?

• Check the other arm

• Obtain a different machine

• Re check the BP with a stethoscope

• Initiate the alarm for a code blue

The patient's O₂ saturation at 8 AM was 95%. At 2 p.m. when vital signs are checked again, it is 90%. What is the first action by the nurse?

• Call the physician

• Check it using another finger

• Do a further assessment

• Elevate the head of the bed.