Nursing Process and Clinical Judgment Questions 1, 7-9

A newly admitted patient is confused about their medications. Which step of the nursing process should the nurse perform first?

• Develop expected outcomes

• Assess medication knowledge and current medication list

• Implement medication teaching

• Evaluate the patient’s understanding after teaching

A patient has uncontrolled pain despite PRN analgesics. After reassessing, the nurse revises the care plan and contacts the provider for a new analgesic order. This action best exemplifies which nursing process principle?

• Static planning

• Dynamic planning and implementation

• Initial assessment only

• Documentation only

A nurse prioritizes interventions after completing a full assessment and identifying three nursing diagnoses. Which activity demonstrates correct use of the nursing process?

• Implement interventions for the least severe problem first

• Order interventions by patient safety and immediacy of need

• Follow unit routine order of tasks

• Delegate all interventions to assistive personnel

A patient’s serum potassium falls to 2.9 mEq/L and the nurse recognizes the need for urgent intervention. Choosing and initiating an appropriate intervention without delay is an example of:

• Routine documentation

• Clinical judgment

• Passive observation

• policy adherence

During a rapid deterioration, a nurse integrates subtle assessment cues and decides to initiate a rapid response. This demonstrates which element of clinical judgment?

• Knowledge of hospital codes only

• Interpretation of clustered data to make a clinical decision

• Waiting for physician orders before acting

• Routine assessment without interpretation

A nurse implements a protocol based on a recent systematic review that showed reduced catheter-associated infections. Which practice best reflects evidence-based practice?

• Using the review plus clinical expertise and patient values to change practice

• Following only tradition and prior habit

• Changing practice without reviewing evidence quality

• Using only textbook recommendations from 20 years ago

A unit introduces a new fall-prevention bundle based on high-quality randomized trials. The nurse participating in the change should prioritize which action to support EBP implementation?

• Refuse the change until personally convinced

• Collect unit-level outcome data and provide feedback to staff

• Implement inconsistently based on preference

• Ignore patient preferences when applying the bundle

A nurse writes a care plan with the goal: “Patient will ambulate 3 times daily by discharge.” This is best classified as which element of care planning?

• Goal with measurable outcome

• Nursing diagnosis

• Intervention without evaluation

• General aspiration without timeline

A patient with congestive heart failure has shortness of breath. Which intervention should be prioritized in the individualized care plan?

• Teach foot care only

• Monitor respiratory status and administer prescribed diuretics promptly

• Schedule routine lab tests only next week

• Refer to social work without addressing breathing

When updating a patient’s care plan after a postoperative complication, the best nursing action is to:

• Reassess, revise diagnoses and update interventions immediately

• Wait until the end of shift to document changes

• Continue with the original plan unchanged

• Delegate revision to the unit clerk