clinical judgement NCLEX

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply.

a. The nurse uses critical thinking skills to plan care for a patient.

b. The nurse correctly administers IV saline to a patient who is dehydrated.

c. The nurse assists a patient to fill out an informed consent form.

d. The nurse learns the correct dosages for patient pain medications.

e. The nurse comforts a mother whose baby was born with Down syndrome.

f. The nurse uses the proper procedure to catheterize a female patient.

a, d.

Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a plan of care for this patient. Which QSEN competency does this action represent?

a. Patient-centered care

b. Evidence-based practice

c. Quality improvement

d. Informatics

C

Quality improvement involves routinely updating nursing policies and procedures.

Providing patient-centered care involves listening to the patient and demonstrating respect and compassion.

Evidence-based practice is used when adhering to internal policies and standardized skills.

The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

A nurse is assessing a 15-year-old female patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of:

a. Clinical judgment

b. Clinical reasoning

c. Critical thinking

d. Blended competencies

A

Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case the recommendation to meet with a nutritionist.

Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems).

Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting.

Blended competencies are the cognitive, technical, interpersonal, and ethical/legal skills combined with the willingness to use them creatively and critically when working with patients.

Which statement is related to the concept that is central to the nursing process?

A .It is dynamic rather than static.

B. It focuses on the role of the nurse.

C. It moves from the simple to the complex.

D. It is based on the patient's medical problem.

A

it is dynamic rather than static

A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is directly related to this concept?

A. Defining characteristics

B. Outcome criteria

C. Etiology

D. Goal

C

etiology: the cause, set of causes, or manner of causation of a disease or condition.

what should the nurse do during the evaluation step of the nursing process?

A. set the time frame for goals

B. revise a plan of care

C. determine priorities

D. establish outcomes

B

Which information supports the appropriateness of a nursing diagnosis?

A. Defining characteristics

B. Planning interventions

C. Diagnostic statement

D. Related risk factors

A

defining characteristics

Which action is associated with the evaluation step of the nursing process?

A. A nurse takes the vital signs when a patient reports chest pain.

B. A nurse determines that a patient is at risk for impaired skin integrity because of reduced mobility and malnutrition.

C. A nurse and patient decide that within 3 days the patient will learn how to draw up and self-administer insulin safely.

D. A nurse determines that further intervention is necessary when the patient experiences sacral edema after being turned and positioned every 2 hours.

D

Explanation:

Revising a plan of care in response to a patient not achieving a desired outcome (absence of signs and symptoms of pressure when turning and positioning a patient every 2 hours) is part of the evaluation step of the nursing process.

A patient became short of breath and reported sudden chest pain while being transferred from the bed to a chair for the first time after surgery for a fractured hip. The nurse immediately returned the patient to bed, raised the head of the bed and started oxygen at 2 L via nasal cannula. Which step of the nursing process was most important in this scenario?

A. Planning

B. Assessing

C. Evaluating

D. Diagnosing

C

Evaluating

Explanation:

The nurse's actions were based on an evaluation of the patient's response to the nursing care being delivered. The reassessment of the patient and comparing the actual outcome to desired outcome is considered evaluation.

List the following nursing interventions in the order representing the steps of the nursing process beginning with the first step and progressing to the last step.

1. Obtaining a list of the patient's allergies.

2. Concluding that a patient has a deficient fluid volume.

3. Administering a prescribed enema to a patient who is constipated.

4. Assessing a patient's level of pain after administering an opioid analgesic.

5. Identify nursing interventions that should be implemented to meets a patient's needs.

1, 2, 5, 3, 4

Explanation:

1. Collecting data from the patient is a form of assessment. Assessment is the first step of the nursing process.

2. Coming to a conclusion about collected data is part of the analysis step of the nursing process. Analysis is the second step of the nursing process.

5. Identifying nursing interventions that should be implemented is related to the planning step of the nursing process. Planning is the third step of the nursing process.

3. Administering an enema is the performance of a procedure. Procedures that require direct patient care are part of the implementation step of the nursing process. Implementation is the fourth step of the nursing process.

4. Determining a patient's response to a medication is part of the evaluation step of the nursing process. Evaluation of care is the fifth step of the nursing process.