KAPLAN DECISION TREE

Priority Question - Key Terms

- focuses on identifying the most important action to take first

- often use words like "first," "best," "initial," or "immediate"

Priority Action vs. Priority Client

- action = one patient

- client = multiple patients

What is this question type?

A client receives IV 0.9% NS at a rate of 125 mL/hr. Two hours later, the nurse notes the client has crackles in both lungs that do not clear with coughing. The client reports shortness of breath. It is important for the nurse to take which action immediately?

Priority Question - Priority Action

Priority Question - Priority Action

- assessment vs. implementation

- physical vs. psychosocial (maslow's)

- ABCs

A client receives IV 0.9% NS at a rate of 125 mL/hr. Two hours later, the nurse notes the client has crackles in both lungs that do not clear with coughing. The client reports shortness of breath. It is important for the nurse to take which action immediately?

Place the client in High-Fowler's position.

3 multiple choice options

What is this question type?

The nurse provides care for clients. Which client will the nurse see first?

Priority Question - Priority Client

Priority Question - Priority Client

- stable vs. unstable

- expected vs. unexpected

- ABCs

- acute vs. chronic

- actual vs. potential

The nurse provides care for clients. Which client will the nurse see first?

A client after a total hip replacement is confused, diaphoretic, and dyspneic.

3 multiple choice options

Evaluation Question - Key Terms

include phrases like "indicates understanding," "further teaching needed," "correct interpretation," "appropriate", or "evaluate"

Evaluation Question - Alternate Strategies

- right/wrong & true/false

- indicated/contraindicated

- expected/unexpected

- normal/abnormal

- if/then

- infectious/non-infectious

- tally risk factors

What is this question type?

The charge nurse evaluates client assignments. The nurse determines that client assignments are appropriate if the unlicensed assistive personnel (UAP) performs which task?

Evaluation Question - Scope of Practice

Evaluation Question - Scope of Practice

- RN: cannot delegate assessment or initial teaching

- LPN/LVN: stable client with predictable outcome

- UAP: standard, unchanging procedures

The charge nurse evaluates client assignments. The nurse determines that client assignments are appropriate if the unlicensed assistive personnel (UAP) performs which task?

Encourages a client to practice the postoperative exercised taught by the nurse.

3 multiple choice options

Evaluation Question - Therapeutic Communication (Key Terms)

often uses words like "response" or "statement"

What is this question type?

A client in the psychiatric unit asks the nurse, "Am I in a special radioactive shelter, and when was it last checked for radioactivity? Which response by the nurse is most therapeutic?

Evaluation Question - Therapeutic Communication

Evaluation Question - Therapeutic Communication (DO)

- respond in feeling tone

- provide information

- focus/use silence and presence

Evaluation Question - Therapeutic Communication (DON'T)

- ask why

- ask yes/no

- say "don't worry"

A client in the psychiatric unit asks the nurse, "Am I in a special radioactive shelter, and when was it last checked for radioactivity? Which response by the nurse is most therapeutic?

"Your safety is of concern to you. This is a hospital."

3 multiple choice options