Clinical Decisions Part 1 Lecture NURN 153 Exam 1

What is the Nursing Process?

A systematic, step-by-step problem-solving method used to make safe, client-centered clinical decisions.

How does the Nursing Process relate to critical thinking?

Nurses use critical thinking within the Nursing Process to solve clinical problems and decide what actions to take.

How does NCLEX describe the Nursing Process?

A scientific clinical reasoning approach to client care.

What are the five steps of the Nursing Process?

Assessment → Analysis → Planning → Interventions/Implementation → Evaluation.

Why is the Nursing Process considered systematic?

It follows organized, sequential steps to guide nursing care.

Why is the Nursing Process dynamic and flexible?

The patient's condition can change, so the nurse must continually adjust the plan of care.

What is the overall purpose of the Nursing Process?

Identify client problems, develop a plan, implement care, and work toward optimal patient outcomes.

What are major advantages of using the Nursing Process?

Individualized care, client participation, continuity, effective communication, organized care planning, and evaluation of interventions.

What occurs during the assessment step?

The nurse gathers and collects information about the client.

What is the primary source of assessment data?

The client.

What are examples of secondary sources of assessment data?

Family, significant others, physical exam, nursing history, healthcare team/EMTs, labs, and diagnostic tests.

What is subjective data?

Information reported verbally by the client; it is a symptom.

What is an example of subjective data?

“I have a headache.”

What is objective data?

Observable or measurable data; it is a sign, such as vital signs, physical assessment findings, labs, or diagnostics.

A client says, “I feel short of breath,” and SpO₂ is 88%. Which is subjective and which is objective?

“I feel short of breath” = subjective; SpO₂ 88% = objective.

What happens during analysis of assessment data?

The nurse asks questions, gathers more data if needed, and clusters related findings to identify patterns and problems.

Why does the nurse cluster assessment data?

To determine which findings are relevant, recognize patterns, and identify possible client problems.

What should the nurse do if the assessment data are insufficient to identify the problem?

Gather more data and ask additional questions before making a conclusion.

During analysis, what major question should the nurse ask?

“What does the assessment data tell me about the client's problem?”

What should the nurse determine after identifying a possible problem?

Whether it is something nursing can address and what should be done about it.

What is critical thinking in nursing?

Actively analyzing and evaluating collected information from observation, experience, and communication to make a decision for action.

Why is prioritization a critical-thinking skill?

The nurse must determine which problems require immediate attention and which can wait.

What frameworks can help establish nursing priorities?

ABCs and Maslow's Hierarchy.

What problems are considered high priority?

Problems involving ABCs/life threats, safety, and pain that require prompt attention.

What is an intermediate-priority problem?

A problem that is non-emergent and non-life-threatening but still requires nursing care.

What is a low-priority problem?

One that may not affect the current medical problem but could affect the client's future well-being.

A client has difficulty breathing and is also worried about missing work. Which problem comes first?

Difficulty breathing because physiologic/ABC problems take priority over lower-level concerns.

Two problems are identified during assessment. What should the nurse do before planning interventions?

Prioritize the problems based on urgency and client needs.

What happens during the planning step?

The nurse organizes the care plan, establishes outcomes with the client, and selects interventions.

How is an expected outcome related to the nursing problem?

The desired outcome should represent improvement or elimination of the problem.

What are the three major purposes of outcomes?

They measure success, guide interventions, and motivate progress.

Why must the nurse establish an outcome before choosing interventions?

The nurse needs to know what they are trying to accomplish before deciding how to accomplish it.

What does it mean for an outcome to be client-centered?

It reflects the client's highest possible wellness and independence and is realistic for their needs/resources.

What is a short-term outcome?

An expected benefit achieved within hours or days.

What is a long-term outcome?

An expected benefit achieved over weeks, months, or years.

What does SMART stand for when writing outcomes?

Specific, Measurable, Attainable, Relevant, Time-Bound.

Why is “The client will improve mobility” a weak outcome?

It is not specific or measurable and has no time frame.

Why is “The client will walk 50 ft in the hall twice a day” a better outcome?

It is specific and measurable and clearly identifies the expected client behavior.

What should nursing interventions be based on?

Evidence, nursing knowledge, experience, and clinical judgment.

What sources can support evidence-based nursing interventions?

Lippincott Advisor, textbooks, research articles, and other credible sources.

What is a rationale for a nursing intervention?

The scientific reason explaining why the intervention is appropriate.

What characteristics should good nursing interventions have?

Clear, specific, prioritized, individualized, feasible, acceptable, and supported by rationales.

What is an independent nursing action?

An action the nurse performs based on nursing judgment and knowledge.

What is a collaborative nursing action?

An action involving mutual decision-making with other healthcare team members.

What is a dependent nursing action?

An intervention that requires a provider/physician order.

Why might the nurse position a client upright when breathing is difficult?

Upright positioning allows greater lung expansion, facilitating breathing and comfort.

What happens during implementation?

The nurse carries out the planned interventions—the “doing” step.

Does implementation include only physical treatments?

No. It can include assessment, treatments, teaching, referrals, and carrying out provider orders.

What happens during evaluation?

Compare the client's actual response with the expected outcome and determine whether interventions are working.

After evaluation, when should the nurse continue, modify, or terminate the plan?

Continue: outcome not achieved and no barrier requiring change is identified. Modify: outcome not achieved and new problems/risk factors or better approaches are identified. Terminate: outcome achieved, no new problems, and the client can care for themself.