Exam 3 Nursing process part 1

What are the Five Rights of Delegation?

Right task, right circumstance, right person, right direction/communication, right supervision/evaluation.

What is the “right task”?

The task must be appropriate to delegate and within the delegatee’s role.

What is the “right circumstance”?

The patient must be stable and the situation appropriate for delegation.

What is the “right person”?

The delegatee must be competent and allowed to perform the task.

What is the “right direction/communication”?

Clear, specific instructions including what to report and when.

What is the “right supervision/evaluation”?

The nurse must follow up, ensure completion, and evaluate the patient.

What can you NOT delegate?

Nursing judgment, assessment, interpretation, decision‑making.

What CAN a CNA/UAP do?

Routine tasks: ADLs, hygiene, feeding, mobility, toileting, routine vital signs.

What does ABC stand for?

Airway, Breathing, Circulation.

Which problem is ALWAYS first?

Airway obstruction.

What comes after airway?

Breathing problems (difficulty breathing, low SpO₂).

What comes after breathing?

Circulation problems (bleeding, shock).

What is the first priority in Maslow?

Physiological needs (air, food, water, temperature).

What is the second priority?

Safety and security.

What is the third priority?

Love and belonging.

What is the fourth priority?

Self‑esteem.

What is the fifth priority?

Self‑actualization.

Which is higher priority: acute or chronic?

Acute/new change.

Which is higher priority: stable or unstable?

Unstable.

Who diagnoses and prescribes?

Physician

NP (Nurse Practitioner)

PA (Physician Assistant).

Who assesses and creates the nursing plan of care?

RN.

Who gives meds within scope and reports changes?

LPN.

Who assists with ADLs and routine vitals?

CNA (Certified Nursing Assistant)

UAP (Unlicensed Assistive Personnel)

Who helps with mobility and walking?

Physical therapist.

Who helps with ADLs and adaptive equipment?

Occupational therapist.

Who treats swallowing problems?

Speech‑language pathologist.

Who manages nutrition?

Registered dietitian.

Who helps with psychosocial needs and resources?

Social worker.

Who coordinates discharge planning?

Case manager.

What is read‑back?

Hear the order → write it → read it back → confirm accuracy.

What is closed‑loop communication?

Sender gives message → receiver repeats → sender confirms.

What does ISBAR stand for?

Identify, Situation, Background, Assessment, Recommendation.

What is “Identify”?

State your name/role and the patient.

What is “Situation”?

State the current problem.

What is “Background”?

Give relevant history.

What is “Assessment”?

State what you found.

What is “Recommendation”?

State what you need next.

What is incivility?

Rude, disrespectful, or disruptive behavior.

What is lateral violence?

Peer‑to‑peer incivility.

What is vertical violence?

Supervisor ↔ subordinate incivility.

Rudeness between a boss and an employee disrespect going both ways..

Examples of uncivil behaviors?

Gossiping, eye‑rolling, mocking, snapping fingers, blaming others.

What policy addresses incivility?

Zero‑tolerance policy.

What is the cognitive domain?

Thinking, understanding, applying knowledge.

What is the affective domain?

Feelings, attitudes, values.

What is the psychomotor domain?

Physical skills, hands‑on tasks.

What is teach‑back?

Client explains the information back to the nurse.

What is return demonstration?

Client performs the skill to show understanding.

How do you teach clients with low health literacy?

Use simple language, avoid jargon, face‑to‑face, repeat, check understanding.

How do you teach a hearing‑impaired client?

Face them, speak clearly, reduce noise, write key info.

How do you teach an elderly client?

Slow pace, repetition, simple language, good lighting, minimize distractions.

Why is a low‑stimulus environment important?

Reduces distractions and improves learning.

What are common barriers?

Fear, anxiety, pain, fatigue, language barriers, cognition issues.