Chatgbt nursing Process test
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122 Terms
What is delegation?
Asking another healthcare team member to perform a specific task for a patient.
Does delegating a task remove the nurse's responsibility?
No. The nurse is still responsible for making sure the task is appropriate, the correct person performs it, instructions are clear, follow-up occurs, and the patient remains safe.
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 is appropriate to delegate and is within the other person's role.
What question should the nurse ask for the Right Task?
“Can I delegate this task?”
What is the Right Circumstance?
The patient's condition and situation make delegation appropriate.
What should the nurse consider for the Right Circumstance?
Whether the patient is stable and whether the situation is appropriate for delegation.
What is the Right Person?
The person receiving the task is allowed and competent to perform it safely.
What is Right Direction & Communication?
Giving clear, specific instructions, including exactly what should be done and what/when to report.
What is Right Supervision & Evaluation?
The nurse follows up, ensures the task was completed correctly, and evaluates the patient and results.
Does delegation end when the nurse assigns the task?
No. The nurse must follow up, assess the patient, evaluate the finding, and take appropriate action.
What can a nurse delegate?
A TASK.
What can a nurse NOT delegate?
Nursing judgment.
Can a CNA collect information?
Yes, when it is an appropriate delegated task.
Can a CNA interpret the information and make nursing decisions?
No. Interpretation and nursing decisions remain the nurse's responsibility.
What is the CNA delegation rule?
DO → OBSERVE → REPORT.
What is the nurse's role?
ASSESS → INTERPRET → DECIDE → EVALUATE.
Can the nurse delegate “Take Mr. Smith's blood pressure”?
Yes, to an appropriate team member.
Can the nurse delegate “Assess Mr. Smith and determine why his BP is low” to a CNA?
No. That requires nursing assessment and judgment.
MEMORY:
CNA = DO, OBSERVE, REPORT
Nurse = ASSESS, INTERPRET, DECIDE, EVALUATE
What is priority setting?
Organizing client care so the most critical intervention or action is completed first.
What does ABC stand for?
A = Airway
B = Breathing
C = Circulation
Which generally comes first: airway, breathing, or circulation?
Airway → Breathing → Circulation.
What does the ABCDE framework stand for?
Airway
Breathing
Circulation
Disability
Exposure
What is the purpose of ABCDE?
Recognize and stabilize the client's most critical issues first before moving to the next vital system.
A client cannot speak or cough. What is the priority?
Airway — this suggests the airway may be blocked.
A client suddenly develops severe difficulty breathing. Is this a priority?
Yes. Breathing problems take priority over comfort and routine needs.
A client is actively bleeding. Which ABC category is affected?
Circulation.
What can cyanosis/blue lips indicate?
Inadequate oxygen, making breathing/oxygenation a priority.
Which is usually more concerning: a new unexpected problem or a stable chronic problem?
A new/unexpected change is generally more concerning.
Which has priority: new chest pain or unchanged chronic back pain?
New chest pain. Do not choose based only on which patient reports the higher pain number.
Why is new confusion concerning?
It represents a new change in condition requiring prompt assessment.
What is the basic rule of Maslow's hierarchy?
Needs lower in the hierarchy should be met before higher-level needs.
What are Maslow's five levels from lowest to highest?
Physiological
Safety/security
Love/belonging
Self-esteem
Self-actualization
What are physiological needs?
Essential physical needs required for survival, such as air, food, water, shelter, sleep, clothing, warmth, and rest.
Which Maslow level is the nurse's first priority?
Physiological needs.
After physiological needs are met, what comes next?
Safety and security.
What are love and belonging needs?
Social relationships such as friendships, family, intimacy, trust, affection, and connection.
What are self-esteem needs?
Confidence, achievement, recognition, appreciation, and respect from others.
What is self-actualization?
Reaching one's greatest potential and achieving self-fulfillment.
PRIORITY MEMORY:
ABC → acute/new changes → physiological → safety → psychosocial
When is interprofessional collaboration needed?
When a patient's needs require assistance from other members of the healthcare team.
Who should help a patient who has difficulty swallowing?
Speech-language pathologist (SLP).
Who helps a patient learn to walk safely?
Physical therapist (PT).
Who helps with mobility, strength, balance, walking, and physical function?
Physical therapist.
Who helps patients perform ADLs as independently as possible and recommends adaptive equipment?
Occupational therapist (OT).
Who helps with nutritional problems?
Registered dietitian (RD/RDN).
Who assesses nutritional needs and develops nutrition recommendations?
Registered dietitian.
Who provides respiratory treatments and assists with oxygen, airway, and breathing therapies?
Respiratory therapist (RT).
What is the pharmacist's role?
Reviews medications for safety, interactions, and dosing and provides medication information.
What is the social worker's role?
Helps with psychosocial needs, resources, support services, finances, and discharge needs.
What is the case manager's role?
Coordinates care, services, discharge planning, equipment, and follow-up needs.
What does the RN do?
Assessment, nursing diagnosis, teaching, IV pushes, complex care.
What can an LPN/PN safely perform?
Focused assessments, data collection, wound care, PO/IM meds, care for stable clients.
What does the UAP/CNA do?
Assists with ADLs, hygiene, feeding, mobility, toileting, and routine measurements such as vital signs, and reports observations to the nurse.
What are the four IPEC core competencies?
Values/ethics
Roles and responsibilities
Interprofessional communication
Teams and teamwork
What is ISBAR?
A structured way to communicate important patient information clearly and quickly.
What does I in ISBAR mean?
Identify — identify yourself and the patient.
What does S mean?
Situation — state the current problem/reason for communicating.
What does B mean?
Background — give relevant patient history/information.
What does A mean?
Assessment — report your assessment/findings.
What does R mean?
Recommendation/Request — state what you need or recommend.
⭐ ISBAR MEMORY:
I = Who?
S = What's happening?
B = What do they need to know?
A = What did I find?
R = What do I need next?
When is read-back especially important?
When receiving verbal or telephone orders.
What are the steps for read-back?
Hear it → Write/enter it → Read it back → Confirm it.
Why is read-back performed?
To confirm accuracy and reduce miscommunication.
According to the material, what should the nurse do when receiving a prescription?
Record it, read it back as written to the prescriber, verify that it is correct, and clarify anything confusing.
What is closed-loop communication?
Making sure a message or task was received, understood, and completed.
What are the steps of closed-loop communication?
Sender gives message → receiver repeats/confirms → sender verifies.
When is closed-loop communication especially useful?
During teamwork and emergencies.
When is the communication loop closed?
When the sender gives a specific message/task, the receiver acknowledges it, and the completion/result is communicated back.
⭐ DIFFERENCE:
Read-back = especially verbal/telephone orders
Closed-loop = confirm a team message/task was received, understood AND completed
What is incivility?
Uncivil workplace behavior that can include gossiping, excluding others, being rude or discourteous, ignoring others, or refusing to help a coworker.
Give examples of uncivil behavior.
Gossiping, eye rolling, mocking others, snapping fingers at someone, blaming someone for your mistake, embarrassing someone, inappropriate tone, sarcastic remarks, raising your voice, or refusing to help.
What is bullying?
Recurring unwelcome behavior intended to harm, humiliate, or distress another person.
What makes incivility become bullying?
Repetition of harmful actions.
What is lateral violence?
Incivility occurring peer to peer/horizontally.
Example of lateral violence?
One nurse bullying or behaving uncivilly toward another nurse at the same level.
What is vertical violence?
Incivility between a supervisor and subordinate, or vice versa.
Example of vertical violence?
A supervisor bullying a staff nurse or a subordinate behaving uncivilly toward a supervisor.
Should incivility be accepted as “part of the job”?
No. These behaviors should not be justified or normalized.
Why is incivility a patient-safety concern?
It undermines communication and teamwork and negatively affects the quality and safety of client care.
⭐ MEMORY:
Lateral = same LEVEL
Vertical = up/down hierarchy
What are the three domains of learning?
Cognitive
Affective
Psychomotor
What is the cognitive domain?
The thinking domain.
What does cognitive learning involve?
Thinking through information, understanding it, and applying knowledge.
What are the six stages listed for the cognitive domain?
Knowledge
Comprehension
Application
Analysis
Synthesis
Evaluation
What is Knowledge?
Remembering facts or information.
What is Comprehension?
Understanding information and explaining it.
What is Application?
Using learned information in real situations.
What is Analysis?
Breaking information into parts to find patterns or relationships.
What is Synthesis?
Combining parts to create something new.
What is Evaluation?
Judging or deciding based on criteria or evidence.
A patient explains why a medication is needed. Which domain?
Cognitive.
What is the affective domain?
The emotional/feeling domain.
What does the affective domain involve?
Feelings, values, attitudes, and beliefs.
A patient expresses acceptance of a new stoma. Which learning domain?
Affective.
What is the psychomotor domain?
The action/hands-on domain involving physical movement, skills, coordination, and the senses.
A patient physically demonstrates how to change a stoma pouch. Which domain?
Psychomotor.
What is an example of progression in psychomotor learning?
The client can progress from observing the nurse perform a skill, to assisting, performing it with supervision, and eventually performing it independently and consistently.