EXAMPLE: NURSING PROCESS (assessment, nursing diagnosis, planning, intervention, and evaluation)
The nurse is caring for a client diagnosed with congestive heart failure who is currently complaining of dyspnea. Which intervention should the nurse implement first?
1. Administer furosemide (Lasix), a loop diuretic, IVP.
2. Check the client for adventitious lung sounds.
3. Ask the respiratory therapist to administer a treatment.
4. Notify the healthcare provider
Checking for adventitious lung sounds is assessing the client to determine the extent of the client’s breathing difficulties causing the dyspnea.
One of the basic guidelines to apply in nursing practice is the nursing process, which consists of five steps—assessment, nursing diagnosis, planning, intervention, and evaluation—usually completed in a systematic order. Many questions can be answered based on “assessment.” If a priority-setting question asks the test taker which step to implement first, the test taker should look for an answer that would assess for the problem discussed in the stem of the question.
The client diagnosed with peptic ulcer disease has a blood pressure of 88/42, an apical pulse of 132, and respirations are 28. The nurse writes the nursing diagnosis “altered tissue perfusion related to decreased circulatory volume.” Which intervention should the nurse implement first?
1. Notify the laboratory to draw a type & crossmatch.
2. Assess the client’s abdomen for tenderness.
3. Insert an 18-gauge catheter and infuse lactated Ringer’s.
4. Check the client’s pulse oximeter reading.
1. Notifying the laboratory for a type & crossmatch would be an appropriate intervention since the client is showing signs of hypovolemia, but it is not the first intervention because it would not directly support the client’s circulatory volume.
2. The stem of the question has provided enough assessment data to indicate the client’s problem of hypovolemia. Further assessment data are not needed.
3. The vital signs indicate hypovolemia, which is a life-threatening emergency that requires the nurse to intervene to support the client’s circulatory volume. The nurse can do this by infusing lactated Ringer’s.
4. A pulse oximeter reading would not support the client’s circulatory volume.
Follow Maslow's hierarchy of needs: (1. Physiologic, 2. Safety and security, 3. Belongingness and affection, 4. Esteem and self respect, 5. Self actualization)
Prioritizing and providing care for a variety of hospitalized clients.
FIRST LEVEL PRIORITY PROBLEMS:
4.Vital signs problem (abnormal v\s)
Note: Cardiac or circulation (first if cardiac arrest “follow CAB”)
SECOND LEVEL PRIORITY PROBLEMS:
3.Untreated medical problems (hyperglycemia, chronic pain, acute elimination issues, abnormal lab result, risk for infection, safety).
Note: Last priority patients are discharge patients, needs teachings, or patients without problems “NORMAL”.
With a question that asks which client should the nurse assess first!
Each option should be examined carefully to determine the priority by asking these questions:
1. Is the situation life threatening or life altering? If yes, this client is the highest priority.
2. Is the situation unexpected for the disease process? If yes, then this client may be priority.
3. Is the data presented abnormal? If yes, then this client may be priority.
4. Is the situation expected for the disease process and not life threatening? If yes, then this client may be—but probably is not—priority.
5. Is the situation/data normal? If yes, this client can be seen last.
TRY THESE QUESTIONS FOR PRACTICE:
The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first?
1. Assist the client to a sitting position.
2. Assess the client’s vital signs.
3. Call 911 for the paramedics.
4. Auscultate the client’s lung sounds.
The CLSC nurse received phone messages from the CLSC secretary. Which client should the nurse phone first?
1. The client diagnosed with hypertension who is reporting a BP of 148/92.
2. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93%.
3. The client diagnosed with congestive heart failure who has edematous feet.
4. The client diagnosed with chronic atrial fibrillation who is having chest pain.
Which medication should the nurse administer first after receiving the morning shift report?
1. The IVPB antibiotic to the client with endocarditis admitted at 0530 today.
2. The antiplatelet medication to the client who had a myocardial infarction.
3. The coronary vasodilator patch to the client with coronary artery disease.
4. The statin medication to the client diagnosed with atherosclerosis.
The client admitted to rule out (R/O) a myocardial infarction is complaining of substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement first?
1. Take the client’s pulse, respirations, and blood pressure.
2. Call for a stat electrocardiogram and a troponin level.
3. Place sublingual nitroglycerin 1/150 g under the tongue.
4. Notify the HCP that the client has pain.
Which client warrants immediate intervention by the nurse?
1. The client diagnosed with pericarditis who has chest pain with inspiration.
2. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse.
3. The client diagnosed with Marfan syndrome who has pectus excavatum.
4. The client diagnosed with atherosclerosis who has slurred speech and drooling.
The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority.
1. The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually.
2. The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday.
3. The 29-year-client diagnosed with septicemia who called to request more blankets because of being cold.
4. The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today.
5. The 37-year-old client who has a Stage 4 pressure sore and the dressing needs to be changed this morning.
The fire alarm starts going off in the family practice clinic. Which action should the nurse take first?
1. Determine whether there is a fire in the clinic.
2. Evacuate all the people from the clinic.
3. Immediately call 911 and report the fire.
4. Instruct clients to stay in their rooms and close the doors.
The male post-op femoral popliteal client notifies the desk via the intercom system he has fallen and is now bleeding. Which interventions should the nurse implement? Rank in order of performance.
1. Apply pressure directly to the bleeding site.
2. Notify the surgeon of the fall and the bleeding.
3. Redress the site with a sterile dressing.
4. Assist the client to a recumbent position in the bed.
5. Make out an occurrence report and document the fall.
The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse’s actions from first (1) to last (5).
1. Open the client’s airway.
2. Check the client’s carotid pulse.
3. Assess the client for unresponsiveness.
4. Perform compressions at a 30:2 rate.
5. Pinch the nose and give two breaths.
The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority.
1. Cleanse the stomal site with mild soap and water.
2. Assess the stoma for a pink, moist appearance.
3. Monitor the drainage in the ostomy drainage bag.
4. Apply stoma adhesive paste to the skin around the stoma.
5. Attach the ostomy drainage bag to the abdomen