Clinical Judgement Flashcards
What skills are needed for critical thinking?
- Intellect
- Creativity
- Inquiry
- Reasoning
- Reflection
- Intuition
What are some common steps used to make decisions?
- Identify the situation or problem
- List all possible alternatives and outcomes
- Compare pros and cons
- Select the best option or alternative to try
- Put the alternative into action
- Evaluate the success
What does the acronym SMART stand for?
S- single specific action M- measurable A- Attainable R- Relevant T- time limited
Define the assessment stage of the nursing process
- Fist step of the nursing process
- Nurse makes decisions about what data to collect, meaning of normal/abnormal findings, data relevant to client’s condition
- Nurse makes decisions about how to react to assessment findings
Define the diagnosis stage of the nursing process
A statement of nursing judgment, nurses are licensed to treat, and human response to health condition.
A statement of nursing judgment and refers to a condition that nurses are licensed to treat
What are the types of nursing diagnoses?
- Actual diagnosis
- Risk diagnosis
- Wellness diagnosis
- Health promotion diagnosis
- Syndrome diagnosis
Define the implementation phase of the nursing process
The action phase of the nursing process. Doing and documenting specific nursing actions needed to carry out interventions.
What are some ways to prioritize care for patients?
- Assessments
- Nursing process
- Maslow’s
- Categories of interventions
- Time constraints
- Significance on client outcomes
- Urgency
What are the urgency levels?
Nonacute
Acute
Critical
Imminent death
Which injured client of a mass casualty disaster should a triage nurse in an emergency department establish as the priority client?
- An unresponsive client with a penetrating head injury
- A partially responsive client with a sucking chest wound
- A client with a maxilla fracture and facial wounds without airway compromise
- A client with third-degree burns over 65% of the body surface area
The correct answer is: A partially responsive client with a sucking chest wound.
A sucking chest wound is a life-threatening but survivable emergency. The patient would be triaged as priority 1.
The unresponsive patient with a penetrating head injury and the severely burned patient have a limited potential for survival, even with definitive care.
The patient with the facial wounds is significant and require medical care, but can wait hours without threat to life.
An adult client experiencing diabetic ketoacidosis has been admitted to an emergency department. Which interventions should a nurse initiate immediately? Select all that apply.
- Administer oxygen
- Administer D5W with 0.9% NaCl solution after establishing an intravenous IV access
- Initiate a regular insulin infusion
- Determine the time and amount of the last insulin injection
- Administer potassium and magnesium to correct electrolyte imbalances
- Assess the client’s breath for the presence of ketones
The correct answers are: Administer oxygen, Initiate a regular insulin infusion, Determine the time and amount of the last insulin injection
Diabetic ketoacidosis is characterized by hyperglycemia (usually above 300mg/dL, ketosis, acidosis, and dehydration. Airway management with oxygen administration is necessary. Regular insulin infusion is initiated to lower the patient’s blood glucose levels. Determining the time and amount of the last insulin injection is needed to ascertain the initial starting dose of the insulin infusion.
The initial IV solution is 0.9% NaCl. Once glucose levels approach 250 mg/dL, 5% dextrose is added.
Although electrolyte imbalances occur due to the loss of electrolytes from hyperglycemic diuresis, laboratory assessment of the patient’s serum values should be completed first.
Assessing the breath odor is an assessment, not an intervention.
A nurse notes that a client has dyspnea and red blotches on the face and arms and appears anxious following exposure to latex. The nurse calls the acute response team (ART) who initiates emergency treatment per protocol. Of all the emergency treatments available which action should be taken first by ART?
- Start oxygen at 1 liter per minute via nasal cannula
- Start an IV access with a large-bore IV catheter
- Administer diphenhydramine IM
- Administer epinephrine hydrochloride 0.4mL subQ
The correct answer is: Administer Epinephrine hydrochloride (Adrenalin) 0.4 mL subcutaneously
Epinephrine is a sympathomimetic that acts rapidly to prevent or reverse cardiovascular collapse, airway narrowing from bronchospasm, and inflammation.
Oxygen should be initiated at the onset, but 1 liter per NC is too low. Generally, emergency oxygen is administered using a non-rebreather mask at 90%-100% oxygen concentration.
Obtaining IV access will take longer, so it should not be the first action.
Intramuscular administration of diphenhydramine (Benadryl) has an onset of 20-30 minutes.
A school-aged child is brought to an emergency department by ambulance. The child is minimally responsive, hypotensive, tachycardic, and has a high fever. Orders are written by a health-care provider. Which order should the nurse initiate first?
- Saline Bolus per weight-based protocol
- Blood cultures times 2
- Ampicillin 25 mg/kg IV q 6h
- Oxygen at 40 % FlO2
The correct answer is: Oxygen at 40% FIO2
The priority is oxygen administration because hyperthermia increases oxygen demand and the low cardiac output secondary to hypotension decreases the availability of oxygen to tissues.
In this case, the child is also minimally responsive, which is the more acute problem that requires oxygen support.
Fluid boluses should then be administered to treat hypotension and increase cardiac output and tissue perfusion.
Blood cultures should be drawn prior to intravenous antibiotics.
A client on a telemetry unit has a blood pressure of 88/40, a heart rate of 44 beats per minute, feels faint, and is pale and confused. When caring for this client, which tasks should a registered nurse delegate to a patient care assistant. Select all that apply.
- Paging for the charge nurse
- Paging for the respiratory therapist
- Applying oxygen per protocol
- Securing an automatic BP machine
- Completing a head-to-toe assessment
- Obtaining a cardiac rhythm strip that the nurse has sent for printing at a central location
The correct answer are: Paging for the charge nurse, Securing an automatic BP machine, and Obtaining a cardiac rhythm strip that the nurse has sent for printing at a central location.
Because the patient’s condition is deteriorating, additional assistance is needed. The PCA should be able to page for the charge nurse, secure an automatic BP machine, and obtain a printed rhythm strip.
There is no indication of respiratory distress, so it is unnecessary to page for a respiratory therapist.
The RN should apply the oxygen and complete a focused assessment, not a complete head-to-toe assessment.
Which assessment findings should indicate to a nurse that an adult client experiencing an acute asthma attack warrants urgent medical intervention with an inhaled beta-2 agonist. Select all that apply.
- Client speaking in short sentences
- Oxygen saturation 94%
- Respiratory rate of 32 BPM
- Wheezes heard on chest auscultation
- HR 122 BPM
- Pulses paradoxus
The correct answers are: Respiratory rate of 32 breaths per minute, Pulses paradoxus, Wheezes heard on chest auscultation, Heart rate 122 beats per minute.
The increased RR is the body’s attempt to increase oxygen intake. Pulses paradoxus is a greater than 10 mm Hg drop in systolic blood pressure or widening of the pulse during inspiration. It occurs in asthma because of the high negative intrathoracic pressure that increases venous return and right ventricular filling. Consequently, the inter-ventricular septum bulges slightly into the left ventricular outflow tract, decreasing cardiac output, and thus BP. Wheezes are expiratory sounds from forced airflow through abnormally collapsed airways with residual air trapping Hr increases to compensate for the decreased oxygenation and Pulses paradoxus.
Dyspneic persons speak in words not sentences
Oxygen saturation of 94% correlates with a paO2 of 70% (normal PaO2 is 70-100%)
