2
N524 assessment 1 questions with precise detailed answers
|| || || || || || ||
clinical judgement steps - ✔✔Recognize cues (assessment): The filtering of information from
|| || || || || || || || || || ||
different sources (i.e., signs, symptoms, health history, environment).
|| || || || || || || ||
Analyze cues (analysis): The linking of recognized cues to the client's clinical presentation
|| || || || || || || || || || || || || ||
and establishing probable client needs, concerns, and problems.
|| || || || || || ||
Prioritize hypotheses (analysis): Establishing priorities of care based on the client's health
|| || || || || || || || || || || ||
problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic
|| || || || || || || || ||
tests, lab values).
|| ||
Generate solutions (planning): Identifying expected outcomes and related nursing
|| || || || || || || || ||
interventions to ensure a client's needs are met. || || || || || || ||
Take actions (implementation): To implement appropriate interventions based on nursing
|| || || || || || || || || ||
knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a
|| || || || || || || || || || || || ||
client's health. ||
Evaluate outcomes (evaluation): To evaluate a client's response to nursing interventions and
|| || || || || || || || || || || ||
reach a nursing judgment regarding the extent to which outcomes have been met.
|| || || || || || || || || || || ||
nursing process - ✔✔Assessment
|| || ||
Diagnosis
Planning
Implementation
Evaluation
,2
5 activities needed to preform a systematic assessment - ✔✔Collect data
|| || || || || || || || || ||
Verify data ||
Organize data ||
Identify Patterns ||
Report and record data
|| || ||
What is important data? - ✔✔Name
|| || || || ||
Age
Gender
Admitting dx ||
Medical/surgical hx ||
Chronic illness ||
Advanced directives ||
Lab data/ diagnostic tests
|| || ||
Medications
Allergies
Support services ||
Psychosocial/Cultural assessment ||
What is clinical reasoning? - ✔✔The thinking process by which a nurse reaches a clinical
|| || || || || || || || || || || || || || ||
judgement
Considers nursing knowledge, client situations, and prioritization of client problems and
|| || || || || || || || || || ||
concerns, while utilizing evidence-based practice
|| || || ||
What is critical thinking? - ✔✔The skill of learning to analyze and interpret data to solve a
|| || || || || || || || || || || || || || || || ||
problem to achieve a desired outcome.
|| || || || ||
,2
Includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive
|| || || || || || || || ||
reasoning, intuition, application, and creativity.
|| || || ||
Individual factors that impact clinical situations - ✔✔•Nursing factors (i.e., knowledge, skills,
|| || || || || || || || || || || ||
specialty)
•Nurse characteristics (i.e., attitudes, prior experience, level of experience)
|| || || || || || || ||
•Cognitive load (i.e., demands on the nurse, stress, problem-solving, memory).
|| || || || || || || || ||
Environmental factors that impact clinical situations - ✔✔•Setting, situation, and
|| || || || || || || || || ||
environment (i.e., safety considerations, equipment, surroundings)
|| || || || ||
•Client observation (i.e., age, symptoms of health alteration)
|| || || || || || ||
•Resources (i.e., staffing, supplies, beds, care partners)
|| || || || || ||
•Health records (i.e., history, labs, diagnostic tests, I&O, medications, treatments)
|| || || || || || || || ||
•Time pressure (i.e., pager, STAT medication, change in client condition)
|| || || || || || || || ||
•Cultural considerations (i.e., language, literacy, religion, diet)
|| || || || || ||
•Task complexity (i.e., level of difficulty, complicated versus simple action, number of people
|| || || || || || || || || || || ||
involved, sound delegation)
|| || ||
•Risk assessment (i.e., identifying and finding ways to remove or minimize harm to promote
|| || || || || || || || || || || || ||
safety and health).
|| || ||
, 2
Prioritization Process - ✔✔ABCD's || || ||
Safety
Stable vs Unstable || ||
Diagnosis
Psychosocial issues ||
Order of required tasks || || || ||
Time sensitive ||
Delegable tasks ||
After a change of shift, you are assigned to care for the following patients. Which patient
|| || || || || || || || || || || || || || || ||
should you assess first?A. A 60-year old patient on a ventilator for whom a sterile sputum
|| || || || || || || || || || || || || || || ||
specimen must be sent to the lab. || || || || || ||
B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 92%
|| || || || || || || || || || || || || || || || || ||
saturation.
C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics.
|| || || || || || || || || || || || || ||
D. A 50-year old with asthma who complains of shortness of breath after using a
|| || || || || || || || || || || || || || || ||
bronchodilator - ✔✔D. A 50-year old with asthma who complains of shortness of breath
|| || || || || || || || || || || || || ||
after using a bronchodilator.
|| || ||
Sterile specimen can be delegated and is a low priority task
|| || || || || || || || || ||
COPD patients will tend to be at a lower oxygen level normally. This patient has no
|| || || || || || || || || || || || || || || ||
additional data that would indicate being unstable || || || || || ||
IV antibiotics are a timed medication and need to be administered on a schedule however,
|| || || || || || || || || || || || || || ||
there is a patient at higher priority
|| || || || || ||
N524 assessment 1 questions with precise detailed answers
|| || || || || || ||
clinical judgement steps - ✔✔Recognize cues (assessment): The filtering of information from
|| || || || || || || || || || ||
different sources (i.e., signs, symptoms, health history, environment).
|| || || || || || || ||
Analyze cues (analysis): The linking of recognized cues to the client's clinical presentation
|| || || || || || || || || || || || || ||
and establishing probable client needs, concerns, and problems.
|| || || || || || ||
Prioritize hypotheses (analysis): Establishing priorities of care based on the client's health
|| || || || || || || || || || || ||
problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic
|| || || || || || || || ||
tests, lab values).
|| ||
Generate solutions (planning): Identifying expected outcomes and related nursing
|| || || || || || || || ||
interventions to ensure a client's needs are met. || || || || || || ||
Take actions (implementation): To implement appropriate interventions based on nursing
|| || || || || || || || || ||
knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a
|| || || || || || || || || || || || ||
client's health. ||
Evaluate outcomes (evaluation): To evaluate a client's response to nursing interventions and
|| || || || || || || || || || || ||
reach a nursing judgment regarding the extent to which outcomes have been met.
|| || || || || || || || || || || ||
nursing process - ✔✔Assessment
|| || ||
Diagnosis
Planning
Implementation
Evaluation
,2
5 activities needed to preform a systematic assessment - ✔✔Collect data
|| || || || || || || || || ||
Verify data ||
Organize data ||
Identify Patterns ||
Report and record data
|| || ||
What is important data? - ✔✔Name
|| || || || ||
Age
Gender
Admitting dx ||
Medical/surgical hx ||
Chronic illness ||
Advanced directives ||
Lab data/ diagnostic tests
|| || ||
Medications
Allergies
Support services ||
Psychosocial/Cultural assessment ||
What is clinical reasoning? - ✔✔The thinking process by which a nurse reaches a clinical
|| || || || || || || || || || || || || || ||
judgement
Considers nursing knowledge, client situations, and prioritization of client problems and
|| || || || || || || || || || ||
concerns, while utilizing evidence-based practice
|| || || ||
What is critical thinking? - ✔✔The skill of learning to analyze and interpret data to solve a
|| || || || || || || || || || || || || || || || ||
problem to achieve a desired outcome.
|| || || || ||
,2
Includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive
|| || || || || || || || ||
reasoning, intuition, application, and creativity.
|| || || ||
Individual factors that impact clinical situations - ✔✔•Nursing factors (i.e., knowledge, skills,
|| || || || || || || || || || || ||
specialty)
•Nurse characteristics (i.e., attitudes, prior experience, level of experience)
|| || || || || || || ||
•Cognitive load (i.e., demands on the nurse, stress, problem-solving, memory).
|| || || || || || || || ||
Environmental factors that impact clinical situations - ✔✔•Setting, situation, and
|| || || || || || || || || ||
environment (i.e., safety considerations, equipment, surroundings)
|| || || || ||
•Client observation (i.e., age, symptoms of health alteration)
|| || || || || || ||
•Resources (i.e., staffing, supplies, beds, care partners)
|| || || || || ||
•Health records (i.e., history, labs, diagnostic tests, I&O, medications, treatments)
|| || || || || || || || ||
•Time pressure (i.e., pager, STAT medication, change in client condition)
|| || || || || || || || ||
•Cultural considerations (i.e., language, literacy, religion, diet)
|| || || || || ||
•Task complexity (i.e., level of difficulty, complicated versus simple action, number of people
|| || || || || || || || || || || ||
involved, sound delegation)
|| || ||
•Risk assessment (i.e., identifying and finding ways to remove or minimize harm to promote
|| || || || || || || || || || || || ||
safety and health).
|| || ||
, 2
Prioritization Process - ✔✔ABCD's || || ||
Safety
Stable vs Unstable || ||
Diagnosis
Psychosocial issues ||
Order of required tasks || || || ||
Time sensitive ||
Delegable tasks ||
After a change of shift, you are assigned to care for the following patients. Which patient
|| || || || || || || || || || || || || || || ||
should you assess first?A. A 60-year old patient on a ventilator for whom a sterile sputum
|| || || || || || || || || || || || || || || ||
specimen must be sent to the lab. || || || || || ||
B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 92%
|| || || || || || || || || || || || || || || || || ||
saturation.
C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics.
|| || || || || || || || || || || || || ||
D. A 50-year old with asthma who complains of shortness of breath after using a
|| || || || || || || || || || || || || || || ||
bronchodilator - ✔✔D. A 50-year old with asthma who complains of shortness of breath
|| || || || || || || || || || || || || ||
after using a bronchodilator.
|| || ||
Sterile specimen can be delegated and is a low priority task
|| || || || || || || || || ||
COPD patients will tend to be at a lower oxygen level normally. This patient has no
|| || || || || || || || || || || || || || || ||
additional data that would indicate being unstable || || || || || ||
IV antibiotics are a timed medication and need to be administered on a schedule however,
|| || || || || || || || || || || || || || ||
there is a patient at higher priority
|| || || || || ||
