Nursing Practice and Clinical Judgment Quiz

Maintaining the client's dignity, independence, preferences, privacy, and safety.

Encouraging the client to do what they can on their own.

Identifying health-related concerns and attaining health outcomes.

To collect data to fully understand the patient's needs.

To analyze and determine key issues for making a judgement.

60 degrees

35lb (16kg) maximum when the patient is cooperative and unlikely to move suddenly

Return to a supine position and take blood pressure.

Lateral/side-lying position

To enhance comfort.

Increased respiratory rate

Prevent contractures and maintain patient position.

Increased bone density.

Predict pressure sore risk.

Pressure slowing blood flow

Wash folds between labia minora then labia majora.

Risk for aspiration.

In a supine position (back) at about 45-60 degree angle

Dress affected side first.

Remove from the unaffected side first

Active, passive, and a combination of both

Social groups, personal preferences, body image, socio-economic status, health beliefs, cultural variables, physical condition

Tracheostomies, drains, dressings, skin integrity, language deficits, sedation, mental illness, reduced physical energy

Close curtains, maintain client dignity, minimize exposure, use a 'do not disturb' sign

Infection control, body mechanics, client ability and risks, water temperature and product use, skin integrity

Assessment, diagnosis, prioritizing hypothesis, planning, and implementation

Promoting client well-being, maintaining privacy and confidentiality, and ensuring fairness

Providing and facilitating care, respecting, trust, integrity, shared vision, and good communication skills

Establishing requirements for entry to practice, promoting practice standards, and administering quality assurance programs

Ensuring a hygienic environment, incorporating infection prevention and control practices, and promoting patient comfort and dignity