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NURSING INTERVENTIONS AND ETHICAL
CONSIDERATIONS IN CARE 2025|212 QUETSIONS
WITH CORRECT ANSWERS |A+ PASS
Physiological Needs Basic survival needs that take priority, including airway, breathing, circulation, food, water, warmth, rest, vital signs, oxygen, pain, elimination, and nutrition. Safety and Security Includes physical safety (fall prevention, infection control) and emotional safety (routine, predictability). Love and Belonging Involves relationships with family, friends, and community. Esteem Relates to respect, self-worth, and achievement.
Self-Actualization The highest level of need, focusing on fulfilling personal potential and personal growth. Specific, Measurable, Achievable, Relevant, Time-bound (SMART) Goals Criteria for setting effective goals in nursing care. Oxygen Saturation Goal The patient will maintain an oxygen saturation of ≥95% on room air during waking hours by the end of the shift. Pain Level Goal The patient will verbalize a pain level of 3 or less on a 0-10 scale within 30 minutes of receiving prescribed analgesic. Ambulation Goal The patient will ambulate 50 feet using a walker three times a day with standby assistance by discharge.
Actions that require a provider's order, such as administering medications or starting an IV. Teaching Deep Breathing An example of an independent nursing action where a nurse teaches a patient how to deep breathe and cough. Repositioning Patients An independent nursing action that involves turning/repositioning a patient every 2 hours. Cold Compress Application An independent nursing action that involves applying a cold compress for swelling. Emotional Support An independent nursing action that includes providing emotional support or therapeutic communication.
Pain Assessment An independent nursing action that involves assessing pain or monitoring for side effects. Administering Medications A dependent nursing action that requires a provider's order. Inserting a Foley Catheter A dependent nursing action that requires a provider's order. Starting an IV A dependent nursing action that requires a provider's order. Applying Oxygen Therapy A dependent nursing action that requires a provider's order.
Help the patient walk How often? How far? With or without assistive devices? Give medication Which medication? Dose? Route? Time? Monitor pain Not measurable or time-specific. Better: 'Assess pain level using 0- scale every 2 hours.' 5 W's + H method Who, What, When, Why, How for critiquing nursing interventions. Implementation Doing the 'Nursing Work' to carry out planned interventions. Medication Management
Giving scheduled insulin injection before meals. Patient Education Teaching how to use a walker before discharge. Safety Applying bed alarm for a fall-risk patient. Emotional/Supportive Sitting with a grieving family member. Five Rights of Delegation Right Task, Right Circumstances, Right Person, Right Direction/Communication, Right Supervision/Evaluation. Right Task
RN's Ultimate Responsibility for Client Care The Registered Nurse (RN) remains legally and ethically responsible for the overall care of the patient, including any delegated tasks. Purpose of Evaluation of Outcomes Determine if Nursing Goals were Met: To assess whether the expected outcomes and goals in the nursing care plan have been achieved. Steps in Evaluation of Outcomes Identify the Criteria and Standards: Use the expected outcomes or goals that were set in the nursing care plan as the benchmark. Appropriate Nursing Actions if Client Goal/Outcomes are Not Met Reassess the Patient: Gather more data to understand why the goal was not achieved (e.g., changes in patient condition, new symptoms). Examples of Evaluative Statements to Critique (Goal Met, Not Met, or Partially Met AEB:...)
Goal Met: Goal met AEB the patient's blood pressure stabilized at 120/80 mmHg for 48 hours without symptoms. Documentation Criteria/Guidelines for correct charting/documentation. Initial and Date the Correction Add your initials and the current date next to the correction. Write the Correct Information Nearby or in a New Entry Record the correct information clearly and accurately, referencing the original error if needed. Example 1 — Clear and Appropriate 0800: Patient reports pain 6/10 at the surgical site. Administered 4 mg morphine IV per order. Reassessed pain at 0830, decreased to 3/10. No adverse reactions noted. Critique: Clear, concise, factual; Includes time, assessment, intervention, and patient response; Uses objective pain scale.
Generally, NO, a nurse should only chart actions they personally performed or directly observed. Exceptions — When Can a Nurse Chart for Someone Else? Verbal Reports or Witnessed Actions: If another healthcare professional verbally reports to the nurse that they performed a task or procedure, the nurse may document that information, but must clearly identify the source. Example of Verbal Reports "Physical therapy assessed patient's mobility at 1000; findings reported to nursing staff." Shared or Delegated Tasks with Oversight If a nurse delegates a task to a competent staff member (e.g., UAP), and the nurse directly observes or verifies the outcome, the nurse can document that task. Example of Delegated Task
"UAP assisted patient with toileting at 0800; patient tolerated procedure well as observed." If Policy Allows Co-Signing or Authentication Some institutions allow nurses to co-sign or authenticate entries made by other licensed personnel, but this must follow facility policy. Factual Data/Cues (Objective Information) Observable, measurable, and verifiable information gathered through your senses or tools. Examples of Factual Data Vital signs (BP 130/80 mmHg); Patient states, "I feel nauseous."; Skin is warm and dry; Wound measures 3 cm with no drainage. Documentation Tips for Factual Data Use clear, specific, and neutral language. Report only what you see, hear, feel, or measure. Avoid interpretations or assumptions.
Alarm Stage: Initial reaction to stress (fight-or-flight response). The body releases adrenaline and cortisol, increasing heart rate, blood pressure, and energy supply. Resistance Stage The body tries to adapt to the stressor. Exhaustion Stage Prolonged stress depletes the body's resources, leading to fatigue, illness, or even death if the stress continues. Local Adaptation Syndrome (LAS) A localized (specific area) response to stress or injury, involving the body's attempt to limit the damage to a specific part rather than the whole system. Reflex Pain Response Immediate withdrawal from painful stimulus.
Inflammatory Response Localized reaction causing redness, heat, swelling, and pain at injury site. Fight or Flight Response The body's immediate, automatic reaction to a perceived threat or danger, triggered by the sympathetic nervous system. Key Physiological Changes in Fight or Flight Response Increased heart rate and blood pressure, rapid shallow breathing, dilated pupils, increased blood flow to muscles, release of adrenaline and cortisol, decreased digestion and immune activity temporarily. Purpose of Fight or Flight Response To provide a quick burst of energy and heightened awareness for survival. Selye's Theory of Stress (General Adaptation Syndrome - GAS)
Enhanced alertness, improved focus, motivation to act, better performance, and increased energy. Nervous System Response to Stress Activates sympathetic nervous system, releases adrenaline and cortisol, increases alertness, and dilates pupils. Endocrine System Response to Stress Releases stress hormones (cortisol, adrenaline, norepinephrine) from adrenal glands to mobilize energy and maintain alertness. Cardiovascular System Response to Stress Increased heart rate and blood pressure to deliver more oxygen and nutrients to muscles and brain. Respiratory System Response to Stress Faster, deeper breathing to increase oxygen intake.
Musculoskeletal System Response to Stress Muscle tension to prepare for action; prolonged tension may cause pain or headaches. Gastrointestinal System Decreased digestion, reduced blood flow to GI tract; can cause nausea, indigestion, or changes in appetite. Immune System Initially boosted but prolonged stress suppresses immunity, increasing risk of infection. Urinary System Reduced urine output initially; chronic stress may affect kidney function. Reproductive System Stress hormones can reduce libido and affect menstrual cycles or fertility.
