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TEST SHELLS
Using the Nursing Process as Test Item Content Categories
The nursing process can easily be used as a systematic approach to solve problems in individualized nursing care situations.
The traditional five-step nursing process consists of assessment, diagnosis, planning, implementation, and evaluation.
MASTER ITEM:
THE
NURSE IS (ASSESSING, CARING, DOCUMENTING, EVALUATING,
WHO (CLIENT VIGNETTE): (DESCRIBE A CLIENT WITH A PROBLEM)
TEACHING)
A
CLIENT,
Lead-In: Which of the following findings (assessments or manifestations), risks/problems,
client goals, drugs, nursing interventions, or evaluation findings?
Options: (List of Assessments, Problems/Risks, Client Goals, Nursing Interventions, and
Evaluations)
NURSING ASSESSMENT & COLLECTION OF DATA
The nurse is caring for a client admitted to the hospital, seen in the home/at the clinic] with a medical diagnosis of _____
[Insert diagnosis/disorder].
A. When taking the client’s history, the nurse should expect _____ [her, him] to describe which _____ [complaint,
symptom, condition]?
B. When taking the client’s history, which information is most significant?
C. Which question indicates that the nurse understands the major symptoms associated with _____ [Insert
diagnosis/disorder]?
D. Which question should the nurse ask the _____ [client, family] (first)?
E. To obtain information needed for _____ {Describe a diagnosis or treatment, etc.}, which question should the
nurse ask (first)?
To determine a client’s self-care ability,
A. it is most important for the nurse to ask the _____ [client, family] which question?
B. the nurse should _____ [measure, determine] the client’s ability to perform which activities of daily living?
A client comes to the _____ [clinic, healthcare provider’s office, mental health center, hospital, emergency department]
because of _____ [Insert signs and symptoms].
A. Which question is most important for the nurse to ask (first)?
B. Which information is most important for the nurse to obtain (first)?
A _____ [client, family] is scheduled for _____ {Describe a procedure, treatment, therapy, etc.}. Which information is
most important to obtain from _____ [him, her, them] _____ [before, after] _____ [the procedure, treatment, therapy,
etc.]?
When _____ [auscultating a newborn’s heart rate, talking with the client], it is most important for the nurse to _____
[implement which intervention, ask which question]?
.Which information relates most directly to a diagnosis of _____ [Insert disease/disorder]?
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Which environmental factors are most disturbing to a client with _____ [Insert diagnosis/disorder]?
Which symptom is the client with _____ [Insert disease/disorder] most likely to exhibit _____ [upon admission to the
hospital, within the first 24 hours after admission to the hospital]?
Which symptom most clearly relates to _____ {Describe a condition, medical diagnosis, etc.}?
Which symptom(s) is (are) most characteristic of _____ [Insert diagnosis/disorder]?
The nurse observes a client for signs of _____ [Insert disease/disorder], which are most likely to include which [symptom,
condition, complaint]?
When observing a client for symptoms of _____ [Insert disease/disorder], [the nurse should assess, it is most important
that the nurse to assess] for which _____ [finding, condition]. {Make distracters discriminating.}
To determine _____ [status or seriousness of complaint],
A. the nurse should _____ [assess for which condition, ask which question]?
B. what question is most important for the nurse to ask (first)?
C. which information is most important for the nurse to obtain?
Which approach is best for the nurse to use when assessing _____ [for the presence of uterine contractions, a client’s risk
for attempting suicide]?
In caring for a client with _____ [Insert disease/disorder], the nurse should be alert for which complication?
When assessing a client, which _____ [blood value, behavior] indicates that the client is experiencing normal changes
associated with _____ [pregnancy, adolescence]?
A client comes to the emergency department with _____ [symptoms of placenta previa/abruption, increased intracranial
pressure]. {Instead of naming a disorder, a description of symptoms could also be used.}
A. What _____ [data, information, lab finding] should the nurse obtain (first)?
B. What assessment data are most important for the nurse to obtain (first)?
C. What information is most important to obtain in determining the client’s _____ [prognosis, immediate nursing
care]?
The nurse anticipates _____ [the baby of a mother who had a high alcohol intake during pregnancy, the child of an
alcoholic] to exhibit which _____ [symptoms, behaviors] during _____ [the first day of life, adolescence]?
Because of the inability to _____ [conceive, walk], the nurse should assess this client’s history for which _____
[condition, factors]?
When performing an initial _____ [post delivery, postoperative] assessment, the nurse should expect the client’s _____
[lochia, bandage, urine] to have which appearance?
A [client, couple] with _____ [late stage ovarian cancer, known fertility problems] is most likely to exhibit which
behavior?
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Which member of the staff should the nurse assign to assess a client with _____ [Insert disease/disorder]
Which information is most important for the nurse to obtain from the family of a woman who _____ [recently attempted
suicide, has just been told she has inoperable cancer]?
CONFIRM DATA
When observing a client for symptoms of _____ [shock, increased intracranial pressure], the earliest symptom of this
condition can be obtained by which _____ [measurement, assessment]?
Prior to administration of each dose of _____ [insert drug name and proprietary name], it is most important for the nurse
to obtain which assessment?
{Describe a medication or treatment.} is prescribed for a client with _____ {Describe a medical diagnosis, symptoms,
certain laboratory findings.}. Which conclusion regarding this _____ [medication, treatment] is accurate?
[Insert drug] is prescribed for a child weighing _____, and the normal dosage is _____/kg. What dosage of the [Insert
drug] should the nurse administer?
The nurse is correct to question which activity of a client with _____ [Insert disease/disorder]?
{Describe a reading from a medical equipment device or a finding that indicates that a medical equipment device is
malfunctioning.}. When encountering a strange reading from a _____ [respirator, fetal monitor], what action should
the nurse take (first)?
COMMUNICATE INFORMATION GAINED IN ASSESSMENT
Which information should the nurse communicate immediately to the _____ [healthcare provider, charge nurse, family,
and client]?
Which group of symptoms should be reported to the _____ [healthcare provider, social worker]?
A client is scheduled to have _____ [an ultrasound, endoscopy, heart catheterization]. Which information is most
important to obtain _____ [before, during, after] the procedure?
IDENTIFICATION OF NEEDS/PROBLEMS
Identify Actual or Potential Healthcare Needs/Problems Based on Assessment
INTERPRET DATA
The _____ [physician, healthcare provider] prescribes _____ {Describe a medication or treatment.}. Before _____
[transcribing the prescription, initiating the treatment], it is most important for the nurse to implement which
intervention?
Two hours after _____ [delivery, surgery], the _____ [infant, child, and client] is lethargic and has developed _____ [mild
generalized cyanosis, a low blood pressure]. The nurse recognizes that the _____ [infant, child client] is most likely
exhibiting symptoms of which condition?
{Describe an assessment finding such as heart rate, temperature, etc.}
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A. Why should the nurse notify the _____ [physician, healthcare provider]?
B. What action should the nurse take (first)?
C. Based on this information, which intervention should the nurse include in the client’s plan of care?
A [woman, adolescent] gained _____ {Insert number.} pounds at _____ [8 weeks gestation, 13 years of age]. According
to expected weight gain for this _____ [gestation, age child], which interpretation by the nurse is accurate?
A client is admitted with a diagnosis of _____ [Insert diagnosis/disorder]. This condition is
A. most often manifested by which _____ [symptom, finding, condition]?
B. primarily due to which _____ [condition, environmental hazard]?
C. most often exacerbated by which _____ [environmental condition, health-related behavior]?
The nurse is assessing a _____ [gravida 5, three days postoperative] client who is complaining of _____ [intermittent
uterine cramping, nausea]. These complaints are most likely due to which condition?
The nurse is assessing _____ [a client, child, or an infant] whose _____ [Insert affected vital signs, laboratories or
manifestations].
A. The _____ [respiratory rate, hematocrit] is most likely due to which _____ [condition, finding]?
B. The _____ [client, infant] is exhibiting which _____ [condition, potential problem, health-related behavior]?
The _____ {Describe the client’s condition, medical diagnosis, etc.} client received _____ [a bolus anesthetic via epidural
catheter before delivery, 10 mg morphine sulfate IV push in the emergency department].
A. It is essential for the nurse to consider which aspect of this client’s care?
B. It is most important for the nurse to collect which information prior to administration?
A client’s susceptibility to _____ [infection] is most likely
A. due to which aspect in the client’s history?
B. related to a history of which condition?
C. due to which environmental factor?
Based on the nurse’s assessment of a _____ [postpartum, postoperative] client, which finding indicates _____ [the
presence of an abnormality, a normal test result]?
The nurse is caring for a _____ [postpartum, postoperative] client who has a prescription for _____ {Describe a
medication or treatment regime.}. What is the main purpose of this _____ [medication, treatment regime]?
Which characteristic of a _____ [newborn, 5-year-old] should the nurse consider _____ [a normal, an abnormal] finding?
When monitoring a client’s respiratory status,
A. which symptom provides the nurse with the earliest indication of respiratory difficulty?
B. which finding should be reported to the _____ [physician, healthcare provider] immediately?
C. the nurse should interpret which finding as within normal limits for a client with _____ [COPD, chronic
bronchitis]?
The client had _____ [epidural anesthesia, an endoscopic procedure], which condition should the nurse anticipate as a
potential problem?
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FORMULATE NURSING DIAGNOSES
{Describe assessment data.} Based on these data,
A. which nursing diagnosis should the nurse document for this client?
B. what is the priority nursing diagnosis for this client?
C. this client’s symptoms are most clearly an example of which _____ [condition, problem]?
As the result of a client _____ [smoking 2 packs of cigarettes a day, using cocaine] during _____ [pregnancy, their adult
life], the _____ [fetus, client] is at greatest risk for developing which _____ [condition, disease]?
A client who is 6 hours _____ [postpartum, postoperative] is having difficulty voiding. The nurse identifies a nursing
diagnosis of “impaired urinary elimination” that is secondary to which condition?
The nurse recognizes which factor in the client’s history is
A. most likely to be related to a diagnosis of _____ [INSERT DIAGNOSIS/DISORDER]?
B. the most important etiological factor in developing _____ [INSERT DIAGNOSIS/DISORDER]?
Which finding is indicative of a nursing diagnosis of _____ [decreased cardiac output, anxiety related to...]?
_____ {Describe a medication or treatment.} is most often used for _____ [postpartum, postoperative] clients with _____
[diabetes, myasthenia gravis] because of _____ [its action on which organ, the low incidence of which side effect]?
The method used to treat _____ [hypertension, arthritis] is based chiefly upon its _____ [action on which organ, ability to
treat which condition]?
COMMUNICATE RESULTS OF ANALYSIS
The nurse understands that the main purpose of the _____ [Apgar score, Glasgow Coma Scale] is to describe which _____
[parameter, condition]?
A client is to receive _____ {Describe a medication or treatment, etc.} for _____ [Insert diagnosis/disorder].
A. Which finding, if present, should the nurse report to the _____ [physician, healthcare provider] before
administering the _____ [medication, treatment]?
B. After administering the _____ [medication, treatment], which assessment finding should the nurse document?
The nurse cautions a client who _____ [is taking a drug, or having a particular manifestation] to _____ [avoid sunlight, eat
small, frequent meals]. Why is this instruction important?
PLANNING OF CARE
Setting Goals for Meeting Client’s Needs and Designing Strategies to Achieve These Goals
PRIORITIZE NURSING DIAGNOSES
When planning care for a client with [Insert diagnosis/disorder],
A. which nursing diagnosis has the highest priority?
B. which nursing diagnosis should the nurse plan to address first?
A client is seen in the _____ [clinic, hospital, emergency room] with _____ [an increased blood pressure, an elevated
temperature, pinpoint pupils]. Which nursing diagnosis has the highest priority?
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Initial treatment for a client with _____ [Insert diagnosis/disorder] should be based on which nursing diagnosis?
DETERMINE GOALS OF CARE
What is the most important goal of care for the client who is receiving _____ {Describe a medication, treatment, etc.}?
Which assessment should the nurse plan to obtain after a client has received a prescription for _____ [an antihypertensive
drug, a central nervous system depressant] to treat _____ [Insert diagnosis/disorder]?
On admission to _____ [the hospital/clinic, labor and delivery] a client reports having _____ [a headache for the past two
days, epigastric pain]. The nurse should give the highest priority to which goal?
When preparing the care plan for a client _____ [with PIH, who has recently attempted suicide], it is most important for
the nurse to include a goal that addresses which need?
FORMULATE OUTCOME CRITERIA FOR GOALS OF CARE
A client has _____ [Insert diagnosis/disorder]. Which [long-term, short-term] outcome is most important
A. for the nurse to consider?
B. for this client?
C. in planning this client’s care?
Upon admission, the nurse should give the highest priority to meeting which need of a client who _____ [recently
aborted an 18-week fetus, is brought to the emergency room unconscious]?
DEVELOP A PLAN OF CARE AND MODIFY AS NECESSARY
A client with a [positive RPR, An HIV positive client] is seen in the clinic for follow-up care. Which nursing intervention
is most essential to include in this client’s plan of care?
In planning a _____ [1,500 calorie diabetic, a low-residue] diet for a client who _____ [was recently diagnosed as
diabetic, is scheduled for abdominal surgery], the nurse should ask the client if they would like to have which _____
[food, snack, dessert]?
When preparing for _____ {Describe a procedure, treatment, etc.}, the nurse should _____ [provide the client/family
with which instruction, review which laboratory finding]?
What instruction should the nurse include in the discharge teaching plan of a client who _____ [was recently diagnosed
with diabetes, had a right cataract extraction]?
As a result of the client’s positive _____ [lab test for STD, infectious disease] culture, the nurse should prepare the client
for which treatment?
Because of the mother’s history of _____ [cocaine use, smoking 2 packs of cigarettes a day,] the nurse should expect the
infant to exhibit which behavior?
Which intervention should the nurse plan to implement to reduce a client’s discomfort during _____ [labor, a bone
marrow aspiration]?
To prevent _____ [increased intracranial pressure, hemorrhage], which intervention should the nurse include in a client’s
plan of care?
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The nurse is caring for a client with _____ [an abdominal incision, a stoma].
A. Which intervention is most important to include in this client’s plan of care?
B. Which nursing intervention has the greatest priority when planning this client’s care?
When preparing a client for _____ [an amniocentesis, surgery], it is essential for the nurse to take which action?
{Describe a situation that involves initiating an IV infusion pump.} The nurse should set the pump to deliver how many
ml per hour? {This could be a fill-in-the-blank test item.}
Hint: Math test items that require rounding should conclude with a rounding instruction such as If rounding is
required, round to the nearest tenths, or If rounding is needed, round to one decimal place/two decimal places/whole
number. Fill-in-the-blank math test items should conclude with an instruction such as Enter numerical value only.
These instructions are usually placed in parentheses at the end of the test item stem.
Which room is best for the nurse to assign a client _____ [who is exhibiting signs of depression, with PIH]?
It is important for the nurse to ensure that a client with _____ [Insert diagnosis/disorder] has a room that _____ [is in
which location, has which feature(s)]?
COLLABORATE WITH OTHER HEALTHCARE TEAM MEMBERS WHEN PLANNING DELIVERY OF CARE
A client is being discharged from the hospital with _____ {Describe equipment, medication, etc.}. When planning this
client’s discharge, it is most important for the nurse to
A. coordinate with which member of the healthcare team?
B. include a referral to which agency?
Assessment findings reveal that a client is _____ [afraid of dying, in need of financial assistance]. Which healthcare team
member is likely to be most helpful in planning this client’s care?
When assigning care of _____ [an older adult, an adolescent], which healthcare team member is best to provide care for
this client?
COMMUNICATE PLAN OF CARE
When teaching a _____ client [insert disease/disorder e.g. diabetic client, client who had a myocardial infarction],
A. it is important for the nurse to focus on which aspect of home care?
B. which instruction is most important for the nurse to include in this client’s discharge teaching plan?
A _____ [couple, client] who is unable to _____ [conceive, self-administer insulin] asks the nurse _____ [what could be
wrong, to tell him what he is doing wrong]. Which information should be included in the nurse’s explanation to this
couple/client?
IMPLEMENTATION OF CARE
Initiate and Complete Actions Necessary to Accomplish Defined Goals
ORGANIZE AND MANAGE CLIENT’S CARE
A client who is 12 hours _____ [postpartum, postoperative] begins to have difficulty breathing and complains of acute
chest pain. What action should the nurse take first?
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After _____ [administering oxygen to a newborn, raising the head of the bed for a client who is having difficulty
breathing], the nurse should implement which intervention?
The nurse provides _____ {Describe a treatment or intervention.} for a _____ [client, newborn]. To achieve the desired
outcome of this procedure, which nursing action
A. should be taken/done first?
B. has the highest priority?
.A client was in a _____ [describe a position e.g. lithotomy, supine] position for two hours during _____ [transition and
vaginal delivery, a surgical procedure].
A. The nurse should perform which intervention during the _____ [early postpartum period, immediate
postoperative period]?
B. Which nursing intervention is most helpful to this client during the _____ [early postpartum period, immediate
postoperative period]?
When developing a plan of care for _____ [a premature infant, an adolescent who is addicted to cocaine], the nurse
recognizes that it is essential to consider which _____ [assessment finding, factor in the client’s family history]?
During the[first trimester of pregnancy], the client tells the nurse that she is voiding only small amounts of urine. In
response to this complaint, which action should the nurse take (first)?
{Describe an emergent situation.}
A. The nurse should immediately take which action?
B. Which intervention should the nurse implement _____ [immediately, first]?
During the night, a _____ [postpartum, postoperative] client perspires profusely. What action should the nurse take
(first)?
When providing care for _____ [an infant’s/older adult’s, a child’s] _____ [orogastric, nasogastric] feeding tube, which
intervention is most important for the nurse to implement?
While caring for a client who has _____ [thrombophlebitis, a postoperative infection], which nursing intervention is most
essential?
A client is scheduled to receive _____ [3,000 ml of D5LR in 24 hours, 1,000 ml of LR in 8 hours]. The nurse should set
the infusion pump to deliver how many ml per hour? {This could be a fill-in-the-blank test item.}
COUNSEL/TEACH CLIENT, SIGNIFICANT OTHERS, AND/OR HEALTHCARE TEAM MEMBERS
The nurse should explain to a _____ [client, family member] that _____ {Describe a treatment, procedure, etc.} is being
implemented
A. for which purpose?
B. to obtain which expected outcome?
The client was taught how to _____ [count her pulse, change her dressing]. On reassessment, the nurse finds that _____
{Give an example of complying with the instructions or not complying with instructions.}. What intervention is
A. best for the nurse to implement?
B. most important for the nurse to implement?
A client who _____ [is newly diagnosed with diabetes, recently had an above-the-knee amputation of the right leg] is
_____ [being discharged, preparing for discharge] from the hospital.
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A. Which information is most important for the nurse to provide the _____ [client, family member] _____ prior to
discharge?
B. Which instruction should the nurse provide to the _____ [client, family member] prior to discharge?
An [antenatal, postpartum, postoperative] client who has had _____ [third trimester bleeding, a postoperative abdominal
incision infection] is being discharged with _____ [precautions, antibiotics]. Before leaving the _____ [hospital,
clinic, treatment center], which instruction is most important for the nurse to provide this client?
A client who _____ [Insert manifestation e.g. is bottle-feeding her infant develops a postoperative infection, has a
colostomy develops skin irritation around the stoma].
A. Which instruction is most important for the nurse to provide the _____ [client, family member]?
B. Which information should the nurse include in the _____ [client’s, family member’s] discharge teaching plan?
To prepare a client for _____ {Describe a treatment, diagnostic procedure, etc.}, which explanation by the nurse is _____
[accurate, most important, most helpful]?
When preparing for _____ {Describe a procedure, treatment, etc.}, the nurse should instruct the client to perform which
action?
At _____ [30 weeks gestation, two weeks postsurgical procedure], a client undergoes an _____ [ultrasound, endoscopy].
The nurse explains that the results of the _____ [ultrasound, endoscopy] should provide which information?
[Bed rest, Ambulation] is prescribed for _____ [a 46-year-old male client, an older adult] with _____ [phlebitis,
pneumonia]. The nurse should explain that the chief purpose of _____ [bed rest, ambulation] is to obtain which
outcome?
.It is most important for the nurse to include which instruction in the healthcare teaching of a client who is diagnosed with
_____ [hypertension, schizophrenia]?
.A client with _____ {Describe a finding in the client’s history or medical diagnosis.} is afraid of _____ [hurting her
newborn, having sexual intercourse with his wife]. Which response by the nurse is likely to be most helpful in
reducing this client’s fears?
A client who recently had a _____ [fourth-degree episiotomy, hemorrhoidectomy] is placed on a _____ [low-residue,
high-protein] diet. The nurse explains that the purpose of this diet is to obtain which outcome?
The nurse is conducting a nutrition class for a group of _____ [new mothers, adolescents]. It is most important for the urse
to include which _____ [instruction, information] in the teaching plan?
Which _____ [directions, instructions, facts] are most important for the nurse to give a client who had _____ [a cesarean
section, abdominal surgery] when teaching about _____ [deep-breathing and coughing exercises, dressing changes]?
A client asks the nurse if an _____ [ultrasound, endoscopy] is painful. Which response by the nurse
A. is best?
B. is accurate?
C. is likely to be most _____ [helpful, supportive]?
A client is receiving _____ {Describe a treatment, procedure, etc.} for _____ {Describe a medical diagnosis, group of
symptoms, etc.}. The nurse should teach the _____ [client, family, parents, staff member] caring for the client that
_____ {Describe a reaction, condition, etc.} is caused by which _____ [condition, health-related behavior,
environmental hazard]?
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The nurse should teach the _____ [parents of a newborn, parents of a newly diagnosed 6-year-old diabetic] that
development of _____ [jaundice, hypoglycemia] is caused by which physiological condition?
A _____ [3-day-old infant, 42-year-old male] has a prescription for _____ [phototherapy, renal dialysis]. The nurse should
teach the _____ [parents, client,]
A. that _____ [phototherapy, renal dialysis] is used to obtain which outcome?
B. which precaution is most important while receiving _____ [phototherapy, renal dialysis].
The client asks the nurse why _____ [her baby is cross-eyed, she feels pain in her leg that was amputated].
A. Which response by the nurse is likely to be most helpful?
B. Which response is best for the nurse to provide?
PROVIDE CARE TO ACHIEVE ESTABLISHED GOALS OF CARE
Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is _____ [acutely
ill, nauseated]?
Which action should the nurse take to prevent _____ {Describe a disease or complication.}?
{Describe an outcome criterion or goal.} To prevent _____ [newborn infection, increased anxiety],
A. what action should the nurse take?
B. which intervention is most important for the nurse to implement?
After inserting an _____ [an invasive device e.g. orogastric, nasogastric] tube, which intervention
A. should the nurse implement (first)?
B. is most important for the nurse to implement?
Which nursing intervention is most effective in preventing the transfer of _____ {Describe a causative organism or
disease.}?
A postoperative client receives a prescription for _____ [a piece of equipment e.g. an abdominal binder, TED hose] to
prevent which condition?
SUPERVISE AND COORDINATE DELIVERY OF CLIENT’S CARE PROVIDED BY NURSING PERSONNEL
With the increased focus on management questions, most of the stems listed under Organize and Manage Client’s
Care can also be used under the category Supervise and Coordinate Delivery of Client’s Care Provided by Nursing
Personnel by simply changing organizing, managing, or implementing care to supervising or coordinating care.
For example, the first stem in Organize and Manage Client’s Care is:
A client who is 12 hours _____ [postpartum, postoperative] begins to have difficulty breathing and complains
of acute chest pain. What action should the nurse take first?
This item can easily be changed to become a stem for this category:
A client who is 12 hours _____ [postpartum, postoperative] begins to have difficulty breathing and complains
of acute chest pain. What action should the nurse instruct the LPN to take first?
Other stems for this category:
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The nurse is assigning care of _____ [client with an acutely changing circumstance e.g. unstable client, a client in first
stage of labor, a postoperative client immediately following return from the post anesthesia care unit]. Which staff
member should be assigned to care for this client?
The RN assigned a client who is _____ [in need of a particular task e.g. sterile dressing change, newly diagnosed with
diabetes mellitus] to an LPN.
A. Which instruction is most important for the RN to provide the LPN?
B. Which information about the care of this client is most important for the RN to provide the LPN?
During report, a staff member tells the charge nurse, “That client makes me sick because she whines so much.”
A. What action should the charge nurse take?
B. How should the charge nurse respond to this staff member?
The nurse sees a colleague taking drugs from the unit.
A. What action should this nurse take (first)?
B. Which intervention should the nurse implement (first)?
During a unit conference, a staff member complains that the daily assignments are unfair.
A. What action should the nurse take?
B. How should the charge nurse respond to this nurse?
COMMUNICATE NURSING INTERVENTIONS
When witnessing a client’s signature on a consent form for _____ [surgery, a procedure], which action is most important
for the nurse to take?
After completing _____ {Describe a procedure, treatment, etc.}, it is most important for the nurse to record which
information?
The nurse is caring for a client with _____ [Insert particular equipment or device e.g. a colostomy, chest tubes]. What
information is most important for the nurse to provide during shift report?
The nurse determines that the prescribed dose of a drug is not within the safe range for administration. What action should
the nurse take (first)?
The nurse observes a staff member _____ [Insert behavior, action or statement e.g. working well with a certain client,
taking supplies home]. To whom should the nurse communicate this observation (first)?
EVALUATION OF GOALS OF CARE
Determine the Extent to Which Goals Have Been Achieved and Interventions Have Been Successful
COMPARE ACTUAL OUTCOMES WITH EXPECTED OUTCOMES OF CARE
What is the probable outcome of the nurse permitting a client to _____ [Insert behavior, action or statement e.g. smoke in
a restricted area, express feelings of guilt]?
When evaluating the effects of _____ {Describe a medication, treatment, prescription, etc.}, the nurse should monitor the
results of which laboratory test(s)?
A client with _____ {Describe a condition, syndrome, diagnosis, etc.} is seen in the clinic. One client outcome was _____
{Describe an outcome associated with the condition, syndrome, diagnosis, etc.}. Which finding indicates that this
outcome _____ [was, was not] met?
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To detect a common untoward effect of _____ {Describe a medication, treatment, etc.},
A. the nurse should expect to obtain which assessment?
B. the nurse should assess the client for development of which _____ [condition, symptom]?
The occurrence of which condition warrants the nurse discontinuing a _____ [insert acutely changing client e.g. laboring
client’s, postoperative client’s] intravenous infusion of _____ [Insert Drug]?
The nurse is correct in withholding which _____ [medication, treatment] if the _____ [respiratory rate, pulse rate] _____
[is above, is below] _____ {Determine a number that corresponds with the client’s age or condition}?
Which _____ [signs, symptoms] exhibited by the client most clearly indicate that it is safe for the nurse _____ [to
administer digoxin, encourage incentive spirometer use]?
{Describe a medication, treatment, etc.}
A. To evaluate the effect of this _____ [medication, treatment], the nurse should assess for which condition?
B. The nurse should evaluate the effectiveness of this _____ [medication, treatment] within _____ [how many
weeks, what period]?
Following an _____ [Insert procedure e.g. amniocentesis, endoscopy], a client voices complaints of _____ {Describe four
complaints.}. Which complaint indicates to the nurse that the client is experiencing a complication of the _____
[Insert procedure]?
A postoperative client who is receiving [Insert a drug e.g. morphine sulfate via PCA pump] _____ [has a particular
finding e.g. respiratory rate of 8 breaths/minute, begins to hallucinate]. In evaluating the potential outcomes of this
finding,
A. what action should the nurse take?
B. which intervention should the nurse implement?
EVALUATE CLIENT’S ABILITY TO IMPLEMENT SELF-CARE
A client has a prescription for a _____ [Type of diet e.g. high-protein, liquid] diet. Selection of which _____ [food, meal]
indicates to the nurse that the client understands the prescribed diet?
Which finding indicates to the nurse that a male client is able to _____ [perform a particular task e.g. irrigate his stoma,
take his own blood pressure]?
Which method is best for the nurse to use when evaluating the ability of a _____ [newly diagnosed diabetic, new mother]
to _____ [perform a particular task e.g. self-administer insulin, feed her newborn]?
EVALUATE HEALTHCARE TEAM MEMBERS’ ABILITY TO IMPLEMENT CLIENT CARE
When evaluating the healthcare team members’ ability to _____ [plan nursing care, change a sterile dressing], it is most
important for the nurse to _____ [implement which intervention, assess for which outcome]?
After teaching a client’s _____ [wife, husband] how to _____ [change a dressing, administer medications], which method
is best for the nurse to use in evaluating _____ [her, his] technique?
Which information is most important for the nurse to include in the performance evaluation of a staff member?
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COMMUNICATE EVALUATION FINDINGS
The nurse determines that a client _____ [insert a task or procedure a client must understand or is unable to perform e.g.
self-care]. To which healthcare team member should this information be communicated (first)?
When evaluating a _____ [insert a circumstance e.g. rape victim’s report, client’s threat of suicide], which information is
most important for the nurse to obtain?
After teaching a client how to _____ [insert a procedure e.g. change a dressing, administer insulin], it is most important
for the nurse to document which information?
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APPENDIX B
Key
Key
Key
Abbreviated
Course Name
Key
Abbreviated
Course Name
Client Needs
Abbreviated
Course Name
Key: A: Activity or Project C: Clinical or Practicum E: Exit Exam F: Faculty Observation R:
Reflection/Journal TI: Theory Introduced TR: Theory Reinforced SL: Skills Lab
Abbreviated
Course Name
Abbreviated
Course Name
2013 NCLEX - RN DETAILED TEST PLAN
Abbreviated
Course Name
Courses
Key
Key
Safe and Effective Care Environment
Management of Care: The nurse provides and directs nursing care that enhances the care delivery setting to protect clients and
health care personnel. (17-23%)
Advanced Directives
Assess client and/or staff member knowledge of advanced directives (e.g. living will,
healthcare proxy, Durable Power of Attorney for Health Care (DPAHC).
Integrate advance directives into client plan of care.
Provide client with information about advanced directives
Advocacy
Discuss identified treatment options with client and respect their decisions
Provide information on advocacy to staff members
Act as a client advocate
Utilize advocacy resources appropriately (e.g., social worker, chain of command, interpreter)
Assignment, Delegation and Supervision#Added
Identify tasks for delegation based on client needs
Ensure appropriate education, skills, and experience of personnel performing delegated tasks
Assign and supervise care provided by others (e.g., LPN/VN, assistive personnel, other RNs)*
Communicate tasks to be completed and report client concerns immediately
Organize workload to manage time effectively*
Utilize the five rights of delegation (e.g., right task, right circumstances, right person, right
direction or communication, right supervision or feedback)
Evaluate delegated tasks to ensure correct completion of activity
Evaluate ability of staff members to perform assigned tasks for the position
(e.g., job description, scope of practice, training, experience)
Evaluate effectiveness of staff members’ time management skills
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Case Management
Explore resources available to assist client in achieving or maintaining independence
Assess client need for supplies and equipment (e.g. oxygen, suction machine, wound care
supplies)
Participate in providing cost effective care
Plan individualized care for client based on need (e.g. client diagnosis, self-care ability,
prescribed treatments)
Provide client with information on discharge procedures to home, hospice, or community
setting
Initiate, evaluate, and update plan of care (care map, clinical pathways etc.)
Client Rights
Recognize client right to refuse treatments/procedures
Discuss treatment options/decisions with client
Provide education to clients and staff about client rights and responsibilities (e.g. ethical/legal
issues)
Evaluate client/staff understanding of client's rights
Advocate for client rights and needs
Collaboration with Interdisciplinary Team
Identify need for interdisciplinary conferences
Identify significant information to report to other disciplines (e.g., health care provider,
pharmacist, social worker, respiratory therapist)
Review plan of care to ensure continuity across disciplines
Collaborate with healthcare members in other disciplines when providing client care
Serve as resource person to other staff
Concepts of Management
Identify roles/responsibilities of health care team members
Plan overall strategies to address client problems
Act as liaison between client and others (e.g., coordinate are, manage care)
Manage conflict among clients and others (e.g. coordinate care, manage care)
Evaluate management outcomes
Confidentiality/Information Security
Assess staff member and client/family/significant other understanding of confidentiality requirements
(e.g., HIPAA)
Maintain client confidentiality/privacy
Intervene appropriately when confidentiality has been breached by staff members
Continuity of Care
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Provide and receive report on assigned clients (standardized hand off communication)
Use documents to record and communicate client information (e.g., medical record,
referral/transfer form)
Use approved abbreviations and standard terminology when documenting care
Perform procedures necessary to safely admit, transfer or discharge a client
Follow up on unresolved issues regarding client care (e.g., laboratory results, client requests)
Establishing Priorities
Apply knowledge of pathophysiology when establishing priorities for interventions with
multiple clients
Prioritize the delivery of client care
Evaluate plan for care for multiple clients and revise plan of care as needed
Ethical Practice
Inform client/staff members of ethical issues affecting client care
Practice in a manner consistent with a code of ethics for registered nurses*
Evaluates outcomes of interventions to promote ethical practice
Informed Consent
Identify appropriate person to provide informed consent for client (e.g., client, parent, legal
guardian)
Provide written materials in client spoken language when possible
Describe components of informed consent
Participate in obtaining informed consent
Verify that the client comprehends and consents to care/procedures, including procedures
requiring informed consent
Information Technology
Receive and/or transcribe primary healthcare provider orders
Apply knowledge of facility regulations when accessing client records
Access data for client/family/staff through online databases and journals
Enter computer documentation accurately, completely and in a timely manner
Utilize information resources to enhance the care provided to a client (e.g., evidenced-based
research, information technology, policies and procedures)*
Legal Rights and Responsibilities
Identify and manage the client’s valuables according to facility/agency policy
Recognize limitations of self/others, seek assistance and /or begin corrective measures at the
earliest opportunity
Review facility policy and state mandates prior to agreeing to serve as an interpreter for staff
or primary health care provider
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Educate client/staff on legal issues
Report client conditions as required by law (e.g., abuse/neglect, communicable disease,
gunshotwound)*
Report unsafe practice of health care personnel to internal/external entities and intervene as
appropriate (e.g. substance abuse, improper care, staffing practices)
Provide care within the legal scope of practice
Performance Improvement (Quality Improvement)
Define performance improvement/ quality assurance activities
Participate in performance improvement/QA process (e.g., formally collect data or participate
on a team)
Report identified client care issues/problems to appropriate personnel (e.g. nurse manager,
risk manager)
Utilize research and other references for performance improvement actions
Evaluate the impact of performance improvement measures on client care and resource
utilization
Referrals
Assess the need to refer clients for assistance with actual or potential problems (e.g., PT or
speech)
Recognize the need for referrals and obtain necessary orders
Identify community resources for client (e.g. respite care, social services, shelters)
Identify which documents to include when referring a client ( e.g. medical record, referral
form)
Supervision*Removed
Safety and Infection Control: The nurse protects clients and health care personnel from health and
environmental hazards. (9-15%)
Accident/Error/Injury Prevention
Assess client for allergies and intervene as needed (e.g., food, latex, environmental
allergies)*
„„ Determine client/staff member knowledge of safety procedures
„„ Identify factors that influence accident/injury prevention (e.g., age, developmental stage,
lifestyle, mental status)
„„ Identify deficits that may impede client safety (e.g., visual, hearing, sensory/perceptual)
„„ Identify and verify prescriptions for treatments that may contribute to an accident or injury
(does not include medication)
„„ Identify and facilitate correct use of infant and child car seats
„„ Provide client with appropriate method to signal staff members
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„„ Protect client from injury (e.g., falls, electrical hazards)*
„„ Review necessary modifications with client to reduce stress on specific muscle or skeletal
groups (e.g., frequent changing of position, routine stretching of the shoulders, neck, arms,
hands, fingers)
Implement seizure precautions for at-risk clients
Make appropriate room assignments for cognitively impaired clients
Ensure proper identification of client when providing care*
Verify appropriateness and/or accuracy of a treatment order*
Emergency Response Plan
Determine which client(s) to recommend for discharge in a disaster situation
Identify nursing roles in disaster planning
Use Clinical decision making/critical thinking for emergency response plan
Implement emergency response plans (e.g., internal/external disaster, fire, emergency plan)
Participate in disaster planning activities /drills
Ergonomic Principles
Assess client ability to balance, transfer and use assistive devices (e.g., crutches) prior to
planning care
Provide instruction/info to client about body positions that eliminate opportunity for repetitive
stress injuries
Use ergonomic principles when providing care (e.g. assistive devices, proper lifting)
Handling Hazardous and Infectious Materials
Identify biohazardous, flammable and infectious materials
Follow procedures for handling bio-hazardous materials
Demonstrate safe handling techniques to staff and client/family/significant others
Ensure safe implementation of internal radiation therapy
Home Safety
Assess need for client home modifications (e.g., lighting, handrails, kitchen safety)
Apply knowledge of client pathophysiology to home safety interventions
Educate client on home safety issues
Encourage the client to use protective equipment when using devices that can cause injury
(e.g., home disposal of syringes)
Evaluate client care environment for fire/environmental hazards
Reporting of Incident/Event/Irregular Occurrence/Variance
Identify need/situation where reporting of incident/event/irregular occurrence/variance is
appropriate
Acknowledge and document practice error (e.g. incident report for medication error)
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Evaluate response to error/event/occurrence
Safe Use of Equipment
Inspect equipment for safety hazards (e.g., frayed electrical cords, loose/missing parts)
Teach client about the safe use of equipment needed for healthcare
Facilitate appropriate and safe use of equipment
Remove malfunctioning equipment from client care area and report the problem to
appropriate personnel
Security Plan
Use client decision making/critical thinking in situations related to security planning
Apply principles of triage and evacuation procedures/protocols
Participate in institution security plan (e.g. newborn nursery security, bomb threats)
Standard/ Precautions/Transmission-Based Precautions/Surgical Asepsis
Assess client care area for sources of infection
Understand communicable diseases and modes of organism transmission (e.g., airborne,
droplet, contact)
Apply principles of infection control e.g. hand hygiene, surgical asepsis, sterile technique,
universal precautions.
Follow correct policy and procedures when reporting a client with a communicable disease
Educate client/staff on infection control measures
Utilize appropriate precautions for immunocompromised clients
Use appropriate technique to set up a sterile field/maintain asepsis (e.g. gloves, mask, sterile
supplies)
Evaluate infection control precautions implemented by staff members
Evaluate whether aseptic technique is performed correctly
Use of Restraints/Safety Devices
Assess appropriateness of the type of restraint/safety device used
Follow requirements for use of restraints and/or safety device (e.g., least restrictive restraints,
timed client monitoring)*
Monitor/evaluate client response to restraints/safety device
Health Promotion and Maintenance (6-12%)
The nurse provides and directs nursing care of the client that incorporates the knowledge of expected growth and development
principles, prevention and/or early detection of health problems, and strategies to achieve health.
Aging Process
Assess client’s reactions to expected age-related changes
„„ Provide care and education for the newborn less than 1 month through old through the
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infant or toddler
„„ Provide care and education for the preschool, school age and adolescent client ages 3
through 17
„„ Provide care and education for the adult client ages 18 through 64 years*
„„ Provide care and education for the adult client ages 65 through 85 years and over*
Ante/Intra/Postpartum and Newborn Care
Assess client psychosocial response to pregnancy (e.g., support systems, perception of
pregnancy, coping mechanisms)
Assess client for symptoms of postpartum complications (e.g., hemorrhage, infection)
Recognized cultural differences in childbearing practices
Calculate expected delivery date
Check fetal heart rate during routine prenatal exams
Assist client with performing/learning newborn care (e.g., feeding)
Provide pre-natal care and education
Provide care to client in labor*
„„ Provide post-partum care and education*
„„ Provide discharge instructions (e.g., post-partum and newborn care)
„„ Evaluate client’s ability to care for the newborn
Developmental Stages and Transitions
Identify expected physical, cognitive, and psychosocial stages of development
Identify expected body image changes associated with client developmental age
Identify family structures and role of family members (e.g., nuclear, blended, adoptive)
Compare client development to expected age/developmental stage of client and report any
deviation
Assess impact of change on family system (e.g., one-parent family, divorce, ill family
member)
Recognize cultural and religious influences that may impact family functioning
Assist client to cope with life transitions ( e.g. attachment to newborn, parenting, puberty,
retirement)
Modify approaches to care in accordance with client development stage (use age appropriate
explanations of procedures and treatments)
Provide education to clients/staff members about expected age related changes and age
specific growth and development (e.g. developmental changes)
Evaluate client achievement of expected developmental level (e.g. developmental milestones)
Evaluate impact of expected body image changes on client and family
Health Promotion/Disease Prevention
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Identify risk factors for disease/illness (e.g. age, gender, ethnicity, lifestyle)
Assess and teach client about health risks based on known population or community
characteristics
Assess client’s readiness to learn, learning preferences and barriers to learning*
Plan and/or participate in community health education*
Educate client on actions to promote/maintain health and prevent disease (e.g. smoking
cessation, diet, weight loss)
Inform the client of appropriate immunization schedules
Integrate complementary therapies in to health promotion activities for the well client
Provide information about healthy behaviors and health promotion/maintenance
recommendations (e.g. physician visits, immunizations)
Provide follow-up to the client following participation in health promotion program (e.g., diet
counseling)
Assist client in maintaining an optimum level of health
Evaluate client understanding of health promotion behaviors/activities ( e.g. weight control,
exercise actions)
Implement and evaluate community-based client care
Health Screening
Apply knowledge of pathophysiology to health screening
Indentify risk factors linked to ethnicity (e.g. hypertension, diabetes)
Perform health history/health and risk assessments (e.g. lifestyle, family and genetic history)
Perform targeted screening examination (e.g. scoliosis, vision and hearing assessments)
Utilize appropriate procedure and interviewing techniques when taking the client health
history
Health Risk Behaviors
Assess client lifestyle practice risks that may impact health (e.g., excessive sun exposure,
lack of regular exercise)
Assist client to identify behaviors/risks that may impact health (e.g. fatigue, calcium deficiency)
Provide information for prevention and treatment of high risk health behaviors (e.g., smoking
cessation, safe sexual practices, drug education)*
Lifestyle Choices
Assess client lifestyle choices (e.g., child-free, home schooling, rural or urban living,
recycling)
Ass client attitudes/perceptions on sexuality
Assess client need/desire for contraception
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Identify contraindications to chosen contraceptive method (e.g. smoking, compliance, medical
conditions)
Indentify expected outcomes for family planning methods
Recognize client who is socially or environmentally isolated
Educate the client on sexuality issues (e.g., family planning, safe sexual practices,
menopause,
impotence)
Evaluate client alternative or homeopathic health care practices (e.g., massage therapy,
acupuncture, herbal medicine and minerals)
Self Care
Assess client ability to manage care in home environment and plan care accordingly (e.g.,
equipment, community resources)*
Consider client self care needs before developing or revising care plan
Assist primary caregivers working with client to meet self-care goals
Techniques of Physical Assessment
Apply knowledge of nursing procedures and psychomotor skills to techniques of physical
assessment
Choose physical assessment equipment and technique appropriate for client (e.g., age of
client, measurement of vital signs)
Perform comprehensive health assessment (e.g., physical, psychosocial and health history)
Psychosocial Integrity (6-12%)
The nurse provides and directs nursing care that promotes and supports the emotional, mental and social well-being of the client and
family/significant others experiencing stressful events, as well as clients with acute or chronic mental illness.
Abuse/Neglect
Assess client for abuse or neglect and intervene as appropriate*
Identify risk factors for domestic, child and/or elder abuse/neglect and sexual abuse
Plan interventions for victims/suspected victims of abuse
Counsel victims/suspected victims of abuse and their families on coping strategies
Provide safe environment for abused/neglected client
Evaluate client response to interventions
Behavioral Interventions
Assess client appearance, mood and psychomotor behavior and identify/respond to
inappropriate/abnormal behavior
Assist client with achieving and maintaining self-control of behavior (e.g., contract, behavior
modification)
Assist client to develop and use strategies to decrease anxiety
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Orient client to reality
Participate in group sessions (e.g., support groups)
Incorporate behavioral management tech when caring for a client (e.g., positive
reinforcement, setting limits)
Evaluate client response to treatment plan
Chemical and Other Dependencies
Assess client reaction to the diagnosis/treatment of substance-related disorder
Assess client for drug/alcohol related dependencies, withdrawal, or toxicities
Plan & provide care to client experiencing substance-related w/d or toxicity (e.g., nicotine,
opioid, sedative)
Provide information on substance abuse diagnosis and treatment plan to
client/family/significant others
Provide care and/or support for a client with non-substance related dependencies (e.g.,
gambling, sexual addiction)
Provide symptom management for clients experiencing withdrawal or toxicity
Encourage client to participate in support groups (e.g., Alcoholics Anonymous, Narcotics
Anonymous)
Evaluate client response to treatment plan and revise as needed
Coping Mechanisms
Assess client support systems and available resources
Assess client ability to adapt to temporary/permanent role changes
Assess client reaction to diagnosis of acute or chronic mental illness (e.g. rationalization,
hopefulness, anger)
Assess client in coping with life changes and provide support*
Identify situations which may necessitate role changes for client/family/significant others (e.g.,
spouse with chronic illness, death of parent)
Provide support to the client with unexpected altered body image (e.g. alopecia)
Evaluate constructive use of defense mechanisms by client
Evaluate whether client has successfully adapted to situational role changes (e.g. accepted
dependency on others)
Crisis Intervention
Assess the potential for violence and initiate/maintain safety precautions (e.g. suicide,
homicide, self destructive behavior)
Identify client in crisis
Use crisis intervention techniques to assist client in coping
Apply knowledge of client psychopathology to crisis intervention
Guide client to resources for recovery from crisis (e.g., social supports)
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Cultural Awareness/Cultural Influences
Assess importance of client culture/ethnicity when planning/providing/evaluating care
Recognize cultural issues that may impact client/family/significant others
understanding/acceptance of psychiatric diagnosis
Incorporate client cultural practice and beliefs when planning and providing care
Respect cultural background/practices of the client (does not include dietary preferences)
Use appropriate interpreters to assist in achieving client/family/significant others'
understanding
Evaluate and document how client language needs were met
End of Life Care
Assess client ability to cope with end-of-life interventions
Identify end-of-life needs of client (e.g., fear, loss of control, role changes)
Recognize need for and provide psychosocial support to family/caregiver
Assist client in resolution of end-of-life issues
Provide end of life care to clients and families
Family Dynamics
Assess barriers/stressors that impact family functioning (e.g., meeting client care needs,
divorce)
Assess family dynamics in order to determine plan of care (e.g., structure, bonding,
communication, boundaries, coping mechanisms)
Assess parental techniques related to discipline
Encourage client participation in group/family therapy
Assist client to integrate new members into family structure (e.g., new infant, blended family)
Evaluate resources available to assist family functioning
Grief and Loss
Assist client in coping with suffering, grief, loss, dying and bereavement
Support the client in anticipatory grieving
Inform client of expected reactions to grief and loss (e.g., denial, fear)
Provide client with resources to adjust to loss/bereavement (e.g., individual counseling,
support groups)
Evaluate client coping and fears related to grief and loss
Mental Health Concepts
Identify signs and symptoms of impaired cognition (e.g. memory loss, poor hygiene)
Recognize signs and symptoms of acute and chronic mental illness (e.g. schizophrenia, depression,
bipolar disorder)
Recognize client use of defense mechanisms
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Explore why client is refusing/not following treatment plan (e.g., nonadherence)
Assess client for alterations in mood, judgment, cognition and reasoning
Apply knowledge of client psychopathology to mental health concepts applied in individual/group/family
therapy
Provide care and education for acute and chronic behavioral health issues (e.g. anxiety,
depression, dementia, eating disorders)
Evaluate client ability to adhere to treatment plan
Evaluate client abnormal response to the aging process (e.g., depression)
Religious and Spiritual Influences on Health
Identify the emotional problems of client or client needs that are related to religious/spiritual
beliefs (e.g., spiritual distress, conflict between recommended treatment and beliefs)
Assess psychosocial, spiritual, cultural and occupational factors affecting care
Assess and plan interventions that meet client emotional and spiritual needs
Evaluate whether client/family/significant others religious/spiritual needs are met
Sensory/Perceptual Alterations
Identify time, place and stimuli surrounding the appearance of symptoms
Assist client to develop strategies for dealing with sensory and thought disturbances
Provide care for a client experiencing visual, auditory or cognitive distortions (e.g.,
hallucinations)*
Provide care in a nonthreatening and nonjudgmental manner
Provide reality based diversions
Stress Management
Recognize non verbal cues to physical and psychological stressors
Assess stressors, including environmental, that affect client care (e.g., noise, fear,
uncertainty, change)
Implement measures to reduce environmental stressors (e.g., noise, temperature, pollution)
Provide information to client on stress management techniques (e.g., relaxation techniques,
exercise, meditation)
Evaluate client use of stress management techniques
Support Systems
Assist family to plan care for client with impaired cognition (e.g., dementia, Alzheimer's
disease)
Encourage client involvement in the health care decision-making process
Evaluate client feelings about the diagnosis/treatment plan
Therapeutic Communication
Assess verbal and nonverbal client communication needs
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Respect client personal values and beliefs
Allow time to communicate with client/family/significant others
Use therapeutic communication techniques to provide support to client and/or family
Encourage client to verbalize feelings (e.g., fear, discomfort)
Evaluate effectiveness of communications with client/family/significant others
Therapeutic Environment
Identify external factors that may interfere with client recovery (e.g., stressors, family
dynamics)
Make client room assignments that support the therapeutic milieu
Provide a therapeutic environment for clients with emotional/behavioral issues
Physiological Integrity
The nurse promotes physical health and wellness by providing care and comfort, reducing client risk potential
and managing health alterations.
Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living
(ADL)- (6-12%)
Assistive Devices
Assess client for actual/potential difficulty with communication and speech/vision/hearing
problems
Assess client use of assistive devices (e.g., prosthetic limbs, hearing aid)
Assist client to compensate for a sensory impairment (e.g., assistive devices, compensatory
techniques)
Manage client who uses assistive devices or prostheses (e.g., eating utensils,
telecommunication devices)
Evaluate correct use of assistive devices by staff/client/family
Elimination
Assess and manage client with an alteration in elimination
Perform irrigations (e.g., bladder, ear, eye)
Provide skin care to clients who are incontinent (e.g., wash frequently, barrier
creams/ointments)
Use alternative methods to promote voiding
Evaluate whether client elimination is restored/maintained
Mobility/Immobility
Identify complications of immobility (e.g., skin breakdown, contractures)
Assess client for mobility, gait, strength, motor skills, and use of assistive devices
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Perform skin assessment and implement measures to maintain skin integrity and prevent skin
breakdown (e.g. turning, repositioning
Apply knowledge of nursing procedures and psychomotor skills when providing care to clients with
immobility
Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts)
Apply and maintain devices used to promote venous return (e.g., anti-0embolic stockings,
sequential compression devices)
Educate client regarding proper methods used when repositioning an immobilized client
Maintain client correct body alignment
Maintain/correct adjustment of client traction device (e.g., external fixation device, halo traction, skeletal
traction)
Implement measures to promote circulation (e.g., active or passive range of motion,
positioning
and mobilization)*
Evaluate client response to interventions to prevent complications from immobility
Nonpharmacological Comfort Interventions
Assess client need for alternative or complementary therapy
Assess client for palliative care
Assess client need for pain management*
Recognize differences in client perception and response to pain
Apply knowledge of pathophysiology to non pharmacological comfort/palliative care
interventions
Incorporate alternative/complementary therapies into client plan of care (e.g. music therapy,
relaxation therapy)
Counsel client regarding palliative care
Respect client palliative care choices
Assist client I receiving appropriate end of life physical symptom management
Plan measures to provide comfort interventions to clients with anticipated or actual impaired comfort
Provide non-pharmacological comfort measures*
Evaluate client response to nonpharmacological interventions (e.g., pain rating scale, verbal
reports)
Evaluate clients outcomes of alternative and/or complementary therapy practices
Evaluate outcome of palliative care interventions
Nutrition and Oral Hydration
Assess client ability to eat (e.g., chew, swallow)
Assess client for actual/potential specific food and medication interactions
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Consider client choices regarding meeting nutritional requirements and/or maintaining dietary
restrictions including mention of specific food items
Monitor client hydration status (e.g., intake and output, edema, signs and symptoms of
dehydration)
Initiate calorie counts for clients
Apply knowledge of mathematics to client nutrition (e.g., body mass index [BMI])
Manage the client’s nutritional intake (e.g., adjust diet, monitor height and weight)*
„„ Promote the client’s independence in eating
„„ Provide/maintain special diets based on the client diagnosis/nutritional needs and cultural
considerations (e.g., low sodium, high protein, calorie restrictions)
„„ Provide nutritional supplements as needed (e.g., high protein drinks)
„„ Provide client nutrition through continuous or intermittent tube feedings*
„„ Evaluate side effects of client tube feedings and intervene, as needed (e.g., diarrhea,
dehydration)
„„ Evaluate client intake and output and intervene as needed*
„„ Evaluate the impact of disease/illness on nutritional status of a client
Personal Hygiene
Assess client for usual personal hygiene habits/routine
Assess and intervene in client performance of activities of daily living*
Provide info to client on required adaptations for performing ADL's (e.g., shower chair, hand
rails)
Perform post-mortem care
Rest and Sleep
Assess client need for sleep/rest and intervene as needed*
„„ Apply knowledge of client pathophysiology to rest and sleep interventions
„„ Schedule client care activities to promote adequate rest
Pharmacological and Parenteral Therapies- providing care related to the administration of medications
and parenteral therapies (12-18%)
Adverse Effects/Contraindications and Side Effects/Interactions
Identify a contraindication to the administration of a medication to the client
Identify actual and potential incompatibilities of prescribed client medications
Identify symptoms/evidence of an allergic reaction (e.g., to medications)
Assess client for actual and potential side effects and adverse effects of medications (e.g.
prescribed, OTC, herbal supplements, preexisting condition)
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Provide information to client/family/significant others on adverse effects and when to notify primary
health care provider
Notify primary health care provider of side or adverse effects and contraindications of meds &
parenteral tx
Document side effects and adverse effects of medications and parenteral therapy
Monitor for anticipated interactions among the client prescribed medications and fluids (e.g.
oral, IV, SQ, IM, Topical)
Evaluate & document client response to actions taken to counteract side and adverse effects of meds
and parenteral tx
Blood and Blood Products
Identify client according to facility/agency policy prior to administration of red blood cells/blood
products (e.g., prescription for administration, correct type, correct client, cross matching
complete, consent obtained)
Check client for appropriate venous access for red blood cell/product administration (e.g.,
correct gauge needle, integrity of access site)
Administer blood products and evaluate client response
Document necessary information on the administration of red blood cells/blood products
Central Venous Access Devices
Educate the client on the reason for and care of a venous access device
„„ Access venous access devices, including tunneled, implanted and central lines*
„„ Provide care for client with a central venous access device (e.g., port-a-cath, Hickman)
Dosage Calculation
Perform calculations needed for medication administration
Use clinical decision making/critical thinking when calculating dosages
Expected Effects/Outcomes
Obtain info on prescribed med for client/family/significant others (e.g., review formulary,
consult pharmacist)
Use clinical decision making when addressing expected effects/outcomes of meds (e.g., PO, ID, SQ,
IM, topical)
Evaluate client use of medications over time (e.g., prescription, over-the-counter, home
remedies)
Evaluate client response to medication (e.g., therapeutic effects, side effects, adverse
reactions)*
Medication Administration
Educate client about medications
Educate client on medication self administration procedures
Prepare and administer medications using rights of medication administration
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Review pertinent data prior to med admin (e.g., vital signs, lab results, allergies, potential
interactions)
Mix medications from two vials when necessary (e.g., insulin)
Administer and document medications given by common routes (e.g., oral, topical)
Administer and document medications given by parenteral routes (e.g.,IV, IM, SQ)
Participate in medication reconciliation process*
Titrate dosage of medication based on assessment and ordered parameters (e.g., giving
insulin
according to blood glucose levels, titrating medication to maintain a specific blood pressure)*
Dispose of unused medications according to facility/agency policy
Evaluate appropriateness/accuracy of medication order for client
Parenteral/Intravenous Therapy
Identify appropriate veins that should be accessed for various therapies
Educate client on the need for intermittent parenteral fluid therapy
Apply knowledge and concepts of mathematics/nursing procedures/psychomotor skills when
caring for a client receiving intravenous and parenteral therapy
Prepare client for intravenous catheter insertion
Insert, maintain, and remove a peripheral intravenous line
Monitor the use of an infusion pump (e.g., IV, patient-controlled analgesia (PCA) device)
Monitor intravenous infusion and maintain site (e.g., central, PICC, epidural and venous
access
devices)*
Evaluate client response to intermittent parenteral fluid therapy
Pharmacological Pain Management
Assess client need for administration of a PRN pain medication (e.g., oral, topical,
subcutaneous,
IM, IV)
Administer and document pharmacological pain management appropriate for client age and
diagnosis (e.g., pregnancy, children, older adults)
Administer pharmacological measures for pain management*
„„ Administer controlled substances within regulatory guidelines (e.g., witness, waste)*
„„ Evaluate and document the client’s use and response to pain medications
Total Parenteral Nutrition
Identify side effects/adverse events related to TPN and intervene as appropriate (e.g.,
hyperglycemia, fluid imbalance, infection)
Educate client on the need for and use of TPN
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Apply knowledge of nursing procedures and psychomotor skills when caring for a client
receiving TPN
Apply knowledge of client pathophysiology and mathematics to TPN interventions
„„ Administer parenteral nutrition and evaluate client response (e.g., TPN)*
Reduction of Risk Potential: reducing the likelihood that clients will develop complications or health
problems related to existing conditions, treatments, or procedure s (9-15%)
Changes/Abnormalities in Vital Signs
Assess and respond to changes in client vital signs
Apply knowledge needed to perform related nursing procedures and psychomotor skills when assessing
vital signs
Apply knowledge of client pathophysiology when measuring vital signs
Evaluate invasive monitoring data (e.g. pulmonary artery pressure, intracranial pressure)
Diagnostic Test
Apply knowledge of related nursing procedures and psychomotor skills when caring for clients
undergoing diagnostic testing
Compare client diagnostic findings with pretest results
Perform diagnostic testing (e.g., oxygen saturation, glucose monitoring, testing for occult
blood, gastric pH, urine specific gravity)
Perform fetal heart monitoring
Monitor results of maternal and fetal diagnostic tests (e.g.., nonstress test, amniocentesis,
ultrasound)
Monitor the results of diagnostic testing and intervene as needed*
Laboratory Values
Know laboratory values for ABGs (ph, PO2, PCO2, SaO2, HCO3) BUN, cholesterol (total)
glucose, hematocrit, hemoglobin, hemoglobin A1C (HBA1C), platelets, potassium, RBC,
sodium, urine-specific gravity and WBC)
Compare client laboratory values to normal laboratory values
Educate client about the purpose and procedure of prescribed laboratory tests
Obtain specimens other than blood for diagnostic testing (e.g., wound cultures, stool, urine
specimens)
Obtain blood specimens peripherally or through central line
Notify primary health care provider about laboratory test results
Monitor client laboratory values (e.g., glucose testing results for the client with diabetes)
Potential for Alterations in Body Systems
Identify client potential for aspiration (e.g., tube, sedation, swallowing difficulties)
Identify client skin breakdown potential (e.g., immobility, nutritional status, incontinence)
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Identify client with increased risk for insufficient vascular perfusion (e.g., immobilized limb,
post surgery, diabetes)
Compare current client data to baseline client data (e.g., symptoms of illness/disease
Educate client on methods to prevent complications associated with activity level/diagnosed
illness/disease (e.g., contractures, foot care for client with diabetes mellitus)
Monitor client output for changes from baseline (e.g., nasogastric [NG] tube, emesis, stools,
urine)
Potential for Complications of Diagnostic Tests/Treatments/Procedures
Apply knowledge of nursing procedures/psychomotor skills when caring for a client w/ potential for
complications
Assess client for an abnormal response following a diagnostic test/procedure (e.g.,
dysrhythmia following cardiac catheterization)
Monitor client for signs of bleeding
Position client to prevent complications following tests/treatments/procedures (e.g., elevate
head of bed)
Insert, maintain and remove a gastric tube*
„„ Insert, maintain and remove a urinary catheter*
„„ Insert, maintain and remove a peripheral intravenous line*
Maintain tube patency (e.g., NG tube for decompression, chest tubes)
Use precautions to prevent injury and/or complications associated with a procedure or
diagnosis
Provide care for client undergoing electroconvulsive therapy (e.g., monitor airway, assess for side
effects, teach client/family/significant others about procedure)
Intervene to manage potential circulatory complications (e.g., hemorrhage, embolus, shock)
Intervene to prevent aspiration (e.g., check NG tube placement)
Intervene to prevent potential neurological complications (e.g., foot drop, numbness, tingling)
Evaluate and document responses to procedures and treatments
Potential for Complications from Surgical Procedures and Health Alterations
Apply knowledge of pathophysiology to monitoring for complications (e.g., recognize signs of
thrombocytopenia (e.g., bleeding gums, bruising))
Evaluate client response to postoperative interventions to prevent complications (e.g., prevent
aspiration, promote venous return, promote mobility)
System Specific Assessment
Assess client for abnormal peripheral pulses after a procedure or treatment
Assess client for abnormal neurological status (e.g.., level of consciousness, muscle strength,
mobility)
Assess client for peripheral edema
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Assess client for signs of hypoglycemia or hyperglycemia
Identify factors that result in delayed wound healing
Recognize trends and changes in client condition and intervene appropriately
Perform a risk assessment (e.g., sensory impairment, potential for falls, level of mobility, skin
integrity)
Perform focused assessment or re-assessment (e.g., gastrointestinal, respiratory, cardiac)
Therapeutic Procedures
Apply knowledge of related nursing procedures/ psychomotor skills when caring for clients
undergoing therapeutic procedures
Assess client response to recovery from local, regional or general anesthesia
Educate client and family about treatments and procedures
Educate client and family about home management of care (i.e.., tracheostomy and ostomy)
Monitor client before, during, and after a procedure/surgery (e.g., casted extremity)
Use precautions to prevent further injury when moving a client with a musculoskeletal condition (e.g.,
log-rolling)
Monitor effective functioning of therapeutic devices (e.g., chest tube, drainage tubes, wound
drainage devices, continuous bladder irrigation)
Provide pre and/or postoperative education
Provide preoperative care
Provide intraoperative care (e.g., positioning, maintain sterile field, operative assessment)
Manage client during and following procedure with moderate sedation
Physiological Adaptation: managing and providing care for clients with acute,
chronic, or life threatening physical health problem (11-17%)
Assess adaptation of client/family/significant others to health alteration, illness and/or disease
Assess tube drainage during the time the client has an alteration in body system (e.g.,
amount, color)
Assess client for signs and symptoms of adverse effects of radiation therapy
Identify signs of potential prenatal complications
Identify signs, symptoms and incubation periods of infectious diseases
Apply knowledge of nursing procedures, pathophysiology and psychomotor skills when caring
for a client with an alteration in body systems
Educate client about managing health problems
Assist with invasive procedures (e.g., central line placement, biopsy, debridement)
Implement and monitor phototherapy
Implement interventions to address side/adverse effects of radiation therapy (e.g., diet
modifications, avoid sun)
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Maintain optimal temperature of client (e.g., cooling and/or warming blanket)*
Monitor and maintain client on a ventilator
Monitor wounds for signs and symptoms of infection
Monitor &maintain devices/equipment used for drainage (e.g., surgical wound drains, chest
tube suction)
Perform and manage care of client receiving peritoneal dialysis
Perform suctioning (e.g. oral, nasopharyngeal, endotracheal, tracheal)
Provide wound care and/or assist with dressing change
Provide ostomy care and education
Provide care to client who has experienced a seizure
Provide care of client with an infectious disease
Provide pulmonary hygiene (e.g., chest physiotherapy, spirometry)
Provide care for client experiencing complications of pregnancy/labor and/or delivery
Provide care for client experiencing increased intracranial pressure
Provide postoperative care
Remove sutures or staples
Evaluate client response to surgery
„„ Evaluate achievement of client treatment goals
Evaluate client response to treatment for an infectious disease (e.g., acquired immune
deficiency
syndrome [AIDS], tuberculosis [TB])
Evaluate and monitor client response to radiation therapy
Fluid and Electrolyte Imbalances
Apply knowledge of pathophysiology when caring for client with fluid and electrolyte
imbalances
Identify signs and symptoms of client fluid and/or electrolyte imbalance
Manage the care of the client with a fluid and electrolyte imbalance
Evaluate client response to interventions to correct fluid and electrolyte imbalance
Hemodynamics
Assess client for decreased cardiac output (e.g., diminished peripheral pulses, hypotension)
Identify cardiac rhythm strip abnormalities (e.g., sinus bradycardia, premature ventricular
contractions [PVCs], ventricular tachycardia, fibrillation)
Apply knowledge of pathophysiology to interventions in response to client abnormal
hemodynamics
Provide client with strategies to manage decreased cardiac output (e.g., frequent rest periods,
limit activities)
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Intervene to improve client cardiovascular status (e.g., modify activity schedule, initiate protocol to
manage cardiac arrhythmias, monitor pacemaker functions)
Monitor and maintain arterial lines
Manage the care of a client with a pacing device (e.g., biventricular pacemaker, implantable
cardioverter defibrillator)
Manage the care of the client with telemetry monitoring
Manage the care of the client receiving hemodialysis
Provide care for client with vascular access for hemodialysis (e.g., arteriovenous [AV] shunt,
fistula, graft)
Manage the care of a client with alteration in hemodynamics, tissue perfusion and hemostasis
(e.g. cerebral, cardiac, peripheral)
Illness Management
Identify client data that needs to be reported immediately
Apply knowledge of client pathophysiology to illness management
Educate client regarding an acute or chronic condition*
Educate the client about managing illness (e.g., acquired immune deficiency syndrome
[AIDS], chronic illnesses)
Implement interventions to manage client recovering from an illness
Perform gastric lavage
Promote and provide continuity of care in illness management activities (e.g., cast placement)
Manage the care of the client with impaired ventilation/oxygenation
Evaluate the effectiveness of the treatment regimen for a client with an acute and chronic
diagnosis
Medical Emergencies
Apply knowledge of pathophysiology when caring for a client experiencing a medical
emergency
Apply knowledge of nursing procedures/psychomotor skills when caring for a client experiencing a med
emergency
Explain emergency interventions to client/family/significant others, as appropriate
Notify primary health provider about client unexpected/emergency situation
Perform emergency care procedures (e.g., cardiopulmonary resuscitation, Heimlich
maneuver, respiratory support, automated external defibrillator)
Provide emergency care for wound disruption (e.g., evisceration, dehiscence)
Evaluate and document client response to emergency interventions (e.g., restoration of
breathing, pulse)
Pathophysiology
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Identify pathophysiology related to an acute or chronic condition (e.g. signs and symptoms)
Understand general principles of pathophysiology (e.g., injury and repair, immunity, cellular
structure)
Unexpected Response to Therapies
Assess client for unexpected adverse response to therapy (e.g., increased ICP, hemorrhage)
Recognize signs and symptoms of complications and intervene appropriately when providing
client care
Promote recovery of client from unexpected response to therapy (e.g., urinary tract infection)
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