6 Take Action Free Online FlashCards

What does “Take Action” mean in clinical judgment?

Take Action is the implementation step of clinical judgment: carry out evidence-based interventions that address the patient’s highest-priority need.

How should a nurse prioritize and sequence actions?

Address the most urgent threat first with an action likely to achieve the intended outcome and appropriate to the patient’s condition and the nurse’s role.

What may help guide the next step for a stable patient?

A focused assessment may clarify what to do next when the patient is stable.

How should a nurse respond when a patient is unstable?

Do not let nonessential assessment or routine tasks delay emergency measures or help. Take appropriate immediate action and continue assessment in parallel when possible.

What patient-identification safeguard should be used before care?

Use two identifiers when providing care, treatment, or services.

What should a nurse verify before an intervention?

Check relevant allergies, orders, and contraindications, and use required medication and procedure safeguards.

What are the key limits on nursing delegation?

Delegate only tasks permitted by jurisdiction and policy and suited to the patient’s condition and the delegatee’s competence. The licensed nurse retains nursing judgment and oversight accountability.

What should a nurse do when a patient’s condition worsens?

Reassess promptly, compare findings with the patient’s baseline and expected course, and respond to the most serious threat.

What is the purpose of a rapid response team?

A rapid response team brings additional clinicians to assess and treat a patient at risk of serious deterioration.

In SBAR, what does Situation communicate?

Situation states what is happening now.

What should the nurse do if an intervention does not address the concern?

Reassess after acting. If the response is inadequate, revise the plan and escalate; if the patient worsens or the concern remains unaddressed, use the chain of command or emergency process.

In SBAR, what belongs in Background?

Background gives relevant history, treatment, or results.