Perform the procedure while the colleague observes

Watch an online tutorial and then attempt the procedure

Decline and inform the charge nurse that the task is outside current competency

Ask the colleague to describe the steps and then proceed independently

Integrating best research evidence, clinical expertise, and patient preferences to guide care

Following hospital policies exactly as written without modification

Relying on the most experienced nurse's opinion for care decisions

Implementing the newest treatment approaches regardless of evidence quality

Right task

Right circumstance

Right direction

Right person

Educator

Advocate

Care provider

Leader

Delegation authority from a physician

A hospital-specific privileging agreement

An expanded scope of practice through advanced licensure

A supervisory waiver from the nursing board

'Do not worry, many people manage diabetes just fine.'

'It sounds like you are feeling overwhelmed. Tell me more about your concerns.'

'I will give you some pamphlets to read about diabetes management.'

'Your doctor will explain everything at your next appointment.'

AIDET

Teach-back method

Motivational interviewing

SBAR

Use of judgemental or labelling language

Failure to use closed-ended questions

Breach of confidentiality

Inappropriate use of medical jargon

Use hand gestures and simple words to explain the procedure

Ask a bilingual family member to interpret

Arrange for a qualified medical interpreter

Provide the consent form and allow the patient to sign

Pre-interaction phase

Orientation phase

Working phase

Termination phase

Before touching the patient, before the aseptic procedure, after body fluid exposure risk, and after touching patient surroundings

Only before and after the dressing change

Only after removing gloves following the procedure

Before and after entering the patient's room only

Contact precautions

Droplet precautions

Airborne precautions

Standard precautions alone are sufficient

Adverse drug event

Near miss

Sentinel event

Never event

Alcohol-based hand rub for 20 seconds

Alcohol-based hand rub for 40 seconds

Any hand hygiene method is equally effective

Washing with soap and water for at least 20 seconds

Activate bed alarm, provide non-slip footwear, and implement hourly rounding

Apply bilateral wrist restraints to prevent the patient from getting up

Administer a sedative to keep the patient in bed

Place the patient in a room closest to the nursing station without further intervention

The reading will be falsely low

The reading will be unaffected

The diastolic value will be accurate but the systolic will be low

The reading will be falsely elevated

Inspection, palpation, percussion, auscultation

Inspection, auscultation, percussion, palpation

Auscultation, inspection, palpation, percussion

Inspection, percussion, auscultation, palpation

Normal age-related blood pressure variation

Hypertensive crisis requiring immediate intervention

Orthostatic hypotension

Essential hypertension with white coat effect

'What makes the pain better or worse?'

'When did the pain first start?'

'Can you describe what the pain feels like?'

'On a scale of 0 to 10, how severe is the pain?'

Document the finding and reassess in one hour

Reposition the pulse oximeter probe and wait five minutes

Immediately apply a non-rebreather mask at 15 litres per minute

Assess the patient's respiratory rate, depth, and effort

It contains a prohibited abbreviation

It uses subjective and judgemental language

It fails to include a nursing diagnosis

It should have been documented in SOAP format

Follow the facility policy for entering a corrected or amended entry

Delete the entry from the record and re-enter it in the correct chart

Notify the physician and take no further action

Leave the entry and add the same data to the correct chart

PRN

NPO

BID

U (for units)

Override the alert because it is likely a nuisance alarm

Discontinue the new medication without consulting the prescriber

Review the alert for clinical significance and consult the prescriber if needed

Document the alert in the nursing notes and proceed with administration

Objective

Subjective

Assessment

Plan

Beneficence

Veracity

Confidentiality

Fidelity

Follow the family's wishes since they know the patient best

Remove the DNR order from the chart to avoid conflict

Ask the physician to override the patient's decision

Honour the patient's documented wishes and support the family through education

Duty, breach of duty, causation, and damages

Intent, action, harm, and restitution

Negligence, recklessness, injury, and liability

Duty, intent, foreseeability, and compensation

Surgery cannot proceed until written parental consent is obtained

Emergency treatment may proceed under implied consent when delay would be life-threatening

The patient can provide their own informed consent at age 16

A court order is required before any treatment of a minor without parental consent

Confront the family member directly and request an explanation

Wait for definitive proof of abuse before taking action

Report the suspected abuse to the appropriate authorities as a mandated reporter

Document the findings and discuss with colleagues informally

Haemodynamic instability indicated by low blood pressure

Pain management

Discharge teaching

Emotional reassurance

Patient will feel better soon

Patient will ambulate 30 metres with a walking frame by post-operative day 2

Patient will understand their medications

Patient will have improved breathing

Impaired gas exchange related to alveolar membrane changes

Activity intolerance related to decreased cardiac output

Ineffective tissue perfusion related to decreased cardiac output

Excess fluid volume related to compromised cardiac pump function

Document that the goal was unmet and discontinue the care plan

Repeat the same interventions with increased frequency

Reassess the patient and revise the care plan based on new data

Notify the physician that nursing interventions have failed

Independent intervention

Dependent intervention

Collaborative intervention

Delegated intervention

Ensure the patient has eaten breakfast

Verify the medication has not expired

Confirm the patient is not allergic to insulin

Check the patient's current blood glucose level

Complete an incident report immediately

Notify the charge nurse and prescriber

Assess the patient for any adverse effects

Document the error in the patient's chart

15 degrees

90 degrees

45 degrees

30 degrees

The medication is given as needed based on the nurse's assessment of the patient

The medication is given at fixed intervals throughout the day

The medication is given only when the patient requests it

The medication is given once daily at the nurse's discretion

Tell the patient to discontinue the supplement during hospitalisation

Add the supplement to the medication administration record independently

Document it in the nursing notes only and continue with admission

Document the supplement and notify the prescriber about the potential interaction

Normal post-surgical weight fluctuation

Fluid volume overload

Malnutrition with dependent oedema

Allergic reaction to IV fluids

Elevate the head of the bed to 30 to 45 degrees during and after feeding

Administer the feeding as a rapid bolus to minimise exposure time

Keep the patient in a flat supine position to promote absorption

Clamp the tube immediately after feeding and lower the head of the bed

This is a normal urine output for this patient's weight

The patient is in a polyuric state requiring fluid restriction

The patient is oliguric and requires prompt further assessment

This output is slightly below normal but does not require intervention

Serum albumin

Total protein

Haemoglobin

Prealbumin

Administer a cleansing enema immediately

Notify the prescriber and request review of the bowel management regimen

Restrict the patient's oral intake until bowel sounds return

Discontinue the opioid medication independently

Deep tissue injury

Stage 2

Stage 1

Unstageable

Wound infection requiring antibiotic therapy

Necrotic tissue requiring debridement

Ischaemic tissue with poor perfusion

Healthy granulation tissue indicating normal healing

A 68-year-old with diabetes, on corticosteroids, with a serum albumin of 25 g/L

A 40-year-old with well-controlled hypertension and adequate nutrition

A 25-year-old athlete with a clean surgical incision

A 55-year-old non-smoker with a minor skin abrasion

Transparent film dressing

Foam dressing

Dry gauze dressing

Hydrogel sheet

The patient is at low risk and requires standard preventive care

The patient is at moderate risk and requires repositioning every 4 hours

The patient is at high risk and requires comprehensive pressure injury prevention

The score is normal and no specific pressure injury interventions are needed

Reassess the pain characteristics and review the current analgesic plan

Administer the next scheduled dose early

Apply a cold compress and encourage deep breathing

Notify the surgeon that the pain is uncontrolled

Numeric Rating Scale (0 to 10)

FLACC scale

Visual Analogue Scale

Brief Pain Inventory

Continue monitoring and recheck in one hour

Reposition the patient and apply a pulse oximeter

Administer the next opioid dose as scheduled

Hold the opioid, support the airway, and prepare to administer the prescribed opioid antagonist

Using the highest available dose of a single opioid to control pain

Alternating between two different opioid medications throughout the day

Combining paracetamol, an NSAID, and a low-dose opioid with non-pharmacological measures

Administering only non-pharmacological interventions to avoid medication side effects

The behaviours indicate pain, and the nurse should assess using a behavioural pain scale and treat accordingly

The behaviours are related to dementia and do not indicate pain

Pain cannot be assessed without a verbal self-report

The nurse should wait for vital sign changes to confirm pain

Administer supplemental oxygen via nasal cannula

Increase the intravenous fluid rate

Assess the surgical site for bleeding

Open the airway and suction secretions

Correct the consent form to match the site marking

Erase the site marking and re-mark the left knee

Stop the transfer and notify the surgeon about the discrepancy

Proceed to the operating room and clarify during the time-out

Surgical site infection

Atelectasis

Deep vein thrombosis

Urinary tract infection

Maintaining strict bed rest for the first 48 hours

Encouraging the use of an incentive spirometer every hour while awake

Administering a prophylactic antibiotic

Applying sequential compression devices to the lower extremities

Small bowel obstruction

Surgical site infection

Internal haemorrhage

Paralytic ileus

Progression of underlying dementia

Delirium requiring urgent investigation for an underlying cause

Normal sundowner syndrome associated with hospitalisation

Depression presenting with cognitive symptoms

Polypharmacy increasing the risk of adverse drug reactions and interactions

The patient's ability to afford all medications

Whether all medications are available in liquid form

The timing of medication administration throughout the day

Urinary incontinence

Memory loss severe enough to impair daily functioning

Recurrent falls

Gradual decline in glomerular filtration rate

Hypertension

Urinary retention

Falls and excessive sedation

Hyperglycaemia

The patient's educational background

A functional status assessment including ADLs and IADLs

The patient's chronological age

The number of chronic conditions the patient has

'I am sure your family loves you very much. Try not to think that way.'

'Let me call the chaplain to come speak with you.'

'It sounds like you are going through a difficult time. Are you having thoughts of harming yourself?'

'Everyone feels that way sometimes. It will pass.'

'That is not true. No one has put anything in your brain.'

'Tell me more about the tracking device. How did they do it?'

'I will contact the authorities to investigate your claim.'

'That must be very frightening for you. I want you to know you are safe here. How are you feeling right now?'

Call for security and prepare for physical restraint

Approach calmly, maintain safe distance, speak in a low steady voice, and offer choices

Firmly instruct the patient to sit down and be quiet

Leave the area and allow the patient to calm down independently

Insight

Affect

Thought content

Orientation

Enrol the patient in group therapy sessions immediately

Encourage the patient to shower and engage in self-care

Ensure adequate nutrition and hydration by offering small frequent meals and fluids

Provide educational materials about depression

Ask the patient to explain in their own words how they will take the medication and what signs to watch for

Provide a written information sheet and ask the patient to read it later

Have the patient sign a form acknowledging they received discharge education

Accept the patient's verbal confirmation and document education as completed

The patient has a scheduled follow-up appointment in one week

The patient lives alone with no identified social support and has difficulty understanding medication instructions

The patient's blood pressure is within normal limits at discharge

The patient has a family member who will drive them home

Add the medication back to the discharge list independently

Instruct the patient to resume the medication at home without further action

Clarify with the prescriber whether the omission is intentional or an oversight

Document the discrepancy in the chart and discharge the patient

Speak slowly and loudly in English while using hand gestures

Give all instructions to the patient's English-speaking child to relay later

Provide instructions in English only and document that education was given

Use a qualified medical interpreter, provide written materials in the patient's language, and use teach-back

Coordinating communication among all members of the care team and ensuring continuity of care

Completing the discharge paperwork and obtaining the physician's signature

Transporting the patient to the next care setting

Delegating all discharge tasks to the social worker