Specific, Measurable, Achievable, Relevant, Time-bound — and patient-centered: the patient will walk 50 feet by day 2.
Three levels of planning
Initial (admission), ongoing (as data change), and discharge planning — which starts at admission.
Maslow's order for setting priorities
Physiological, safety, love and belonging, esteem, self-actualization — lower needs first.
ABC priority
Airway, Breathing, Circulation — an airway threat outranks every other need.
Unstable vs stable rule
Unstable, new, or worsening findings are seen before stable, expected, or chronic ones.
The three kinds of interventions
Independent (nurse-initiated), dependent (provider order), collaborative (with other disciplines).
The five rights of delegation
Right task, right circumstance, right person, right direction, right supervision.
What the RN cannot delegate
Nursing judgment and critical decision-making: nursing diagnosis, planning, initial assessment and teaching that require RN judgment, and outcome evaluation. Scoped data collection or teaching reinforcement may be assigned under the state practice act; accountability remains with the RN.
Typical UAP tasks
Stable, routine, predictable care: vital signs on stable patients, hygiene, ambulation, feeding, intake and output reporting.
Typical LPN/LVN scope
Routine medications and treatments for stable patients, within the state practice act — under RN supervision.
SBAR
Situation, Background, Assessment, Recommendation — the structure for hand-offs and provider notifications.
The three evaluation ratings
Met, partially met, not met — each leads to continue, revise, or reassess everything.
When evaluation happens
Ongoing (every encounter) and terminal (against discharge goals) — it always feeds back into reassessment.
Quiz
A nurse has finished collecting a patient's history and physical findings. Which step of the nursing process comes next?
Planning
Diagnosis (answer)
Evaluation
Implementation
Assessment feeds diagnosis: cluster the cues into a nursing diagnosis before any goals are written. Planning comes third, and there is nothing to implement or evaluate yet.
Which of the following is subjective data?
Blood pressure is 88/50 mm Hg
Vomitus is present in the emesis basin
The patient states, “I feel nauseated.” (answer)
The patient's skin is pale and sweaty
Subjective data are symptoms only the patient can feel. Basin contents, blood pressure, and skin appearance are observable, so they are objective.
A patient reports sudden chest pain. Which nursing action reflects the assessment step of the nursing process?
Ask about the pain's onset, character, and radiation, and take vital signs (answer)
Administer the prescribed as-needed pain medication
Call the patient's family with an update
Document that the patient seems anxious
Assessment means collecting data before acting: characterize the pain and check vital signs. Medication is implementation, and “seems anxious” documents an impression instead of gathering data.
Which of the following is a nursing diagnosis rather than a medical diagnosis?
Ineffective airway clearance related to retained secretions (answer)
Pneumonia
Appendicitis
Type 2 diabetes mellitus
Nursing diagnoses name human responses a nurse can treat. Pneumonia, appendicitis, and diabetes are diseases diagnosed and treated by providers.
In “Acute pain related to surgical incision as evidenced by a report of 7 out of 10,” what does “related to surgical incision” identify?
The defining signs and symptoms
The expected outcome
The evaluation criterion
The etiology of the problem (answer)
The PES format pairs Problem with Etiology and Signs/symptoms: “related to” names the etiology; “as evidenced by” names the evidence.
Which expected goal is written correctly?
Patient will be more active
Nurse will encourage walking every shift
Patient will ambulate 50 feet in the hallway by day 2 (answer)
Patient will try to walk often
A goal is patient-centered, measurable, and time-bound. “More active” and “try to walk often” cannot be measured, and the nurse's behavior is an intervention, not an outcome.
What is missing from the goal “Patient will drink enough fluids”?
Nothing; the goal is complete
A medical order
A measurable amount and a time frame (answer)
The nurse's signature
“Enough” cannot be measured and no deadline exists. A complete version names the amount (for example 1,500 mL over 24 hours, if appropriate for that patient) and the time frame.
Four patients need care. Which patient should the nurse see FIRST?
A patient waiting for admission paperwork
A stable postoperative patient requesting pain medication
A patient needing a routine dressing change
A patient with sudden shortness of breath (answer)
Breathing problems take priority under the ABC framework — airway, breathing, circulation. The other three are stable, routine, or expected needs that can safely wait.
A patient with no dietary restriction reports hunger and says they feel anxious about tomorrow's appointment. Using Maslow's hierarchy, which need does the nurse address first?
Anxiety about the appointment
Self-esteem concerns
The need for social support
Hunger (a physiological need) (answer)
Physiological needs come before safety and psychosocial needs on Maslow's hierarchy when both are unmet. Anxiety is addressed once the basic need is met.
Which task can the RN delegate to unlicensed assistive personnel (UAP)?
Take vital signs on a stable postoperative patient (answer)
Assess breath sounds after transfer
Teach a newly diagnosed patient insulin injection technique
Evaluate whether a pain plan is working
UAP perform stable, routine, predictable tasks such as vital signs on stable patients. Teaching, assessment, and evaluation remain RN responsibilities.
Which activity is within the typical LPN/LVN scope rather than RN-only?
Performing the initial comprehensive admission assessment
Writing the patient's nursing diagnoses
Administering routine oral medications to a stable patient (answer)
Developing the discharge teaching plan
Within the state practice act, LPN/LVNs give routine medications to stable patients under supervision. The comprehensive assessment, diagnoses, and teaching plan are RN responsibilities.
Which of the following is NOT one of the five rights of delegation?
Right task
Right diagnosis (answer)
Right circumstance
Right supervision
The five rights are task, circumstance, person, direction, and supervision. Nursing diagnosis is a step of the nursing process — and it is never delegated.
A nurse compares a patient's walking distance with the goal written on day 1. Which step of the nursing process is this?
Assessment
Evaluation (answer)
Implementation
Planning
Evaluation compares outcomes with goals. Walking the halls would be implementation; writing the goal was planning.
The goal states the patient will walk 50 feet by day 2. On day 2 the patient walks 20 feet. How should the nurse record the evaluation?
Goal met
Outcome partially met; revise the plan (answer)
Goal not applicable
Patient noncompliant
Progress without reaching the criterion means partially met, which triggers reassessment and revision. “Noncompliant” is a judgment, not an evaluation.
A nurse raises the head of the bed to reduce a patient's reflux — no provider order is needed. This is which type of intervention?
Dependent
Collaborative
Delegated
Independent (nurse-initiated) (answer)
Independent interventions fall within nursing scope and need no order. Dependent interventions require a provider order; collaborative ones involve other disciplines.
Which charting entry contains objective data?
“Patient states the pain is severe.”
“Patient appears upset.”
“Patient vomited 50 mL of clear fluid.” (answer)
“Patient seemed restless all morning.”
Objective entries record observable, measurable facts. “Appears” and “seemed” are impressions, while the quoted pain score records a reported symptom.
When does assessment occur?
Only at admission
On admission and continuously throughout care (answer)
Only when the patient complains
Only during shift hand-off
Assessment begins with the admission database and continues every shift and every encounter — the nursing process is cyclical, not a one-time event.
A patient has a new incision with no signs of infection. Which nursing diagnosis is written correctly?
Risk for infection related to surgical incision (answer)
Risk for infection related to elevated temperature
Infection related to surgical incision
Acute infection as evidenced by incision redness
Risk diagnoses name a vulnerability with no signs or symptoms present. Writing infection as actual requires evidence, and an elevated temperature would itself be a sign of a current problem.
Evaluation shows the outcome “patient will ambulate 50 feet by day 2” was not met. What should the nurse do next?
Stop working on the goal
Repeat the identical plan without changes
Reassess the patient and revise the care plan (answer)
Ask the patient to try harder
An unmet outcome triggers reassessment — find out why (pain, weakness, fear) and revise. Evaluation feeds back into the process; it does not end it.
Which nursing action demonstrates the assessment step?
Ask the patient to describe the pain and measure vital signs (answer)
Administer the prescribed analgesic
Notify the family of the admission
Document the completed dressing change
Assessment is data collection: ask, observe, and measure. Giving medication is implementation, and the other options are communication and documentation tasks.
After abdominal surgery, a nurse writes “Potential complication of surgery: hemorrhage.” This statement is:
A nursing diagnosis
A medical diagnosis
An expected outcome
A collaborative problem (answer)
Collaborative problems — written “potential complication of” — are complications the nurse monitors for and manages with the provider. Nursing diagnoses are clinical judgments about human responses; their interventions may be independent or collaborative; this is neither an outcome nor a provider's diagnosis.
During a shift hand-off, the nurse reports using SBAR. The “A” stands for:
Actions taken
Allergies
Admission data
Assessment (answer)
SBAR = Situation, Background, Assessment, Recommendation — a structure that forces data, not adjectives, into hand-offs and provider calls.
Which outcome statement contains all five required parts?
Patient will walk 100 feet in the hallway with a rolling walker twice daily by day 3 (answer)
Patient will walk when able
Patient will walk with a walker
Patient will walk
Subject (patient) + verb (walk) + measurable criterion (100 feet, twice) + modifier (rolling walker, hallway) + target time (by day 3). The others drop the criterion, the condition, or the deadline.
A UAP reports a stable patient's blood pressure as 90/60 mm Hg; yesterday it was 135/85. What should the RN do FIRST?
Tell the UAP to recheck it in an hour
Reassess the patient's vital signs and clinical status (answer)
Chart the UAP's finding and continue rounds
Notify the provider of the change
Unexpected or conflicting data require prompt RN assessment and validation before acting; the RN may repeat the measurement or direct a competent delegatee to repeat it per policy. Charting an unvalidated number or calling the provider without your own assessment both skip the validation step.
Which interview question is open-ended?
Tell me what you understand about your new medication. (answer)
Are you feeling better today?
Do you have pain?
Did you sleep well last night?
Open-ended questions invite narrative and surface misunderstandings. Yes/no questions close the interview and can miss data the patient would have offered.
Formula Sheet
ADPIE: Assessment → Diagnosis → Planning → Implementation → Evaluation → back to Assessment
Assessment first: collect and validate data before acting
Subjective = what the patient reports; Objective = what you observe or measure
Primary source = the patient; secondary sources = family, clinicians, records (name them)
Four assessment types: complete (admission), focused, time-lapsed (ongoing), emergency
Validate data: assess the patient, repeat or direct a competent repeat measurement per policy, clarify, and compare with baseline and norms
Nursing diagnosis (PES): Problem + related to Etiology + as evidenced by Signs and symptoms
Risk diagnosis: name the vulnerability only — no signs or symptoms
Collaborative problem: “potential complication of X” — monitor and co-manage with the provider
Nursing Fundamentals Study Guide: The Nursing Process
Free, no sign-in30 flashcards25-question quiz25 formulas
A focused study guide to the five-step nursing process — assessment, diagnosis, planning, implementation, and evaluation — with priority frameworks, delegation rules, exam-style questions, rationales, and flashcards.
Read the summary for the big picture, then scan the mind map to see how the topics connect.
The nursing process (ADPIE) is a five-step cycle — assessment, diagnosis, planning, implementation, evaluation — that turns patient data into safe care; exams test whether you can tell the steps apart, rank priorities, and hold the delegation line.
Quick answer: the nursing process is a five-step cycle nurses use on every patient, every shift. You collect and validate data (assessment), name the human response you can treat (diagnosis), write measurable outcomes and set priorities (planning), carry out the plan (implementation), and compare results with the goals (evaluation) — then cycle back. It is patient-centered, universal, cyclical, and dynamic. Exams test the boundaries: which step an action belongs to, which patient comes first, and which task can be delegated.
Assessment is systematic, continuous data collection: subjective (what the patient reports) versus objective (what you observe or measure), from the primary source (the patient) and named secondary sources. It runs from the admission database through focused, time-lapsed, and emergency assessments, organized by body system or Gordon's 11 functional health patterns. Conflicting, incomplete, or unexpected data get prompt RN assessment and validation; a competent delegatee may repeat a measurement when directed, but the RN interprets it. Diagnosis names the response, not the disease, in the PES format: acute pain related to surgical incision as evidenced by a report of 7 out of 10. Four types — problem-focused, risk (no symptoms, ever), health promotion, syndrome — plus collaborative problems written as “potential complication of,” which are co-managed with the provider.
Planning happens at admission, every shift, and for discharge from day one. Outcomes have five parts — patient, verb, measurable criterion, modifier, target time. Priorities come from the ABCs, then Maslow, then unstable-before-stable. Implementation begins with reassessment and splits into independent, dependent, and collaborative interventions, with delegation governed by the five rights and communication structured by SBAR. Evaluation rates outcomes met, partially met, or not met — and every rating sends you back to assessment.
Exam questions follow six patterns: name the step, choose the first action, pick the delegable task, spot the nursing diagnosis, find the finding that needs validation, and answer the SBAR/documentation item. For first-action questions, the assessment choice usually wins when data are incomplete — unless a life-threatening airway or breathing problem demands immediate action.
Key points
ADPIE cycles; evaluation feeds back into reassessment
Partially met outcomes trigger reassessment and revision
Discharge planning starts at admission
Common traps
Choosing an intervention while the scenario still lacks data
Writing a disease name where a nursing diagnosis belongs
Calling a vague wish (“more active”) a goal
Putting signs and symptoms into a risk diagnosis
Treating collaborative problems as nursing diagnoses
Delegating nursing judgment, initial assessment or teaching, or outcome evaluation
Accepting an abnormal UAP-reported vital sign without an RN recheck
Charting “appears fine” instead of what you observed
Marking a goal “met” because the patient tried hard
Treating evaluation as a discharge-day form
Choosing an option because it is kind rather than prioritized
Starting discharge planning on the last day
The Nursing Process Study Guide — ADPIE
Sources: the StatPearls review of the nursing process, the American Nurses Association's five-step framework, and the Open RN Nursing Fundamentals textbook (CC BY).
Symbols used: ADPIE = Assessment, Diagnosis, Planning, Implementation, Evaluation. RN = registered nurse; LPN/LVN = licensed practical or vocational nurse; UAP = unlicensed assistive personnel. PES = Problem, Etiology, Signs and symptoms. SBAR = Situation, Background, Assessment, Recommendation. mm Hg is blood pressure; °C and °F are temperature units.
PART 1 — THE FIVE STEPS
1.1 The one-line answer
The nursing process is the five-step framework nurses use to turn patient data into safe, individualized care: Assessment, Diagnosis, Planning, Implementation, Evaluation — and then it cycles back to assessment. It is patient-centered (everything starts from the patient's data), universal (it applies in every setting), cyclical (evaluation restarts assessment), and dynamic (the plan changes as the patient changes). Exams love it because every question tests one of the five steps or the boundaries between them.
1.2 Step 1: Assessment
Assessment is the systematic, continuous collection, validation, and communication of patient data. It never really ends.
Subjective versus objective:
Subjective data are what the patient reports and only the patient can feel — “I feel nauseated,” “my pain is 7 out of 10,” “I am worried about surgery.” A family member reporting what the patient said is still reporting subjective data (as a secondary source).
Objective data are what you observe or measure — vital signs, lab values, wound appearance, 50 mL of clear vomitus in the basin. Document observations as facts, not impressions: “pale and diaphoretic,” not “looks sick.”
Sources: the patient is the primary source. Secondary sources are family, significant others, other clinicians, and the medical record. Use secondary sources when the patient cannot communicate (unconscious, confused, very young) — and record who provided the data.
Interviewing: open-ended questions (“Tell me what you understand about your medication”) invite narrative and surface what closed questions miss (“Do you have pain?” — a yes/no question that ends the conversation). Best practice: open to open, funnel to closed, then summarize and validate what you heard.
Four types of assessment:
Complete (admission) database — full baseline: biographic data, history, head-to-toe physical, functional status, psychosocial and cultural profile.
Focused assessment — one problem or body system, triggered by a new concern or follow-up need: lung sounds after surgery, neuro checks after a fall.
Time-lapsed (ongoing) assessment — comparing current status with the baseline at intervals: start-of-shift review, scheduled rechecks.
Emergency assessment — a rapid look for immediate life threats: airway, breathing, circulation.
Organizing the data: by body system, by Gordon's 11 functional health patterns (health perception–management; nutrition–metabolic; elimination; activity–exercise; sleep–rest; cognitive–perceptual; self-perception–self-concept; role–relationship; sexuality–reproductive; coping–stress tolerance; values–beliefs), or by nursing diagnosis domains.
Validating data — do this whenever data are conflicting, incomplete, or unexpected: recheck the measurement yourself (a UAP-reported 90/60 deserves an RN recheck), clarify with the patient, compare with the baseline and expected norms, and consult another clinician or the record.
Exam tells: when findings are new, worsening, or conflicting, the assessment or validation action is usually the correct first step — and the RN promptly assesses the patient and validates the result; a competent delegatee may repeat a measurement when directed, but the RN retains the clinical judgment.
1.3 Step 2: Diagnosis
The nursing diagnosis names the human response the nurse can treat — not the disease. Diagnostic reasoning runs: analyze the data, cluster related cues, compare the cluster with the defining characteristics of possible diagnoses, rule out what does not fit, and confirm what does.
The PES format: Problem, related to Etiology, as evidenced by Signs and symptoms. Example (original): acute pain related to surgical incision as evidenced by a report of 7 out of 10 and guarding of the abdomen. The etiology is the cause or contributing factor nursing care can address; the signs and symptoms are the defining characteristics that prove the problem exists.
Four types of nursing diagnoses:
Problem-focused (actual) — the problem exists now, with signs and symptoms present.
Risk — vulnerability exists but no signs yet: risk for infection related to surgical incision. A risk diagnosis is never written with “as evidenced by.”
Health promotion — readiness for enhanced behavior: readiness for enhanced nutrition.
Syndrome — a cluster of diagnoses that occur together.
Collaborative problems are not nursing diagnoses. Written as “potential complication of X” (for example, potential complication of surgery: hemorrhage), they are complications the nurse monitors for and manages together with the provider. Nursing diagnoses are clinical judgments about human responses; their interventions may be independent or collaborative; collaborative problems are co-managed.
Nursing versus medical diagnosis: pneumonia is a medical diagnosis made by a provider; ineffective airway clearance related to retained secretions is a nursing diagnosis made by the RN. One patient can have one medical diagnosis driving three nursing diagnoses — and each nursing diagnosis changes as the patient's response changes.
Diagnoses every fundamentals student should recognize on sight: ineffective airway clearance; impaired gas exchange; ineffective breathing pattern; acute pain; impaired physical mobility; risk for falls; risk for infection; deficient knowledge; anxiety; ineffective coping; imbalanced nutrition; fluid volume deficit; constipation; impaired skin integrity; disturbed sleep pattern; readiness for enhanced health management.
Diagnostic statement errors (exam favorites): wrong label for the cues; the etiology merely restates the medical diagnosis as the problem; signs and symptoms in a risk diagnosis; a judgmental label such as noncompliant — use deficient knowledge or ineffective health management instead when teaching has not yet occurred.
1.4 Step 3: Planning
Planning writes the outcomes, sets priorities, and chooses the route. It happens at three levels: initial planning (on admission), ongoing planning (every shift, as data change), and discharge planning — which starts at admission, not on the last day.
Outcome statements have five parts: subject (the patient, never the nurse), verb (observable action — ambulate, describe, demonstrate), measurable criteria (50 feet; 3 or less on a 0-10 scale), modifiers or conditions (with a rolling walker; after teaching), and target time (by day 2; within 30 minutes). “Patient will be more active” has a subject and a verb and nothing else — not a goal.
Short-term outcomes are met during the stay, often in hours to days; long-term outcomes extend past discharge in weeks to months.
Priorities come from the frameworks in Part 3 plus the patient's own preferences, anticipated needs (a patient who will walk tomorrow needs a falls plan today), and resources.
Care plans range from the student care plan (detailed, a learning tool that proves your reasoning) to standardized protocols and interdisciplinary plans built with the whole team. Whatever the format, the plan must be individualized: two patients with the same medical diagnosis can need opposite nursing plans.
1.5 Step 4: Implementation
Implementation carries out the plan — but it starts with reassessment: check that the planned intervention is still safe and still needed right before you do it.
Three kinds of interventions:
Independent (nurse-initiated): raising the head of the bed, teaching splinted coughing, repositioning, relaxation techniques. No order needed.
Dependent (provider-ordered): medications, IV fluids, wound orders. The nurse still verifies dose, route, and safety — an order does not remove judgment.
Collaborative (interdependent): with other disciplines — physical therapy, respiratory therapy, case management, dietitian.
Nursing orders are written with: date, action verb, what, how, and when — “11-02: Assist to ambulate 50 feet in hallway with rolling walker, twice daily before meals.”
Delegation follows the five rights: right task, right circumstance, right person, right direction, right supervision. The RN retains nursing judgment and critical decision-making in assessment, diagnosis, planning, and evaluation, plus initial teaching that requires RN judgment. Appropriately scoped data collection and teaching reinforcement may be assigned under the state practice act; accountability for delegated care remains with the RN. Typical UAP work: vital signs on stable patients, hygiene, feeding, ambulation, intake and output reporting. Typical LPN/LVN work (per state practice act): stable patients, routine medications and treatments. The decision tree in one line: if the task is stable, routine, predictable, and needs no nursing judgment, it can move; if it requires nursing judgment, an initial assessment, initial teaching, or outcome evaluation, it stays with the RN.
Communication during implementation: SBAR (Situation, Background, Assessment, Recommendation) structures hand-offs and provider notifications — see the worked example in Part 4. Teaching is also implementation: assess readiness first, match reading level and language, and evaluate with teach-back, not “do you understand?”
1.6 Step 5: Evaluation
Evaluation is the judgment step: compare the outcomes with the goals.
Goal met — the measurable criterion was reached. Continue or terminate that part of the plan.
Partially met — progress without the full criterion (goal 50 feet, walked 20). Reassess why, revise the plan.
Not met — no progress or regression. Reassess everything: the diagnosis may be wrong, the goal unrealistic, the interventions ineffective, or the patient's condition changed.
Evaluation is ongoing (every encounter) and terminal (against discharge goals). Quality programs also evaluate structure, process, and outcome — the same words appear in quality-improvement questions. Whatever the result, evaluation feeds back into reassessment: the process is a cycle, not a hallway with an exit.
1.7 Part 1 checklist
Name all five steps, and say for any action which step it belongs to.
Sort any finding into subjective or objective, and name the source.
Run the four assessment types and three validation methods.
Write a PES diagnosis and a five-part outcome from one scenario.
Separate nursing diagnoses from collaborative problems.
Apply the delegation decision tree to any task list.
PART 2 — HOW EXAMS TEST THE PROCESS
2.1 The six question patterns
Which step is the nurse demonstrating? Match action words to steps: collecting and validating data — assessment; clustering cues and naming the response — diagnosis; writing measurable outcomes and ranking problems — planning; carrying out care and delegating — implementation; comparing outcomes with goals — evaluation.
What should the nurse do FIRST? Rank with the Part 3 frameworks. When data are incomplete, the assessment action usually wins.
Which task can be delegated? Apply the five rights: stable, routine, predictable moves to UAP; judgment tasks stay with the nurse.
Which statement is a nursing diagnosis? Look for the human response in PES form — not the disease, not a collaborative problem.
Which finding requires immediate follow-up? New, worsening, or conflicting data — validate before acting (and the RN rechecks, not the UAP).
Communication and documentation questions — SBAR parts, objective charting, and what belongs in the record.
2.2 The assessment-first rule, and its limit
If a scenario gives too little data to act safely, the assessment choice is the right answer. The limit: never delay a life-saving action to gather data — absent breathing needs action now, not a questionnaire.
2.3 Notify the provider, or assess first?
When findings are new or worsening and the picture is incomplete, assess first, then notify with data. When the data already show a problem beyond nursing scope — a prescribed treatment failing, a suspected serious complication — notify with what you have, using SBAR.
2.4 Test-taking moves that earn points
Read the stem for the action verb: first, initial, priority, most appropriate — each changes the ranking.
Identify which ADPIE step the question lives in before looking at the options.
Rank options with ABCs, Maslow, and stability before emotional appeal.
Be suspicious of absolutes (always, never, every) and of options that blame the patient.
If two options are both assessments, the better one measures something (vital signs, pain scale) rather than doing something generic.
2.5 Part 2 checklist
Sort a stack of questions into the six patterns before answering.
Recite the assessment-first rule and its exception.
Explain why “call the provider” can be premature or late — depending on the data.
PART 3 — PRIORITY FRAMEWORKS
3.1 ABCs
Airway, then breathing, then circulation. A patient with sudden stridor outranks every stable patient in the building — including the one in visible pain.
3.2 Maslow
Physiological (oxygen, food, water, temperature, elimination, rest) before safety (injury, infection threat, security) before love and belonging before esteem before self-actualization. A patient who has no dietary restriction and reports hunger and anxiety has an unmet physiologic need, so food comes before the psychosocial concern. If the patient is fasting for a procedure, do not offer food: verify the restriction, explain it, use permitted comfort measures, and address anxiety without violating the NPO order. Pain and elimination are physiological — they outrank psychosocial concerns when both compete, unless a safety restriction changes what can be done.
3.3 Unstable beats stable; acute beats chronic
New, worsening, or unstable findings come before expected or chronic ones. Early-post-op bleeding beats long-term diabetes education. An old stable problem becomes a priority the moment it becomes unstable.
3.4 A four-patient ranking, worked
Room 1: sudden shortness of breath (breathing — first). Room 2: stable patient, pain 6 out of 10, analgesic due (stable physiology — second). Room 3: routine dressing change (scheduled care — third). Room 4: admission paperwork (no clinical urgency — last). Reorder the letters and the logic still works: apply ABCs, then Maslow, then stability, then schedule.
3.5 Part 3 checklist
Rank any four patients with ABCs, then Maslow, then stability.
State the one exception: an identified emergency overrides everything.
Explain why schedule order never outranks clinical priority.
PART 4 — FOUR ORIGINAL WALKTHROUGHS
4.1 A postoperative case through all five steps
Assessment (day 1 after abdominal surgery): patient reports pain 7 out of 10, guards the incision, heart rate 104, temperature 37.9 °C, has not ambulated, states “I do not want to move.” Diagnosis: acute pain related to surgical incision as evidenced by report of 7 out of 10 and guarding; risk for falls related to unsteady gait and opioid use. Planning: the patient will report pain of 3 or less within 30 minutes of analgesia by end of shift; the patient will ambulate 50 feet with a rolling walker twice by day 2. Implementation: give the prescribed analgesic (dependent), position for comfort and teach splinted coughing (independent), case-manager consult for home support (collaborative). Evaluation (30 minutes later): pain 4 of 10 — partially met, so reassess timing and non-drug measures and revise. Day 2 walking: 50 feet twice — met; document and continue.
4.2 What should the nurse do first?
A patient calls out with sudden shortness of breath on day 2. Between “finish the dressing change in the next room” and “assess the patient's airway and breathing now,” the ABC framework sends the nurse to the breathless patient first. The dressing change is stable and routine; the new breathing problem is not.
4.3 A delegation decision
Four tasks: take routine vital signs on a stable patient, assess new crackles, teach insulin technique, evaluate today's pain plan. Vital signs on a stable patient go to UAP. Initial assessment, initial teaching, and outcome evaluation require RN judgment; appropriately scoped data collection or reinforcement may be assigned under the state practice act; routine medication administration for a stable patient is typical LPN/LVN work within the state practice act. The RN stays accountable for the vital signs result: check the numbers, not just the completion.
4.4 An SBAR call to the provider
Situation: “This is the nurse for room 12; Mr. L's drainage output jumped this hour.” Background: “Day 1 post-op abdominal surgery, no anticoagulants, stable until now.” Assessment: “Dressing saturated, blood pressure 92/58, heart rate 118, patient reports dizziness on standing.” Recommendation: “I would like you to evaluate for bleeding; I have kept him supine and held the ambulation goal.” Assessment data, not adjectives, carry the call.
APPENDIX A — EXAM-DAY CHECKLIST
Did I pick the step that matches the action words in the stem?
Did I rank patients with ABCs, then Maslow, then stability?
Is the answer something a nurse can assess, treat, or delegate correctly?
Does my goal answer who, what, how much, with what help, by when?
Did I keep nursing judgment, initial assessment and teaching, diagnosis, planning, and outcome evaluation with the RN?
Did I validate conflicting data before acting on it?
Did I chart facts and measurements, not impressions?
Is there any option that blames the patient? It is almost always wrong.
APPENDIX B — TRAP LIST
Choosing an intervention while the scenario still lacks data. Assess first — unless the airway is in danger.
Confusing a medical diagnosis with a nursing diagnosis. The disease belongs to the provider; the response belongs to nursing.
Writing “patient will be more active” and calling it a goal. No number, no deadline, no goal.
Putting signs and symptoms into a risk diagnosis. Risk means it has not happened.
Treating collaborative problems as nursing diagnoses. “Potential complication of” is co-managed with the provider.
Delegating nursing judgment, initial assessment or teaching, diagnosis, planning, or outcome evaluation. Task-level data collection or teaching reinforcement depends on scope, competence, policy, and patient stability.
Accepting a UAP-reported abnormal vital sign without prompt RN assessment and validation. The RN may repeat the measurement or direct a competent delegatee to repeat it per policy.
Charting “appears fine” or “seemed restless” instead of observable facts with numbers.
Marking a goal “met” because the patient tried hard. Met means the measurable criterion was reached.
Treating evaluation as the discharge-day form. It happens every time data are compared with a goal.
Choosing an option because it is kind. Correct options are both safe and prioritized — kindness does not outrank an ABC problem.
Discharge planning on the last day. It starts at admission.
These are original HyNote study notes for nursing fundamentals students. They follow the public five-step nursing process framework and cite public references. They are not official materials of any nursing organization, they are not exam questions, and they are not clinical advice. All scenarios are fictional and educational.
Shortcuts: 1–5 switch steps · ← → previous / next · Space flip a card · A–D answer · Enter next question
