Nursing Process

The nurse repositions a client who has difficulty breathing. Which nursing action, when performed following the intervention, demonstrates evaluation?

• Instructing the client the importance of mobility

• Arranging the pillows behind the client's back

• Checking the client's respiratory status

• Changing the rate of flow for the oxygen delivery system

Which statement is correctly stated as an expected client outcome?

• Client will ambulate safely.

• Client will be able to safely walk down the hallway.

• Nurse will assist the client with ambulation three times daily.

• Client will ambulate with assistance to nurse's station on second postoperative day.

The nurse is caring for a one day postoperative client with a new colostomy. What nursing diagnosis would be the primary concern for the nurse?

• Activity intolerance

• Ineffective Health Maintenance

• Impaired bowel elimination

• Ineffective coping

The nurse knows which intervention is a dependent intervention?

• Obtaining a client's BP

• Massaging a client's back

• Administering medications to a client

• Assessing a client's lung sounds

The nurse is caring for a client recovering from a CVA (cerebrovascular accident). When reviewing orders, the nurse notes that a healthcare provider has written an order for the client to ambulate, while another has written for strict bedrest. What is the most appropriate nursing intervention?

• Collaborate with the physical therapist to determine if the client can ambulate

• Assess the client to determine the client's ability to ambulate

• Instruct the client to clarify with the healthcare provider ambulation orders

• Clarify ambulation orders with healthcare providers

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?

• Discuss the frequency of pain medication orders with the client.

• Assess the client to determine the cause of the pain

• Consult with the healthcare provider for additional pain orders

• Assist the client to reposition and splint the incision site