ADPIE

A nurse notes that a shift report states tat a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate?

• Correct initial assessment form

• Redo the initial assessment and document current findings

• Conduct and document an emergency assessment

• Perform and document a focused assessment of skin integrity

The nurse is preparing for data collection ,which part of the nursing process is the nurse demonstrating?

• Evaluating

• Diagnosing

• Assessing

• Implementing

A nurse is caring for a patient who presents with labored respirations, productive cough and fever. What would be appropriate nursing diagnoses for this patient. Select all that apply.

• Bronchial pneumonia

• Impaired gas exchange

• Ineffective airway clearance

• Potential complication:sepsis

• Risk for septic shock

The nurse is establishing priorities and identifying expected results. Which step of the nursing process is the nurse performing?

• Assessing

• Evaluating

• Implementing

• Outcome

The purpose of implementation is which of the following?

• Help patient achieve valued health outcomes.

• Help patient achieve a better nursing diagnosis.

• Help patient history data with more information

• Help patient nurse relationship get stronger