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

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

_______ assessments can be done with an initial assessment. They identify new or overlooked problems. They are important because they can "flag" existing problems.

• Initial

• Focused

• On-going

• Emergency

Time lapsed assessments compare current status to the ______data

• Subjective

• Projected

• Objective

• Baseline

_______ data is observable and measurable data that can be seen, heard, felt or measured by someone other than the person experiencing them

• Objective

• Subjective

_______ is the conscious and deliberate use of the five senses to gather data

• Assessment

• Interview

• Observation

The _____ step of the nursing process interprets and analyzes data gathered

• Assessment

• Diagnosis

• Implementation

• Evaluation

Caring for a patient who presents with labored respirations, productive cough, and fever. What would be an appropriate nursing diagnosis for this patient? (select all that apply)

• Bronchial pneumonia

• Impaired gas exchange

• Ineffective airway clearance

• Potential complications: sepsis

• Risk for septic shock