MM - Decision-Making & Endo/Resp

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

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

_______ 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

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

• Objective

• Subjective

The four methods used to collect data during an assessment (select all that apply)

• Inspection

• Palpitation

• Percussion

• Clarify

• Auscultation

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

• Assessment

• Diagnosis

• Implementation

• Evaluation

An example of subjective data for assessment is:

• "I feel like I have a fever"

• Patient appears flushed

• Patient's temperature is 101 degrees F - orally

• Patient is experiencing a high fever

Implementation best refers to:

• Deciding on the appropriate interventions

• Carrying out the physicians orders

• Determining if the goal has been met

• Carrying out the planned interventions

The nursing assistant reports that a patient is complaining of SOB (shortness of breath). Which action should the nurse take next?

• Let the patient rest and check on him in 30 minutes

• Instruct the nursing assistant to take a set of vital signes

• Contact the physician immediately

• Assess the patient her/him self

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