Nursing Process

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

• Establish client outcomes

• Collect information about past health problem

• Determine whether the client has met specific goals

• Identify the client's specific health problems

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

• Planning

• Evaluation

• Assessment

• Implementation

A nurse on a medical surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

• Identify goals for client care

• Obtain client information

• Document nursing care needs

• Evaluate the effectiveness of care

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

• Vital signs

• Plan of care

• Nursing interventions performed

• Evaluation of progress

Answer explanation

Because obtaining vital signs is part of the assessment which needs to come first. First, figure out what you are dealing with - vital signs, some background info, important medical history, etc.

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

• Instill proparacaine hydrochloride eye drops

• Perform ocular irrigation of the right eye

• Place the client in a supine position with the head turned toward the affected side

• Ask the client about first aid performed at the scene

Answer explanation

This is the answer because ASSESSMENT is always your first step when you get a patient for the first time. You need to figure out what is going on first and what has been done. What if he already got those eye drops and then you're giving him too much? Those drops have an anesthetic in them and you can overdose and have permanent damage. Yes you should lie someone down on their affected side to put in eye drops, but that isn't the first thing.