A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

Analysis.

Implementation.

Planning.

Evaluation.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D, Evaluation.

Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions that were implemented during the implementation step. In this scenario, the nurse administered pain medication and is now evaluating its effectiveness by asking the client to rate their current level of pain on a scale of 0 to 10. Based on the client's response, the nurse can determine whether the intervention was successful or whether adjustments to the plan of care are necessary.

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Correct Answer is A

Explanation

The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.

A. The nurse identifies the patient has pain and formulates this as the patient's priority health problem. B. The nurse removes bandages from a burn victim's arm and performs sterile dressing change once a shift. C. The nurse ambulates a post-operative patient in the hall during their shift. D. The nurse assesses a patient to determine their nutritional status. E. The nurse turns a patient every 2 hours to prevent pressure injuries.

Correct Answer is ["C","E"]

Explanation

The nursing actions that best represent the step of performing interventions in the nursing process are:

C. The nurse ambulates a post-operative patient in the hall during their shift.

E. The nurse turns a patient every 2 hours to prevent pressure injuries.

Explanation: In the step of performing interventions, the nurse takes action to implement the nursing care plan and achieve the identified goals. The interventions should be specific, measurable, and realistic to address the patient's needs. Ambulating a post-operative patient in the hall during their shift and turning a patient every 2 hours to prevent pressure injuries are both specific interventions that address patient needs and promote positive health outcomes. Removing bandages from a burn victim's arm and performing sterile dressing change once a shift is more related to the step of assessment or implementation, while identifying a patient's priority health problem or assessing a patient's nutritional status are more related to the step of analysis and diagnosis in the nursing process.

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A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

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Naxlex Comprehensive Predictor Exams

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Correct Answer is A

Explanation

A nurse is taking action and performing interventions in the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step in the nursing process? Select all that apply.

Correct Answer is ["C","E"]

Explanation

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