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.
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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Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A.Observe for signs and symptoms of respiratory distress.
B.Auscultate anterior and posterior lung fields.
C. Inspect the skin for pallor and cyanosis.
E. Observe rate, rhythm, and depth of respirations.
When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.
Correct Answer is D
Explanation
Upon discovering that the client's abdominal wound has been eviscerated, the nurse should immediately cover the wound area with sterile gauze moistened with sterile 0.9% normal saline. This will help to protect the exposed organs and prevent them from becoming dry or exposed to contaminants. Pouring hydrogen peroxide into the abdominal cavity can cause further damage to the exposed organs and is not recommended. Similarly, normal saline should be gently poured on the area to moisten it, but organs should not be placed back into the cavity as this can cause further injury. Attempting to close the wound area with reinforced adhesive skin closures is also not appropriate as the wound needs to be assessed and repaired by a healthcare provider. The nurse should call the healthcare provider and provide ongoing assessment and support to the client while waiting for further interventions.
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