A nurse is developing pain management goals to a post-operative client. Which of the following steps of the nursing process is the nurse performing?

Planning

Assessment

Implementation

Evaluation

Answer and Explanation

The Correct Answer is A

A. Planning: Developing goals is part of the planning phase, where the nurse sets objectives and outcomes for the patient’s care.
B. Assessment: Assessment involves collecting data about the patient’s condition.
C. Implementation: Implementation involves putting the care plan into action.
D. Evaluation: Evaluation involves determining whether the patient has met the goals and outcomes set during the planning phase.

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Correct Answer is B

Explanation

A. “I am calling about Mrs. Smith’s recent development of dyspnea." This statement is part of the Situation (S) step, describing why the nurse is calling.
B. "The client is post-op day 1 following a lung resection." This statement provides Background (B) information, giving context about the patient’s medical history and recent events.
C. "Could you provide an order for an incentive spirometer?" This statement is part of the Recommendation (R) step, where the nurse suggests a specific action or order.
D. "The client's respirations are 24, even and bilateral. Afebrile." This statement is part of the Assessment (A) step, describing the current clinical findings or assessment of the patient’s condition.

A. The client states that she will be staying with her daughter after discharge. B. Client states she is having pain. C. The client states she uses a pill container to divide her daily meditation. D. The client states her pharmacy also provides information on the medication.

Correct Answer is B

Explanation

A. The client states that she will be staying with her daughter after discharge: Staying with her daughter could potentially be a support system, not a barrier to learning.
B. Client states she is having pain: Pain can significantly impair a client's ability to focus and understand new information, making it a potential barrier to learning.
C. The client states she uses a pill container to divide her daily medication: Using a pill container indicates that the client has a system in place for managing medications and is not a barrier to learning.
D. The client states her pharmacy also provides information on the medication: Having access to additional information from the pharmacy is an aid to learning, not a barrier.

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A nurse is developing pain management goals to a post-operative client. Which of the following steps of the nursing process is the nurse performing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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