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.
The nurse identifies the patient has pain and formulates this as the patient's priority health problem.
The nurse removes bandages from a burn victim's arm and performs sterile dressing change once a shift.
The nurse ambulates a post-operative patient in the hall during their shift.
The nurse assesses a patient to determine their nutritional status.
The nurse turns a patient every 2 hours to prevent pressure injuries.
Correct Answer : C,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Protein is most important for wound healing. After abdominal surgery, the client requires adequate protein to promote wound healing and tissue repair. Protein is essential for collagen synthesis, a protein that is responsible for the tensile strength of the wound. The recommended daily allowance for protein for an adult is 0.8 g/kg of body weight. Foods high in protein include meat, fish, poultry, dairy products, beans, and nuts.
Correct Answer is B
Explanation
The correct answer is B. Sanguinous. Sanguinous drainage is bright red, indicating fresh bleeding, and may be seen in the first few hours after surgery. Dark red drainage may indicate that there is an increase in bleeding, and the nurse should notify the provider immediately. Serosanguineous drainage is pink in color and consists of both blood and serum. Purulent drainage is thick, yellow or green in color and consists of pus, indicating an infection. Serous drainage is clear or light yellow in color and contains serum without red blood cells.
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