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 B
Explanation
The correct answer is choice B: Contact Precautions. Clostridium difficile (C-diff) is a bacterium that can cause severe diarrhea and other gastrointestinal problems. It is highly contagious and spreads through contact with contaminated surfaces or objects. Therefore, it is necessary to apply Contact Precautions for patients with C-diff to prevent the transmission of the infection. Contact Precautions involve wearing gloves and gowns when entering the patient's room and disposing of contaminated items properly. Additionally, hand hygiene is critical to preventing the spread of C-diff.
Correct Answer is D
Explanation
The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.
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