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
A. Skin was pink, warm, dry, and intact. Capillary refill was less than 5 seconds in all fingers. Radial pulses were +4 and equal bilaterally. Grips were strong 10 out of 10 and equal bilaterally:
Incorrect. Capillary refill should be less than 2-3 seconds for normal findings; less than 5 seconds would be too long and could indicate poor perfusion. Radial pulses graded +4 are not typical and suggest a bounding pulse, which could indicate an abnormal condition. Grips graded 10/10 is not the standard grading system; typically, grips are graded out of 5.
B. Skin was pink, warm, dry, and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were +2 and equal bilaterally. Grips were strong 5/5 and equal bilaterally:
Correct. This option uses proper terminology. Capillary refill of less than 3 seconds is normal, radial pulses graded +2 are normal, and grips are appropriately graded on a 5-point scale, with 5/5 being the normal strength.
C. Skin was pink, warm, dry, and intact. Capillary refill was more than 3 seconds in all fingers. Radial pulses were 1 and equal. Grips were strong 4/4 and symmetrical:
Incorrect. Capillary refill of more than 3 seconds indicates delayed perfusion, which is abnormal. Radial pulses graded 1 indicate a weak pulse, which is not within normal limits. Additionally, grips are usually graded out of 5, not 4.
D. Skin was warm and dry and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were 3. Grips were strong and equal:
Incorrect. While some aspects are correct (capillary refill), the pulse grading system is incomplete here. Radial pulses should be recorded as +1 to +4, and +3 would indicate a stronger-than-normal pulse, which is not typical for normal findings. Grip strength is not fully documented here either, as it should include a scale (e.g., 5/5).
Correct Answer is C
Explanation
The correct answer is choice C, Pulse amplitude. Pulse amplitude is a measure of the strength of the pulse and is rated on a 0-4 scale, with 0 indicating no pulse and 4 indicating a bounding pulse. A brisk pulse with a +2 rating suggests a normal pulse strength that is easily felt and is not weak or bounding. Pulse rhythm describes the regularity or irregularity of the pulse beats and is not related to pulse strength. Pulse deficit refers to the difference between the apical and radial pulse rates and is determined by auscultating the apical pulse while simultaneously palpating the radial pulse. Pulse arrhythmia refers to an irregular pulse rhythm.
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