Which of the following are examples of nursing implementations? (Select All That Apply)
changing a surgical dressing
return demonstration by the patient
changing an ostomy bag
planning patient outcomes
analyzing assessment data
Correct Answer : A,B,C
A. Changing a surgical dressing: This is an example of a nursing implementation. Nurses frequently change dressings as part of their patient care responsibilities.
B. Return demonstration by the patient: This is also an example of a nursing implementation. Nurses often educate patients and then assess their understanding through return demonstrations to ensure the patient can perform tasks correctly at home.
C. Changing an ostomy bag: This is another example of a nursing implementation. It involves hands-on care for patients with ostomies, a responsibility often carried out by nurses.
D. Planning patient outcomes: While planning patient outcomes is crucial for nursing care, it falls more under the category of nursing interventions and nursing process rather than direct implementations.
E. Analyzing assessment data: Analyzing assessment data is part of the nursing process and helps in making decisions about nursing care. While it's essential, it's not a direct implementation action.
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Correct Answer is D
Explanation
A. "Refuses to have blood drawn. Doctor notified."
This option documents the patient's refusal but lacks specific information about the patient's reason for refusal, which is important for the care team to understand the context.
B. "Doctor notified of failure to draw ordered blood work."
This option focuses more on the failure to draw blood than on the patient's specific refusal and reasoning. It lacks information about the patient's perspective, which can be crucial for understanding their decision-making process.
C. "Blood not drawn because tests are no longer desired by the patient."
This choice provides a clear reason for not drawing blood (the patient's refusal) and includes the patient's perspective on the tests being 'useless.' However, it does not mention the action taken, such as informing the doctor, which is important for continuity of care.
D. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
This option combines both the patient's refusal and their reason ('useless' tests) for refusing. Additionally, it includes the action taken, which is informing the doctor. This choice offers a comprehensive and informative description of the situation.
Correct Answer is C
Explanation
A. Assessment:
Explanation: Assessment is the first step in the nursing process. It involves gathering information about the patient's health status. This can include a patient's medical history, physical examination, and other vital signs. It's the phase where the nurse collects data to identify the patient's problems or needs.
B. Nursing Diagnosis:
Explanation: Nursing diagnosis is the second step in the nursing process, following assessment. During this step, the nurse analyzes the data collected during the assessment to identify nursing diagnoses or issues. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes.
C. Evaluation:
Explanation: Evaluation is the last step in the nursing process. It involves assessing the patient's response to nursing interventions and determining if the goals and outcomes have been met. In the given scenario, the nurse is evaluating whether the pain medication administered 45 minutes ago has had the desired effect and has relieved the patient's pain.
D. Implementation:
Explanation: Implementation is the third step in the nursing process. During this phase, the nurse carries out the care plan that was designed during the planning phase. This can involve a variety of nursing actions, including administering medications, providing treatments, and educating patients. In the context of the scenario, giving pain medication is part of the implementation phase.
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