nursing process

According to the nursing process, what is the correct order of steps to take in caring for a client who reports chest pain? 1. Perform a focused assessment of the client. 2. Administer 2 L of oxygen via nasal cannula. 3. Create a care plan to minimize the client's symptoms. 4. Determine the most appropriate NANDA-I diagnosis for the client.

1. Perform a focused assessment of the client. Correct2.Determine the most appropriate NANDA-I diagnosis for the client. Correct3.Create a care plan to minimize the client's symptoms. Correct4.Administer 2 L of oxygen via nasal cannula. According to the nursing process, the nurse would first perform an assessment to look for subjective and objective data. Next, the nurse would formulate a nursing diagnosis that best represents what is happening with the client. Creation of a care plan based on the diagnosis is the next step, followed by implementation of the identified interventions, like administration of oxygen.Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing a nursing action or skill such as those involved in medication administration.

Which step in the nursing process involves the nurse interviewing a client about a current health problem and taking the client's vital signs? 1 Planning 2 Diagnosis 3 Assessment 4 Implementation

Assessment The scenario is an example of the assessment phase of the nursing process. Assessment involves the collection of comprehensive data pertinent to the client's health. During the planning level of nursing care, the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. The nurse analyzes the assessment data to determine the diagnoses during the diagnosis level of nursing practice. The nurse implements the health care plan identified for the client during the implementation level of the standards of nursing practice. This level may include administering prescribed medications or health care procedures.

The nurse is interviewing a client for admission to the hospital. Which phase of the nursing process is being used in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Diagnosis

Assessment involves taking the history of and verbally interviewing the client. Planning is the phase of the nursing process that includes the development of a written document of expected outcomes. Evaluation is the phase of the process when the care plan is modified and updated. Diagnosis involves the documentation and validation of health care needs and priorities via verbal discussion with the client.

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client? 1 Evaluation 2 Assessment 3 Implementation 4 Diagnosis

Assessment-Correct2 An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned. Diagnosis is formulation of a problem based on the gathering and interpretation of data collected about the client.Test-Taking Tip: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment.

Place the steps of the nursing process in the correct order. -Plan the care by determining priorities, goals, and expected outcomes of care. -Evaluate the effects of the nursing interventions performed. -Perform the nursing interventions competently. -Identify the client's health care needs by collecting subjective and objective data. -Define the nursing diagnoses or collaborative problems

Correct1.Identify the client's health care needs by collecting subjective and objective data. Correct2.Define the nursing diagnoses or collaborative problems clearly. Correct3.Plan the care by determining priorities, goals, and expected outcomes of care. Correct4.Perform the nursing interventions competently. Correct5.Evaluate the effects of the nursing interventions performed. The nursing process consists of five steps. The first step is assessment, which involves identifying the client's need by collecting subjective and objective data. Based on this information, nursing diagnoses are made to define the client's problems. The care plan is created based on the nursing diagnoses and includes determining priorities, goals, and expected outcomes of care. During the implementation phase, the planned care is delivered to the client. In the evaluation phase, the nurse evaluates the effectiveness of the nursing care provided by reassessing the client's condition.

Place each step of the nursing process in the correct order. 1. Identify goals for care. 2. Develop a plan of care. 3. State the client's nursing needs. 4. Implement nursing interventions. 5. Obtain the client's nursing history.

Correct1.Obtain the client's nursing history. Correct2.State the client's nursing needs. Correct3.Identify goals for care. Correct4.Develop a plan of care. Correct5.Implement nursing interventions. First the nurse would gather data. Based on the data, the client's needs are assessed. After the needs have been determined, the goals for care are established. The next step is planning care based on the knowledge gained from the previous steps. Implementation follows the development of the plan of care.

According to the nursing process, which would the nurse do after administering pain medication to a postoperative client? 1 Administer nonpharmacological comfort measures. 2 Inform the health care provider of the nursing action. 3 Create a care plan that addresses the client's pain level. 4 Determine whether the pain medicine relieved the client's pain.

Determine whether the pain medicine relieved the client's pain. After implementation of a nursing action (administration of pain medication), the nurse must evaluate the intervention's effectiveness. Administering nonpharmacological comfort measures is a different intervention and does not occur as a result of the pain medication. The nurse does not need to inform the provider of the nursing action. The nurse creates a plan of care before administering the pain medication, not after.

When the nurse revises the care plan because the goals have not been met, which phase of the nursing process is being applied? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

Implementation The basic step of implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, and social culture. Topics

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

planning The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of a nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.