Case Study- Nursing Process Exam

A nurse is implementing priority-based interventions for a group of clients. Which of the following clients should the nurse see first?

A client who has a cast on a compound fracture and has SaO2 of 88% When using the airway, breathing, circulation approach to client care, the nurse should determine that the finding of SaO2 of 88% indicates hypoxia and requires priority-based interventions.

A nurse is admitting a client who reports increased thirst and fatigue. Which of the following actions should the nurse include in the assessment step of the nursing process?

Ask the client when the condition started. Assessment is the first step of the nursing process, where the nurse gathers subjective and objective information about the client's condition.

A nurse is following the steps of the nursing process when caring for a group of clients. Which of the following actions by the nurse demonstrates the evaluation step of the nursing process?

Check and document a client's pain level 30 min after administering pain medication. The nurse is evaluating, which is the final step of the nursing process, to determine if the pain medication administered to the client is effective. Evaluation is the same as assessment; however, to determine the client's status and progress, evaluation is performed.

A nurse is preparing a plan of care for a client who is experiencing pain after surgery. Which of the following components should the nurse identify as part of the planning step of the nursing process?

Formulate client goals for prioritized problem. Formulating client goals for prioritized problems is a component of planning, which is the third step in the nursing process.

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates the use of critical thinking skills?

Intervene after reviewing arterial blood gas results for a client who is on mechanical ventilation. The nurse is using critical thinking when analyzing a client's critical issues and then planning to intervene with an appropriate action.