NSG 211 Ch. 7 ATI Application Exercises

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

"I will determine the most important client problems that we should address" Prioritize the client's problems during the planning step of the nursing process. Review the client's history during the assessment/ data collection step of the nursing process. Implement nurse- and provider- initiated actions during the intervention step of the nursing process. Gather information about whether the client's problems have been resolved during the evaluation step of the nursing process.

A charge nurse is observing a new licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?

Assessment The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain.

A nurse educator is reviewing with a group of nursing students the actions and thought processes nurses use during the steps of the nursing process. Use the ATI Active Learning Template: Basic Concept to complete this item. Nursing Interventions - List at least three actions to take during the analysis or data collection step. - List four factors to consider during the evaluation step when clients have not achieved their goals.

NURSING INTERVENTIONS Analysis/ data collection - Recognize patterns or trends - Compare the data with expected standards or reference ranges. - Arrive at conclusions to guide nursing care Factors to consider during evaluation for unmet goals - An incomplete database - Unrealistic client outcomes - Nonspecific nursing interventions - Inadequate time for the client to achieve the outcomes

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Reassess the client to determine the reasons for inadequate pain relief. Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care.

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply).

Respiratory rate is 22/min with even, unlabored respirations The client's skin is pink, warm, and dry The assistive personnel reports that the client walked with a limp Objective data includes information the nurse measures (vital signs), includes information the nurse observes (skin appearance), includes information from the observations of others (family and staff).

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.)

Showing a client how to use progressive muscle relaxation Performing a daily bath after the evening meal Repositioning a client every 2 hr to reduce pressure injury risk Showing a client how to use progressive muscle relaxation is an appropriate nurse- inititated intervention for stress relief. Unless there is a contraindication {of a condition or circumstance} suggest or indicate {a particular technique or drug} should not be be used in the case in question) for a specific client, use this technique with clients without a provider's prescription. Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider's prescription. Repositioning a client every 2 hr is an appropriate nurse- initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider's prescription.