Which of the following nursing interventions is the best example ...

[xclash]

Which of the following nursing interventions is the best example of the implementation part of the nursing process?
 
  a. Determining that the client's ankle edema is worse after he ambulates
  b. Asking the client to rate his ankle pain after receiving oral pain medication
  c. Arranging for the client to receive pain medication
  d. Crushing the client's pain medication to facilitate easier swallowing and thus minimize choking

Question 2

The client has recently had a mitral valve replacement. To prevent excess serosanguineous fluid buildup, which of the following does the nurse anticipate will be included in care?
 
  a. Increased oxygen therapy
  b. Frequent chest physiotherapy
  c. Incentive spirometry on a regularly scheduled basis
  d. Chest tube placement in the thoracic cavity

[johnharpe]

Answer to Question 1

D
Taking the appropriate action demonstrates the implementation step in the nursing process.
Assessment involves gathering data.
Assessment involves gathering data.
Planning involves establishing goals and expected outcomes.

Answer to Question 2

D
Chest tubes are inserted to remove air and fluids from the pleural space, to prevent air or fluid from re-entering the pleural space, and to re-establish normal intrapleural and intrapulmonic pressures. The client who has had mitral valve replacement surgery (chest surgery) would be ex-pected to have a chest tube postoperatively to prevent excess fluid buildup in the pleural space.
Increased oxygen will not prevent excess fluid buildup.
Frequent chest physiotherapy may help facilitate removal of secretions but will not prevent ex-cess fluid buildup.
Incentive spirometry is used to promote deep breathing and to prevent or treat atelectasis in the postoperative client. It will not prevent excess fluid buildup.