Answer to Question 1
ANS: D
Before intervening, the nurse must check the patient's orders. For example, if the patient is on bed rest, the nurse will need to explain the use of a bedpan rather than helping the patient get out of bed to go to the bathroom. Interventions sometimes will be determined by orders and availability of resources. Asking for assistive personnel is appropriate after making sure the patient can get out of bed. If the patient is obese, the nurse will likely need assistance in getting the patient to the bathroom. Medicating the patient before checking the orders is not advised in this situation. Before medicating for pain, the nurse needs to perform a pain assessment. Offering the patient a walker is a premature intervention until the orders are verified.
Answer to Question 2
ANS: A
Before implementing any intervention, the nurse uses critical thinking to determine whether an intervention is correct and appropriate for a clinical situation. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment because patient conditions can change very rapidly. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse.
The nurse needs to note the source of the patient health history
The nurse applies a pulse oximeter sensor on the client’s finger.
Application of an ostomy bag or pouch: B, An ostomy nurse applying an ostomy bag to a stoma;
For ice massage, ice is frozen in a cylindrical container or a paper cup (A). The top half of the cu
The patient's signature on the informed consent form indicates that the patient understands the
Patient Physical Status Classification