A nurse enters a client's room to evaluate the response to IV ...

[a0266361136]

A nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier.
 
  The nurse finds the client in the same position as when the medication was administered. The client states, I do not want to move. The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these action represent?
  Select all that apply.
  A) Assessment
  B) Diagnosis
  C) Planning
  D) Implementation
  E) Evaluation

Question 2

A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do?
 
  A) Ask the client about readiness to walk.
  B) Call for a wheelchair to start the process.
  C) Conduct a breathing assessment.
  D) Evaluate the client's level of pain.

[covalentbond]

Answer to Question 1

Answer: A, D, E

The nurse is engaging simultaneously in an assessment, implementation, and evaluation as she (1) observes the client's behavior and asks about her current pain level (assessment), (2) implements an aspect of care by following up on the prior pain administration (implementation), and (3) evaluates the client's response to the earlier pain administration (evaluation). Phases of the nursing process overlap and are not separate entities.

Answer to Question 2

Answer: D

Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.

[a0266361136]

Excellent

[bblaney]

TYSM