Answer to Question 1
ANS: D
Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves and if goals have been met. Assessment, the first step of the process, includes data collection. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing interventions. During implementation, nurses carry out nursing care, which is necessary to help patients achieve their goals.
Answer to Question 2
ANS: A, B, C, E
Nursing priorities include interventions directed at enhancing wound healing. Teaching the patient about signs and symptoms of infection will help the patient identify signs of appropriate wound healing and know when the need for calling the health care provider arises. Performing dressing changes, controlling blood sugars through administration of medications, and instructing the family in dressing changes all contribute to wound healing. As long as a patient is stable and alert, it is appropriate to allow family to assist with care. The patient should be allowed to discuss body image changes.
The nurse assesses the patient's ability to use the walker correctly
The nurse applies a pulse oximeter sensor on the client’s finger.
Providing patient education
All messages must be documented and placed in the patient's chart.
Nurse administering enteral nutrition through a feeding tube.
Colorimetric multiplex assay to determine anti-HLA antibodies in a patient's serum.