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.
Assessing Palpebral Conjunctiva, Patient Position
The nurse assesses the patient's ability to use the walker correctly
Patient learns to not be afraid
To check pupillary reflexes the nurse first holds the penlight
A hearing-impaired patient using an interpreter.
Role-Playing a Situation in Which a Patient Is from Another Culture