Podcast
Questions and Answers
Which nursing intervention is appropriate for assessing a client with end-stage chronic kidney disease?
Which nursing intervention is appropriate for assessing a client with end-stage chronic kidney disease?
- Assess for jugular vein distention (JVD) (correct)
- Evaluate for skin integrity
- Instruct on proper catheter care
- Monitor blood glucose levels
What intervention should be included in the care plan for a client experiencing Kussmaul respirations?
What intervention should be included in the care plan for a client experiencing Kussmaul respirations?
- Provide sedatives for relaxation
- Monitor for and document Kussmaul respirations (correct)
- Encourage deep breathing exercises
- Administer supplemental oxygen immediately
Which intervention is most effective for managing dry mouth in a client with end-stage chronic kidney disease?
Which intervention is most effective for managing dry mouth in a client with end-stage chronic kidney disease?
- Limit fluid intake significantly
- Encourage the use of hard candies
- Advise drinking carbonated beverages
- Provide frequent mouth rinses (correct)
Which method should be prioritized when teaching discharge instructions to an elderly client with low literacy?
Which method should be prioritized when teaching discharge instructions to an elderly client with low literacy?
What is the most appropriate type of discharge teaching for a client with low literacy and COPD?
What is the most appropriate type of discharge teaching for a client with low literacy and COPD?
If the desired outcomes for a client with ESKD were not achieved, what is the first action to take?
If the desired outcomes for a client with ESKD were not achieved, what is the first action to take?
How should a nurse respond if a client with COPD expresses a desire to look up health information online?
How should a nurse respond if a client with COPD expresses a desire to look up health information online?
Which of the following signs is most important to monitor for during the evaluation phase for a client with ESKD?
Which of the following signs is most important to monitor for during the evaluation phase for a client with ESKD?
Flashcards
Implementation (Nursing Process)
Implementation (Nursing Process)
The nursing process is a systematic approach to delivering patient care. Implementation involves carrying out the planned interventions and assessments to meet the client's needs.
Evaluation (Nursing Process)
Evaluation (Nursing Process)
This phase of the nursing process involves evaluating the effectiveness of the interventions and adjusting the plan of care as needed based on the patient's response.
Nursing Interventions
Nursing Interventions
These are measures the nurse takes to address the patient's health needs during the implementation phase of the nursing process.
Client Education
Client Education
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Jugular Vein Distention (JVD)
Jugular Vein Distention (JVD)
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Kussmaul Respirations
Kussmaul Respirations
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Melena
Melena
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Low Literacy Client Education
Low Literacy Client Education
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Study Notes
Nursing Process II
- Implementation:
- Nursing interventions: Assess, monitor, observe, and provide procedures, medications, and client education.
Evaluation
- Evaluation:
- Reassess the client to determine if desired outcomes were achieved.
- Adapt the care plan based on the new assessment, identifying potential errors or problems.
- Make adjustments as needed.
Client Education: Low Literacy
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Cognitive: Thought processes and intellect.
- Example: Choosing low-sodium foods.
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Psychomotor: Physicality and actions.
- Example: Insulin injection administration.
-
Affective: Emotions and feelings.
- Example: Client willingness to learn about the disease process.
-
Instructional Methods:
- Written materials: Use simple language and appropriate reading levels.
- Demonstrations: Show clients how to perform skills.
- Other resources: Videos, audio recordings, books, validated websites.
-
Evaluation Methods:
- Teach-back: The client explains the learning back to the nurse.
ATI Question
- Client with end-stage chronic kidney disease (ESKD):
- Assess for jugular vein distention (JVD).
- Provide frequent mouth rinses.
- Observe for Kussmaul respirations.
- Monitor for melena.
Top Missed NCLEX Question
- 82-year-old client with COPD:
- Use visual aids (pictures) for inhaler use instructions.
- Involve family members during discharge teaching.
- Speak clearly and slowly.
- Encourage reliable internet resources.
- Provide a professional, credible video if appropriate.
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