Nursing Process II PDF

Nursing Process II Fundamentals of Nursing ATI Question I Implementation → nursing actions Client with end-stage chronic kidne...

Nursing Process II Fundamentals of Nursing ATI Question I Implementation → nursing actions Client with end-stage chronic kidney disease (ESKD)... interventions to include in the plan of care? Select All That Apply Nursing interventions: Assess, monitor, observe, provide Assess for jugular vein distention (JVD) Provide frequent mouth rinses Procedures, meds, client education Observe for Kussmaul respirations Monitor for melena E Evaluation → Objective & Measurable NCLEX TIP ! Reassess the client. Were the desired ASSESSMENTS outcomes achieved? Adapt the plan of care based on new assessment: PLANNING Identify potential errors or problems in the plan of care Make adjustments as needed Client Education: Low Literacy Top Missed NCLEX Question Choose the best discharge teaching strategies for an 82-year-old Cognitive: Thought process & intellect client with a low literacy level who has been newly diagnosed Example: A client learning how to choose with COPD? Select all that apply. low sodium food choices. 1. Print out pictures showing the steps of correct inhaler use. Psychomotor: Involves physicality/action 2. Perform discharge teaching with a family member present. 3. Raise your voice, speak clearly and slowly Example: A client practicing medication 4. Strongly discourage internet usage to look up health information. administration. (Insulin injection) 5. Show the client a professionally produced video from a credible source. Affective: Involves emotions/feelings Example: A client’s willingness to learn about the disease process. Instructional Methods Written Materials: primary language, using simple terms, & appropriate reading level. Demonstration: Showing a client how to perform a skill (Insulin injection) Others: Videos, audio recordings, books, verified websites. Evaluation Methods Teach Back: The client will demonstrate their learning by explaining it back to the nurse. Notes