The nurse begins to auscultate the client's lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of:
1. Performing a nursing assessment
2. Reorganizing the nursing diagnoses
3. Implementing nursing interventions
4. Critically analyzing client assessment data
ANS: 4
The nurse who stops auscultating lung sounds to take measures to stop noticeable bleeding is an-alyzing data presented. This is demonstrated by the nurse setting priorities and effectively im-plementing the safest nursing action. The nurse is doing more than performing a nursing assess-ment. The nurse is taking action based on new assessment data. The nurse is not reorganizing nursing diagnoses. The nurse is implementing the priority nursing action. This is not an example of setting realistic goals and implementing nursing interventions. Applying direct pressure to a wound site to stop bleeding demonstrates critical analysis of the data and implementation of the safest nursing action.
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