Page 99 - Saunders Comprehensive Review For NCLEX-RN

2. The steps include assessment, analysis, planning,
implementation, and evaluation (AAPIE) and are
followed in this order.
3. Assessment
a. Assessment questions address the
process of gathering subjective and
objective data relative to the client,
confirming the data, and
communicating and documenting the
data.
b. Remember that assessment is the first
step in the nursing process.
c. When you are asked to select your first,
immediate, or initial nursing action,
follow the steps of the nursing process
to prioritize when selecting the correct
option.
d. Look for words in the options that
reflect assessment (see Box 4-4).
e. If an option contains the concept of
assessment or the collection of client
data, the best choice is to select that
option (Box 4-11).

Box 4-11
Practice Question: The
Nursing Process—Assessment
A client who had an application of a right arm cast
complains of pain at the wrist when the arm is
passively moved. What action should the nurse
take first?
1. Elevate the arm.
2. Document the findings.
3. Medicate with an additional dose of an
opioid.
4. Check for paresthesias and paralysis of the
right arm.
Answer: 4
Test-Taking Strategy
Note the strategic word, first. Based on the data in
the question, determine whether an abnormality
exists. The question event indicates that the client
complains of pain at the wrist when the arm is
passively moved. This could indicate an
abnormality; therefore, further assessment or
intervention is required. Use the steps of the
nursing process, remembering that assessment is
the first step. The only option that addresses
assessment is the correct option. Options 1, 2, and 3
address the implementation step of the nursing
process. Also, these options are incorrect first
actions. The arm in a cast should have already been
elevated. The client may be experiencing

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