A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client’s leg is pain free, without redness or edema. The nurse’s actions reflect which phase of the nursing process? Select one answer
Implementation
Evaluation
Outcomes identification
Assessment
The Correct Answer is B
Choice A reason: Implementation is a phase of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. The nurse’s actions do not reflect this phase, as they are not performing any interventions or activities, but rather observing and measuring the client’s condition. Therefore, this choice is incorrect.
Choice B reason: Evaluation is a phase of the nursing process that involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. It also involves comparing the actual outcomes with the expected outcomes, and modifying the plan of care if needed. The nurse’s actions reflect this phase, as they are assessing the client’s leg for signs of improvement or resolution of thrombophlebitis, and noting that the client is ready for discharge. Therefore, this choice is correct.
Choice C reason: Outcomes identification is a phase of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. The nurse’s actions do not reflect this phase, as they are not setting any goals, but rather evaluating whether they have been met.
Therefore, this choice is incorrect.
Choice D reason: Assessment is a phase of the nursing process that involves collecting and analyzing data about the client’s health status, history, and environment. It also involves identifying any factors that may affect the client’s health or well-being, and forming a nursing diagnosis. The nurse’s actions do not reflect this phase, as they are not collecting or analyzing any new data, but rather reviewing the existing data and confirming the diagnosis. Therefore, this choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Collects data is not an activity that the nurse performs during the planning step of the nursing process. Collecting data is an activity that the nurse performs during the assessment step of the nursing process, which involves gathering and analyzing information about the client’s health status, history, and environment.
Therefore, this choice is incorrect.
Choice B reason: Records data is not an activity that the nurse performs during the planning step of the nursing process. Recording data is an activity that the nurse performs during the documentation step of the nursing process, which involves writing or entering the data and findings in the client’s record or chart. Therefore, this choice is incorrect.
Choice C reason: Prioritizes care is an activity that the nurse performs during the planning step of the nursing process. Prioritizing care is an activity that involves ranking the client’s problems, needs, or risks according to their urgency, importance, or potential impact. It helps the nurse to allocate time and resources efficiently, and to address the most critical or significant issues first. Therefore, this choice is correct.
Choice D reason: Carries out interventions is not an activity that the nurse performs during the planning step of the nursing process. Carrying out interventions is an activity that the nurse performs during the implementation step of the nursing process, which involves executing the plan of care and performing the interventions and activities that were planned. Therefore, this choice is incorrect.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: This is correct because it is an approved nursing diagnosis that describes a lack of cognitive information related to a specific topic.
Choice B reason: This is incorrect because it is not an approved nursing diagnosis, but rather a data or assessment finding that describes the condition of the client’s pupils.
Choice C reason: This is correct because it is an approved nursing diagnosis that describes an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Choice D reason: This is correct because it is an approved nursing diagnosis that describes a decrease in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary membrane.
Choice E reason: This is incorrect because it is not an approved nursing diagnosis, but rather a medical diagnosis that describes a malignant neoplasm of any body part.
Choice F reason: This is incorrect because it is not an approved nursing diagnosis, but rather a medical diagnosis that describes a dysfunction of the kidneys.
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