A client is to be started on a heparin intravenous infusion at 2,000 units per hour. On hand is an IV bag labeled 25,000 units/ 250 mL. At what rate (mL/hour) will the nurse set the pump? (Answer to the nearest whole number)

A) The nurse formulates a goal "The client will be free from infection for the duration of the hospitalization": This action reflects the planning phase of the nursing process. The planning phase involves setting goals and determining the best interventions to achieve the desired outcomes for the client. In this case, the goal is to prevent infection, which is a specific, measurable outcome that can guide further interventions.

B) The nurse assesses the client's white blood cell count: Assessing the client's white blood cell count is an important step in data collection, which is part of the assessment phase of the nursing process. It helps the nurse gather information about the client's current health status but is not a planning activity. The nurse would use the information from the assessment phase to formulate goals and plan interventions.

C) The nurse administers the ordered oral antibiotics: Administering antibiotics is an action related to the implementation phase of the nursing process. The implementation phase involves carrying out the planned interventions. In this case, the administration of antibiotics is a direct action taken to address the risk for infection, but it is not the planning phase.

D) The nurse teaches the client the appropriate hand washing technique: Teaching hand hygiene is an important intervention, but it falls under the implementation phase of the nursing process. It involves educating the client to help prevent infection, which is an action taken based on the goals and plan developed earlier. While important, it’s not the planning phase itself.

A) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. It involves determining if the interventions provided were effective in achieving the desired outcomes. In this scenario, the nurse is still
gathering information before the action is taken, so evaluation is not the correct phase.

B) Planning: Planning is the phase in the nursing process where the nurse develops a care plan, which includes setting goals and determining interventions based on the client's needs. Although reviewing the medical record and blood glucose level is important for planning the administration of insulin, this is more about gathering data rather than forming a plan of care.

C) Implementation: Implementation refers to the actual delivery of the nursing interventions or actions. In this case, administering the insulin would be part of the implementation phase, but reviewing the medical history and obtaining a fingerstick blood glucose reading are steps taken before implementing the medication.

D) Assessment: The nurse is collecting pertinent information about the client’s condition, including reviewing the medical record and obtaining the blood glucose level. Assessment is the first step in the nursing process and involves gathering information to help guide clinical decisions.

E) Diagnosis: Diagnosis is the phase in which the nurse analyzes the assessment data to identify the client’s health problems or potential risks. While the nurse is collecting data, the diagnosis comes after the assessment phase, when the nurse has enough information to make a clinical judgment about the client's health status.