A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?

Choice A reason: Assessment is the first and most important phase of the nursing process, as it involves collecting and analyzing data about the patient's health status, needs, and preferences. The nurse should have assessed the patient's blood pressure before administering the antihypertensive medication, as it could have been contraindicated or required a dosage adjustment. By failing to do so, the nurse put the patient at risk of hypotension and its complications.

Choice B reason: Planning is the second phase of the nursing process, in which the nurse sets goals and outcomes for the patient's care and selects appropriate interventions. The nurse did not make an error in this phase, as the administration of the antihypertensive medication was part of the plan of care for the patient with hypertension.

Choice C reason: Diagnosis is the third phase of the nursing process, in which the nurse identifies the patient's actual or potential health problems based on the assessment data. The nurse did not make an error in this phase, as the diagnosis of hypertension was accurate and supported by the patient's history and vital signs.

Choice D reason: Evaluation is the fourth and final phase of the nursing process, in which the nurse measures the patient's progress and outcomes and modifies the plan of care as needed. The nurse did not make an error in this phase, as the re-checking of the blood pressure and the recognition of the patient's symptoms were part of the evaluation process. However, the nurse should have also notified the provider and implemented interventions to treat the hypotension.

Choice A reason: Encouraging the patient to wait for 24 hours before applying new knowledge is not an effective strategy to promote learning. It may cause the patient to forget or lose interest in the information. The RN should encourage the patient to apply new knowledge as soon as possible to reinforce learning and improve retention.

Choice B reason: Organizing the content from complex to simple is not an effective strategy to promote learning. It may confuse or overwhelm the patient with too much information at once. The RN should organize the content from simple to complex, starting with the most essential and relevant information and building on it gradually.

Choice C reason: Repeating the key concepts is an effective strategy to promote learning. It helps the patient to remember and recall the important information and clarify any misunderstandings. The RN should repeat the key concepts at the beginning, during, and at the end of the lesson.

Choice D reason: Asking the patient to hold questions until after the lesson is completed is not an effective strategy to promote learning. It may discourage the patient from asking questions or expressing concerns that may affect their learning. The RN should encourage the patient to ask questions at any time and provide feedback and answers.