A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

Implementation.

Planning.

Evaluation.

Assessment.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse is demonstrating the phase of nursing care known as "Implementation." During this phase, the nurse carries out the interventions and actions that were planned in the previous stages of the nursing process. In this scenario, applying warm compresses to the client's joint is a planned intervention that is being executed by the nurse.

Choice B rationale:

Planning is not the correct choice for this scenario. Planning is the phase of nursing care where the nurse sets goals, outcomes, and develops a plan of action based on the assessment data. It occurs before the implementation phase.

Choice C rationale:

Evaluation is not the correct choice for this scenario. Evaluation is the phase where the nurse assesses the outcomes of the interventions and determines whether the goals have been met. It comes after the implementation phase.

Choice D rationale:

Assessment is not the correct choice for this scenario. Assessment is the initial phase of the nursing process where the nurse collects data about the client's health status. It precedes the planning, implementation, and evaluation phases.

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Correct Answer is B

Explanation

Choice A rationale:

Placing the cuff bladder over the client's brachial artery is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff placement, which is essential for an accurate measurement.

Choice B rationale:

Placing the client's arm above the level of the client's heart is an incorrect action when obtaining a blood pressure reading. The client's arm should be supported at heart level to ensure accurate measurement. This choice indicates a need for further instruction as it could lead to an artificially low blood pressure reading.

Choice C rationale:

Wrapping the blood pressure cuff snugly around the client's arm is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff application, which is necessary for accurate results.

Choice D rationale:

Checking the instrument gauge to ensure the reading starts at zero is a correct action when obtaining a blood pressure reading. This choice reflects a proper step to verify that the equipment is calibrated correctly.

A. Admission assessment of a new client. B. Evaluating changes to a client's pressure ulcer. C. Performing tracheostomy care on a client. D. Administering a blood transfusion to a client.

Correct Answer is C

Explanation

Choice A rationale:

Admission assessment of a new client requires comprehensive evaluation, critical thinking, and clinical judgment. This task is within the scope of a registered nurse's responsibilities and should not be delegated to an LPN.

Choice B rationale:

Evaluating changes to a client's pressure ulcer also involves clinical judgment and assessment skills that fall within the domain of a registered nurse's role.

Choice C rationale:

This is the correct choice. Tracheostomy care involves routine and standardized procedures that an LPN can perform under the supervision of a registered nurse. LPNs are trained to provide this type of care safely and effectively.

Choice D rationale:

Administering a blood transfusion is a complex procedure that requires careful monitoring and assessment for potential adverse reactions. This task is typically within the scope of a registered nurse's practice, not an LPN's.

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A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?

Correct Answer is B

Explanation

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

Correct Answer is C

Explanation

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