A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process?
Assessment
Planning
Diagnosis
Evaluation
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Fluid volume deficit is a condition in which the body loses more fluid than it gains, resulting in dehydration, hypotension, and electrolyte imbalances. It is not a complication of IV fluid therapy, but rather a reason for initiating it.
Choice B reason: Fluid volume excess is a condition in which the body retains more fluid than it needs, resulting in edema, hypertension, and heart failure. It is a potential complication of IV fluid therapy, especially in older adults who have reduced renal function and cardiac output. The nurse's assessment findings of crackles, shortness of breath, and jugular vein distention are indicative of fluid overload and pulmonary congestion.
Choice C reason: Speed shock is a systemic reaction that occurs when a substance is administered too rapidly into the bloodstream, causing adverse effects such as chest pain, dyspnea, hypotension, and cardiac arrest. It is not a complication of IV fluid therapy, but rather a risk associated with IV medication administration.
Choice D reason: Pulmonary embolism is a blockage of one or more pulmonary arteries by a blood clot, fat, or air, causing impaired gas exchange, chest pain, dyspnea, and hemoptysis. It is not a complication of IV fluid therapy, but rather a possible outcome of venous thromboembolism, which can be prevented by using anticoagulants and mechanical devices.
Correct Answer is B
Explanation
Choice A reason: This is not the correct answer because this statement by the client indicates that the client understands the dietary restrictions and guidelines that are necessary after bariatric surgery. A liquid/pureed diet and limited fluid intake are recommended to prevent complications such as nausea, vomiting, dehydration, and dumping syndrome.
Choice B reason: This is the correct answer because this statement by the client indicates that the client does not understand the importance of a thorough evaluation by the surgeon prior to the procedure. Bariatric surgery is a major surgery that involves significant risks and benefits, and requires careful consideration of the client's medical history, physical condition, psychological status, and readiness for lifestyle changes. The surgeon should assess the client's eligibility, suitability, and expectations for the surgery, and provide informed consent and education.
Choice C reason: This is not the correct answer because this statement by the client indicates that the client understands the basic principles and types of bariatric surgery. Bariatric surgery can be classified into restrictive, malabsorptive, or combined procedures, depending on how they affect the size of the stomach and the absorption of food. The most common types of bariatric surgery are gastric bypass, sleeve gastrectomy, and adjustable gastric banding.
Choice D reason: This is not the correct answer because this statement by the client indicates that the client understands the long-term implications and commitments of bariatric surgery. Bariatric surgery is not a quick fix or a magic solution for obesity, but rather a tool that helps the client achieve and maintain weight loss and improve health outcomes. The client should be aware that bariatric surgery requires lifelong changes in diet, exercise, medication, supplementation, and follow-up care.
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