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 C
Explanation
Choice A reason: Cognitive domain of learning involves the mental processes of acquiring, storing, and applying knowledge. It includes skills such as remembering, understanding, analyzing, and evaluating. An example of cognitive learning is the RN asking the client to explain the purpose and effects of his inhaler.
Choice B reason: Affective domain of learning involves the emotional aspects of learning, such as attitudes, values, beliefs, and feelings. It includes skills such as receiving, responding, valuing, and committing. An example of affective learning is the RN asking the client how he feels about using his inhaler.
Choice C reason: Psychomotor domain of learning involves the physical aspects of learning, such as movement, coordination, and manipulation. It includes skills such as imitating, practicing, adapting, and creating. An example of psychomotor learning is the RN asking the client to demonstrate proper use of his inhaler.
Choice D reason: Kinesthetic domain of learning is not a recognized domain of learning, but rather a learning style that refers to the preference of learning by doing or experiencing. Kinesthetic learners tend to learn best by engaging in physical activities, such as hands-on tasks, simulations, and experiments.
Correct Answer is D
Explanation
Choice A reason: White rice is not a food that can cause diarrhea, as it is a bland and starchy food that can help bind the stool and reduce the frequency of bowel movements.
Choice B reason: Ripe bananas are not a food that can cause diarrhea, as they are rich in potassium, which can help replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help firm up the stool.
Choice C reason: Low-fiber cereal is not a food that can cause diarrhea, as it is easy to digest and does not irritate the intestinal lining. It can also provide some energy and nutrients for the body.
Choice D reason: Prunes are a food that can cause diarrhea, as they are high in sorbitol, a sugar alcohol that can have a laxative effect and draw water into the colon. They also contain insoluble fiber, which can increase the bulk and speed of the stool.
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