A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

Assessment

Evaluation

Diagnosis

Planning

Answer and Explanation

The Correct Answer is B

A. Assessment. This is incorrect because assessment refers to the initial data collection before interventions are performed. The nurse auscultating the lungs after administering the medication is part of evaluating the effectiveness of treatment.

B. Evaluation. This is correct because evaluation involves determining whether the intervention was successful in achieving the desired outcome. The nurse is assessing lung sounds to determine if the inhaled medication improved airway clearance and breathing.

C. Diagnosis. This is incorrect because diagnosis involves identifying the patient's health problems based on assessment data. The nurse is not formulating a diagnosis in this scenario but rather checking the response to treatment.

D. Planning. This is incorrect because planning involves setting patient goals and selecting interventions before implementation. The nurse auscultating lung sounds after treatment is an evaluation step, not a planning step.

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Correct Answer is C

Explanation

A. While delegation is important, it occurs after the nurse establishes patient-centered goals and a care plan.

B. Evaluating the effectiveness occurs later in the nursing process. The nurse must first set goals and interventions before assessing their outcomes.

C. After analyzing data, the next step in the nursing process is planning, which includes setting measurable, individualized goals for the patient.

D. Discharge planning is important but comes later. The nurse must first establish patient goals and care priorities before involving other healthcare team members.

A. Review the patient's medication history for any potential drug interactions. B. Educate the patient about the potential side effects of the new medication. C. Document the patient's baseline blood pressure before starting the medication. D. Assess the patient's blood pressure to determine if the medication is effective.

Correct Answer is D

Explanation

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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