A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?
Re-collection of data
Implementation
Evaluation
Data Collection
The Correct Answer is B
Explanation:
A. Re-collection of data:
This step involves gathering additional information or data about the client's condition. It may be necessary if there are new developments, changes in the client's status, or if the initial data collected was insufficient or inaccurate. Re-collection of data helps ensure that the nurse has comprehensive and accurate information to base the care plan on.
B. Implementation:
Implementation is the phase where the nurse puts the planned interventions into action. This step involves performing nursing actions, administering treatments or medications, providing education and support to the client and their family, and collaborating with other healthcare team members. The nurse follows the care plan developed during the planning phase to address the client's needs and achieve desired outcomes.
C. Evaluation:
Evaluation is the final step of the nursing process where the nurse assesses the client's response to interventions and the effectiveness of the care provided. The nurse compares the client's actual outcomes with the expected outcomes identified during the planning phase. If the outcomes are met, the plan may continue as is or be modified for ongoing care. If the outcomes are not met, the nurse revises the plan as necessary to improve client outcomes.
D. Data Collection:
Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, emotional, social, and environmental factors. This step involves conducting assessments, gathering medical history, reviewing laboratory and diagnostic tests, and obtaining information from the client and their family. Data collection forms the basis for identifying nursing diagnoses, developing care plans, and implementing appropriate interventions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation:
A. Questioning: This step involves asking relevant questions to gather information and clarify understanding. It's about exploring the problem or situation, identifying key issues, and seeking information to guide decision-making and problem-solving.
B. Creativity: This step involves generating new ideas, solutions, or perspectives to address a problem or situation. It often involves thinking outside the box, considering alternative approaches, and fostering innovation in problem-solving.
C. Analysis: This step involves examining and evaluating information, data, or evidence to understand its meaning, relevance, and implications. It includes breaking down complex information into manageable parts, identifying patterns or relationships, and drawing conclusions based on evidence.
D. Intuition: This step involves relying on gut feelings, instincts, or hunches to guide decision-making or problem-solving. While intuition can be a valuable aspect of critical thinking, it is not specifically focused on interpreting data but rather on using intuitive insights in combination with other critical thinking skills.
Correct Answer is D
Explanation
Explanation:
A. "I promise I won't tell anyone about this."
This statement is not appropriate because nurses are mandated reporters of suspected child abuse. Promising confidentiality in cases of abuse goes against legal and ethical responsibilities. The nurse must report suspected abuse to the appropriate authorities for the safety and well-being of the child.
B. "Your family is bad for doing this to you."
This statement is judgmental and may make the child feel guilty or conflicted about their family. It is essential to avoid blaming or shaming language when addressing a child who has been abused. The focus should be on providing support, validation, and appropriate intervention.
C. "Let's discuss what you have told me with your family members."
This statement is not appropriate because it suggests involving the family members in the discussion of abuse, which can potentially put the child at risk of further harm. It's essential to prioritize the safety of the child and follow appropriate reporting procedures rather than involving potentially abusive family members in discussions about abuse.
D. "It is not your fault that this happened."
This statement is appropriate and supportive. It reassures the child that they are not to blame for the abuse they have experienced. It acknowledges the child's feelings and helps them understand that they are not responsible for the actions of the abuser. This statement can provide comfort and validation to the child during a difficult time.
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