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

Answer and Explanation

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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Correct Answer is D

Explanation

Explanation:

A. Evaluating the collected data:

This step in EBP involves assessing and analyzing the data that has been gathered through research or other sources. It includes examining the quality, relevance, and reliability of the data to determine its applicability to the clinical question or problem being addressed. Evaluation of data is crucial in EBP to ensure that decisions and interventions are based on sound evidence.

B. Implementing recommendations:

Implementing recommendations is a later step in EBP that comes after evaluating the evidence. Once credible sources have been identified, and the data has been analyzed, recommendations or interventions based on the best available evidence are put into practice. This step involves applying evidence-based guidelines, protocols, or interventions to patient care to improve outcomes and quality of care.

C. Identifying a problem:

This is the initial step in the EBP process where a specific clinical problem or question is identified. It involves recognizing gaps in knowledge, areas of uncertainty, or issues that require improvement in clinical practice. Identifying a problem is essential as it sets the stage for formulating focused research questions and seeking relevant evidence to address the problem effectively.

D. Searching for credible sources:

Searching for credible sources is a critical step in EBP where healthcare professionals gather evidence from reputable and reliable sources. This includes conducting literature searches, accessing databases, and reviewing published studies, clinical guidelines, systematic reviews, and other scholarly sources. The goal is to find the best available evidence to answer clinical questions, guide decision-making, and inform evidence-based practice.

A. Avoid touching the client. B. Continue to talk to the client as if they are awake. C. Limit the client's visitors to one at a time. D. Whisper when talking in the client's room.

Correct Answer is B

Explanation

Explanation:

A. Avoid touching the client:

While it's essential to be gentle and respectful when touching an unresponsive client, avoiding all touch may not be appropriate. Touch can be a comforting and reassuring gesture, and many clients at the end of life benefit from gentle touch, such as holding their hand or providing a gentle massage.

B. Continue to talk to the client as if they are awake:

Talking to the client, even if they are unresponsive, is encouraged. Hearing is often the last sense to diminish, and talking to the client in a soothing and reassuring manner can provide comfort and a sense of presence. The nurse should speak calmly and compassionately, addressing the client by name and providing updates on care activities.

C. Limit the client's visitors to one at a time:

Limiting the number of visitors and controlling the environment can help maintain a calm and peaceful atmosphere for the client. However, the specific number of visitors allowed at a time may vary based on the client's preferences, cultural considerations, and facility policies. It's important to respect the client's wishes regarding visitors while ensuring their comfort and well-being.

D. Whisper when talking in the client's room:

Whispering may not be necessary unless the client is particularly sensitive to loud noises. Speaking in a calm and gentle tone is generally more appropriate, as it allows the client to hear clearly without causing unnecessary strain or confusion.

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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?

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