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 C

Explanation

Explanation:

A. "I will keep my walker at the end of my bed."

Keeping the walker at the end of the bed is generally a good practice for accessibility and mobility support, especially for clients who use walkers to assist with walking. However, this statement alone does not directly address falls prevention strategies or indicate a comprehensive understanding of home safety measures related to falls.

B. "I will place an area rug at the entry of my bathroom."

Placing an area rug at the entry of the bathroom can actually increase the risk of falls rather than prevent them. Area rugs are common tripping hazards, especially in areas where water or moisture may be present (like bathrooms). This statement indicates a potential misunderstanding of falls prevention strategies because it suggests an action that could contribute to falls rather than prevent them.

C. "I will place a bath seat in my shower to use when I bathe."

This statement demonstrates a clear understanding of falls prevention strategies. Placing a bath seat in the shower is a proactive measure to enhance safety during bathing, as it provides stability and reduces the risk of slipping and falling on wet surfaces. Using assistive devices like a bath seat is recommended for individuals with a history of falls or balance issues.

D. "I will keep the fluorescent ceiling light on in my room at night."

Keeping the room well-lit at night is beneficial for falls prevention, as adequate lighting can help individuals see potential hazards and navigate their environment safely. While this statement reflects a general awareness of falls prevention principles related to lighting, it is not as specific or directly related to falls prevention during activities like bathing (as mentioned in option C).

A. Grab bars are installed in the bathroom. B. Medications are stored in a clear bag. C. Area rugs are placed in the living room. D. Dim lighting installed throughout the house. E. The hot water heater is set at 54°C (130° F).

Correct Answer is ["B","C","D","E"]

Explanation

A. Grab bars are installed in the bathroom:

Correct placement of grab bars in the bathroom can enhance safety for individuals who have mobility challenges, such as those who have experienced a stroke. This is not a safety hazard but rather a safety measure.

B. Medications are stored in a clear bag:

Storing medications in a clear bag may increase the risk of accidental misuse or confusion, particularly for a stroke client who may have cognitive or visual impairments.

C. Area rugs are placed in the living room:

Area rugs can be a safety hazard, especially for individuals with mobility issues or those at risk of falls. Rugs can cause tripping hazards if they are not properly secured or if there are wrinkles or uneven surfaces.

D. Dim lighting installed throughout the house:

Dim lighting can contribute to safety hazards, particularly for individuals with visual impairments or mobility challenges. Insufficient lighting increases the risk of falls and accidents, especially in areas such as staircases, hallways, and bathrooms.

E. The hot water heater is set at 54°C (130° F):

Water temperature set at 54°C (130° F) is excessively hot and poses a scalding hazard, especially for individuals with sensory impairments or reduced ability to perceive temperature changes. Lowering the water heater temperature to a safer range is recommended to prevent scalding injuries.

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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?

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is ["B","C","D","E"]

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