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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Related Questions
Correct Answer is A
Explanation
Explanation:
A. Medical condition:
Including the client's medical condition in the Situation component of the ISBARR communication tool is important because it provides an overview of the client's health status. This may include a brief description of the primary diagnosis, current symptoms, or any significant changes in the client's condition since the last shift. It helps the receiving nurse understand the context and urgency of the report.
B. Treatment:
While treatment information is crucial for providing comprehensive care to the client, it is typically included in the Background or Assessment components of the ISBARR communication tool. The Situation component focuses on summarizing the client's current status rather than detailing specific treatments or interventions.
C. Vital signs:
Vital signs, such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation, are essential clinical data. However, they are usually included in the Assessment component of the ISBARR communication tool, where the nurse provides a detailed assessment of the client's physiological parameters and trends.
D. List of medications:
Similar to treatment information, a list of medications is typically included in the Background or Assessment components of the ISBARR communication tool. It is important for the receiving nurse to know what medications the client is taking, including doses, frequencies, and any recent changes, but this information is more detailed and specific than what is typically included in the Situation component.
Correct Answer is B
Explanation
Explanation:
A. "Reliance on personal experiences is important to the process of EBP."
This statement is not accurate in the context of evidence-based practice (EBP). EBP emphasizes the use of the best available evidence from research, combined with clinical expertise and patient values and preferences. While personal experiences can provide context, they should not be the primary basis for decision-making in EBP.
B. "Identifying the problem is the first step of the EBP process."
This statement is correct. The first step in the EBP process is identifying a clinical problem or question that requires evidence-based intervention or decision-making. This step involves clearly defining the issue and understanding its significance.
C. "Reviewing the effectiveness of the findings is the last step of the EBP process."
This statement is not accurate. While evaluating the effectiveness of the chosen intervention or practice change is an essential component of EBP, it is not necessarily the last step. EBP involves an iterative process where findings are continuously evaluated, integrated into practice, and refined based on ongoing evidence and outcomes.
D. "There are four steps in the process of EBP."
This statement is not entirely accurate. While different models and frameworks may outline EBP in different steps or stages, it typically involves multiple steps that include formulating a clinical question, searching for evidence, critically appraising the evidence, applying the evidence to practice, and evaluating outcomes.
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