A nurse in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?

Assessment

Planning

Implementation

Evaluation

Answer and Explanation

The Correct Answer is A

A.   During the Assessment phase, the nurse gathers information about the client's health status, including any potential allergies. This information is crucial for planning safe and effective care.
B.   The Planning phase involves developing a care plan based on the assessment data.
While allergies are an important consideration in planning care, they are first identified during the assessment phase.
C.   The Implementation phase involves carrying out the care plan. While it is important to be aware of allergies during this phase to ensure the safe administration of treatments, the initial identification of allergies occurs in the assessment phase.
D.   The Evaluation phase involves assessing the client's response to interventions and determining if goals have been met. While allergies are relevant in evaluating the client's response to certain treatments, they are initially identified during the assessment phase.

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Correct Answer is D

Explanation

A. After removal of an indwelling urinary catheter, it is common for a client to experience urinary frequency for a few days. This is due to the bladder readjusting to its normal function.
B. Blood-tinged urine may occur after catheter removal, but it is not an expected outcome. It should be assessed and reported if it occurs.
C. Highly concentrated urine is not typically an expected outcome after catheter removal.
It may indicate dehydration or another issue that should be addressed.
D. Temporary urinary retention can occur after catheter removal, especially in older adults. This is why it's important to monitor the client for signs of retention, such as discomfort, restlessness, or a palpable bladder.

A. One nurse lifting as the client pushes with his feet B. Two nurses lifting the client under the shoulders C. Two nurses using a friction-reducing device D. One nurse lifting the client's legs as the client uses a trapeze bar

Correct Answer is C

Explanation

A. Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.
B. Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.
C. When a client is only partially able to assist, using a friction-reducing device, such as a slide or transfer board, is an effective and safe method. This device helps reduce the
friction between the client and the bed, making it easier to move the client up in bed.
D. Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.

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A nurse in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Correct Answer is D

Explanation

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Correct Answer is C

Explanation

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A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (Select all that apply.)

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)