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
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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Related Questions
Correct Answer is C
Explanation
A. Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B. Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C. Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D. Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.
Correct Answer is D
Explanation
A. Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.
B. While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.
C. This positioningis not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.
D. Ensuring the wheels of both the bed and the wheelchair are locked helps maintain stability and safety during the transfer process, reducing the risk of accidental movement and potential falls.
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