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 ["A","D","E"]

Explanation

A. Keeping the client's bed in the lowest position helps minimize the potential fall distance if the client attempts to get out of bed.
B. Assessing the client every 4 hours is a good practice for general monitoring but may not be specific to fall prevention. More frequent assessments may be necessary for a client at high risk for falls.
C. Keeping the client's room dark at night can actually increase the risk of falls. It's important to ensure there is adequate lighting to help the client navigate safely.
D. Teaching the client to use the call light allows them to request assistance when needed, reducing the likelihood of attempting to move or get out of bed independently.
E. Placing a fall-risk identification band on the client's wrist helps alert all healthcare providers that the client is at risk for falls. This information is crucial for ensuring appropriate precautions are taken.

A. Gloves B. Face shield C. Gown D. Mask

Correct Answer is A

Explanation

A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.

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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

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Correct Answer is ["A","D","E"]

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Correct Answer is A

Explanation

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