A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Establishing the priorities of client care

Reinforcing teaching about the client's diagnosis

Asking the client about the presence of pain

Comparing the client's current laboratory values to previous results

Answer and Explanation

The Correct Answer is B

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

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Correct Answer is A

Explanation

A) Initiate oxygen therapy via nasal cannula for a client who has COPD:

Clients with chronic obstructive pulmonary disease (COPD) often have impaired gas exchange and may experience acute exacerbations requiring oxygen therapy to improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical intervention to address hypoxemia and prevent complications such as respiratory failure. Therefore, initiating oxygen therapy for a client with COPD is the highest priority among the options provided.

B) Initiate a 24-hr urine collection for a client who has end-stage kidney disease:

Initiating a 24-hour urine collection is an important nursing task for clients with end-stage kidney disease to monitor renal function and assess urine output. However, compared to the immediate need for oxygen therapy in a client with COPD, starting a urine collection is a lower priority and can be scheduled once the client's respiratory needs are addressed.

C) Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:

Administering antibiotics for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection is important to control the spread of infection and prevent complications. However, unless the client's condition is critically unstable or the antibiotic administration is time-sensitive, addressing oxygenation needs for a client with COPD takes precedence due to the potential for respiratory compromise and hypoxemia.

D) Change the dressing for a client who has a decubitus ulcer:

Changing dressings for clients with decubitus ulcers is essential for wound care management and prevention of infection. While maintaining skin integrity is important, addressing respiratory distress in a client with COPD is a higher priority to ensure adequate oxygenation and prevent respiratory compromise.

A. A newborn has an Apgar score of 7 at 5 min after birth. B. A newborn has respiratory distress and requires oxygen. C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth. D. A newborn receives a heel stick on the outer aspect of the heel.

Correct Answer is C

Explanation

Answer: C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

Rationale:

A. A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 is within the acceptable range and does not indicate an adverse event or require an incident report. This score reflects a newborn transitioning well to extrauterine life with only mild adjustments needed.

B. A newborn has respiratory distress and requires oxygen:
While respiratory distress requires prompt intervention, it can be an expected complication in some neonates. Administering oxygen in this context is an appropriate clinical response, not a reportable incident.

C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Erythromycin should be administered within 1 to 2 hours after birth to prevent ophthalmia neonatorum. A 4-hour delay exceeds this timeframe and poses a potential risk to the infant’s health, qualifying as a deviation from standard protocol that warrants an incident report.

D. A newborn receives a heel stick on the outer aspect of the heel:
Performing a heel stick on the outer aspect of the heel is the correct location to avoid nerve and bone injury. This is a safe and standard practice and does not require an incident report.

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