A nurse is completing the evaluation phase of the nursing process. The part of the client care plan that is evaluated during this phase are the

interventions.

expected outcomes.

definitions.

diagnoses.

Answer and Explanation

The Correct Answer is B

B. Expected outcomes are specific, measurable criteria used to determine goal achievement. These outcomes are set during the planning phase of the nursing process in collaboration with the client. During evaluation, the nurse compares the client's actual progress with these expected outcomes. This assessment helps determine whether the goals were met, partially met, or not met, which guides further nursing actions.

A. During the evaluation phase, the nurse assesses the effectiveness of these interventions in achieving the desired outcomes rather than the interventions themselves. The focus is on determining whether the interventions were appropriate, timely, and effective in meeting the client's goals.

C Definitions typically refer to the meaning or understanding of terms used in the nursing process, such as nursing diagnoses or medical conditions. They provide clarity and context to ensure accurate assessment, planning, and intervention. However, definitions themselves are not directly evaluated in the evaluation phase of the nursing process.

D. In the evaluation phase, the nurse assesses the client's response to interventions aimed at addressing these diagnoses. The focus is on determining the effectiveness of the care provided rather than evaluating the diagnoses themselves.

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Correct Answer is C

Explanation

C. Before administering a feeding through a gastrostomy tube, it is essential to verify that the tube is patent (open and unobstructed). Tube patency ensures that the feeding formula or medication can flow freely into the stomach or intestines without encountering any blockages or resistance. The nurse should flush the tube with water to check for patency and ensure proper functioning before initiating the feeding.

A. Vital signs are typically assessed for overall health monitoring and to detect any immediate changes in the client's condition. However, they are not specifically required before every feeding via gastrostomy tube unless there are specific concerns about the client's stability.

B. This option is not typically necessary before administering a feeding through a gastrostomy tube. In fact, elevating the head of the bed to at least 30 to 45 degrees is often recommended during and after feeding to minimize the risk of aspiration. This position helps to promote digestion and reduce the likelihood of reflux or regurgitation of the feeding.

D. Assisting the client to a prone (face-down) position is unnecessary and potentially unsafe before administering a feeding through a gastrostomy tube. The recommended position for feeding via gastrostomy tube is typically semi-Fowler's position (elevated head of the bed), which helps prevent aspiration and facilitates digestion.

A. ibuprofen liquid 300 mg Q 6 hours prn for pain B. potassium chloride XL 40 mEq daily C. levothyroxine 25 mcg daily D. multivitamin liquid 10 mL daily

Correct Answer is B

Explanation

B.This formulation is not intended for administration through a gastrostomy tube and could be harmful to the patient. It is essential to consult with a pharmacist or physician to find a suitable alternative that is safe for administration through the gastrostomy tube

A. Ibuprofen is typically administered orally (PO) and is absorbed in the gastrointestinal tract.

C. Levothyroxine is a thyroid hormone replacement medication crucial for maintaining thyroid hormone levels in individuals with hypothyroidism. It is typically administered orally in the morning on an empty stomach to ensure optimal absorption.

D. Liquid formulations are suitable for administration through gastrostomy tubes, as they are generally well-tolerated and absorbed.

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A nurse is completing the evaluation phase of the nursing process. The part of the client care plan that is evaluated during this phase are the

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?

Correct Answer is C

Explanation

The nurse reviews the list of medications that will be administered through a client's new gastrostomy tube. All medications were previously given PO. Which medication order will the nurse question?

Correct Answer is B

Explanation

The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

The nurse is caring for a 74-year-old male client. The client has a family history of prostate cancer, is 50 pounds overweight and history of smoking tobacco X 60 years. Which of the following are modifiable risk factors for this client's health? (SELECT ALL THAT APPLY)

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

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Which of the following are essential in the care for a patient with incontinence-associated dermatitis? (SELECT ALL THAT APPLY)

A client's serum potassium level is approaching 7 mEq/L. Which physical assessment would the nurse prioritize based on this serum lab value?

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