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 A

Explanation

A. Hyperkalemia can have significant cardiac effects, potentially leading to life-threatening arrhythmias such as bradycardia, heart block, ventricular tachycardia, or ventricular fibrillation. As potassium levels rise, it affects the electrical conduction of the heart, leading to changes in the ECG (electrocardiogram) and potentially causing fatal arrhythmias.

B. While hyperkalemia primarily affects the cardiovascular system, gastrointestinal symptoms can also occur. These may include nausea, vomiting, abdominal pain, and diarrhea. However, these symptoms are typically less severe compared to cardiac manifestations. Monitoring for gastrointestinal symptoms helps in assessing overall clinical status but is not as critical as assessing cardiac function in the context of hyperkalemia.

C. Respiratory symptoms are not typically associated with hyperkalemia unless severe acid-base disturbances are present. Potassium imbalance itself does not directly affect respiratory function. Therefore, while it is important to assess respiratory status in any client, it is not the priority in the context of hyperkalemia.

D. Hyperkalemia can affect the nervous system, leading to symptoms such as muscle weakness, tingling sensations, and even paralysis in severe cases. However, neurologic symptoms usually occur at higher potassium levels or in the presence of significant electrolyte imbalances affecting nerve function.

Monitoring for neurologic symptoms is important but is generally secondary to assessing cardiac status in the context of approaching severe hyperkalemia.

A. "All patients should be treated fairly, regardless of age, gender, or income." B. "We want to prevent harm by minimizing risk." C. "You will feel some discomfort during this procedure." D. "I have returned immediately, as promised, with your pain medication."

Correct Answer is D

Explanation

D. This statement exemplifies the ethical principle of fidelity, also known as faithfulness or commitment. Fidelity involves keeping promises, being reliable, and fulfilling commitments made to patients. By returning promptly with the pain medication as promised, the nurse demonstrates fidelity by honoring their commitment to the patient's care and comfort.

A. This statement reflects the ethical principle of justice, which emphasizes fairness and equality in treatment for all patients. Justice ensures that resources and treatments are distributed fairly among individuals.

B This statement demonstrates the ethical principle of nonmaleficence, which focuses on preventing harm and minimizing risks to patients. It emphasizes the nurse's commitment to avoiding harm or injury to the patient.

C. This statement relates to truth-telling or veracity, which involves providing honest and accurate information to patients about their care, procedures, and potential outcomes. It reflects transparency and respect for patient autonomy.

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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

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is considering ethical principles during rounds. Which nursing statement demonstrates the principle of fidelity?

Correct Answer is D

Explanation

The nurse notes that various factors influence a client's pain. Which of the following factors could be influencers of pain? (SELECT ALL THAT APPLY)

A client is prescribed a cleansing enema. Prior to administering the enema, the client should be told to:

Which goal is appropriate for a client who is experiencing diarrhea? The client will:

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The nurse will be assisting the client to walk. What should the nurse do first?

The nurse understands that motivation to learn is strongest when the client:

The nurse realizes that a medication error may have occurred. The nurse's first responsibility is to:

The nurse recognizes that which statement correctly characterizes drug absorption?