A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and organize client data.

Critically analyze client data to determine priorities.

Determine effectiveness of interventions.

Set client-centered, measurable and realistic goals.

Answer and Explanation

The Correct Answer is A

A. Collect and organize client data: The first step in the nursing process involves gathering and organizing data about the clients, which is essential for making informed decisions and planning care.

B. Critically analyze client data to determine priorities: Analysis of data and setting priorities come after the initial collection and organization of client data.

C. Determine effectiveness of interventions: Evaluating the effectiveness of interventions occurs after implementing the care plan and is not the first step in the process.

D. Set client-centered, measurable and realistic goals: Goal-setting follows the collection and analysis of data and is part of the planning phase in the nursing process.

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Correct Answer is D

Explanation

A. Providing a community program on stress reduction: This is an example of primary prevention, which aims to prevent disease or injury before it occurs.

B. Referring a client who has had a mastectomy to a support group: This is tertiary prevention, which focuses on helping individuals manage long-term health conditions and improve their quality of life.

C. Teaching foot care to a client who has diabetes: This is an example of tertiary prevention, aimed at managing complications and improving quality of life in individuals with existing conditions.

D. Performing monthly breast self-examinations: This is an example of secondary prevention, which involves early detection and screening to identify diseases in their early stages before symptoms appear.

A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side. B. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion. C. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body. D. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body.

Correct Answer is C

Explanation

A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side: The direction of the snap is not as critical as ensuring the use of proper technique to avoid injury and contamination.

B. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion: Breaking the ampule downward could risk contamination and injury if not done properly.

C. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body: This method minimizes the risk of glass shards and helps to prevent injury and contamination, ensuring safe handling of the medication.

D. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body: Breaking the ampule toward the body is unsafe and increases the risk of injury from glass shards.

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A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?

Correct Answer is D

Explanation

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?

Correct Answer is C

Explanation

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