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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer the medication using a Z-track technique: This is correct as ceftriaxone should be administered using the Z-track technique to prevent leakage of the medication into the subcutaneous tissue and minimize irritation.
B. Administer the medication using a 5/8-inch needle: A longer needle is typically needed for IM injections to reach the muscle tissue, so a 5/8-inch needle is not appropriate.
C. Administer the medication in the deltoid muscle: Ceftriaxone is usually administered in the larger muscle groups such as the ventrogluteal or vastus lateralis muscles rather than the deltoid.
D. Administer the medication at a 45° angle: IM injections are generally given at a 90° angle to ensure that the medication is properly deposited into the muscle tissue.
Correct Answer is B
Explanation
A. The client waits 10 min between inhalations: Waiting 10 minutes between inhalations is unnecessary for a rescue inhaler like albuterol. Typically, it is sufficient to wait for 1 to 2 minutes if more doses are required.
B. The client holds his breath for 10 seconds after inhaling the medication: This is correct. Holding the breath for about 10 seconds after inhalation allows the medication to settle in the airways and enhances its effectiveness.
C. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. A slow, deep inhalation is recommended to ensure that the medication reaches the lower airways.
D. The client exhales as the medication is released from the inhaler: This is incorrect. The client should exhale fully before inhaling the medication to ensure that the medication can be inhaled deeply into the lungs.
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