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 A

Explanation

A. I will check your medication order again: This response addresses the client's concern by verifying that the medication is correct and reassures the client by ensuring that the prescribed medication matches their expectation.

B. Sometimes the same pill comes in a different color: While this might be true, this response does not directly address the client’s concern about the specific medication they are supposed to take.

C. Let me explain the purpose of the medication: This response is helpful but does not address the client's concern about the discrepancy in the medication's appearance.

D. This is the medication that your doctor wants you to take: This response may not resolve the client's concern about the pill's color and does not involve verifying the medication’s accuracy.

A. Prior to administering each medication B. Before aspirating gastric contents C. When the flow of the medication by gravity slows D. After giving multiple medications E. After each medication

Correct Answer is ["A","D","E"]

Explanation

A. Prior to administering each medication: Instilling water before administering each medication helps ensure that the medication is properly delivered into the stomach and prevents the tube from clogging.

B. Before aspirating gastric contents: Instilling water before aspiration is not required and may not affect the aspiration process.

C. When the flow of the medication by gravity slows: This situation indicates a potential blockage or need for adjustment rather than a need for additional water.

D. After giving multiple medications: Instilling water after giving multiple medications helps to clear the tube of residual medication and prevents blockages.

E. After each medication: Instilling water after each medication ensures that the tube is flushed and all medication is delivered to the stomach.

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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 administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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