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. Specific characteristics of the medications: This is correct. The primary consideration for determining the medication schedule is the specific characteristics of each medication, including its pharmacokinetics, such as how often it should be administered and whether it needs to be taken with food or at certain times of the day.
B. Time at which the medication can be available from the pharmacy: While this may affect the timing of administration, it is not the primary factor. Medications should be scheduled based on their specific requirements for effectiveness and safety, regardless of pharmacy availability.
C. Institutional policies regarding routine medication administration times: Although institutional policies may provide guidelines for routine administration, they should be adjusted based on the specific needs of the medication and the client.
D. Schedule of administration that the client follows at home: While this may be relevant for maintaining continuity of care, the primary factor in determining the administration schedule should be the specific characteristics and requirements of the medications themselves.
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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