After administration of an antihypertensive medication, the nurse notes the client’s blood pressure decreases by 10 points. Which part of the nursing process is being fulfilled?
Planning.
Assessment.
Evaluation.
Analysis.
The Correct Answer is C
Choice A rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data and identified nursing diagnoses. It involves setting goals and determining the appropriate interventions to achieve those goals. In this scenario, the nurse is not developing a plan but rather observing the effects of an intervention that has already been implemented.
Choice B rationale
Assessment is the initial phase of the nursing process where the nurse collects and analyzes data about the client’s health status. This includes gathering information through observation, interviews, physical examinations, and diagnostic tests. In this scenario, the nurse is not collecting new data but rather observing the outcome of a previously administered medication.
Choice C rationale
Evaluation is the phase of the nursing process where the nurse assesses the client’s response to the interventions and determines whether the goals of care have been met. In this scenario, the nurse is evaluating the effectiveness of the antihypertensive medication by noting the decrease in the client’s blood pressure. This assessment helps determine if the medication is achieving the desired therapeutic effect.
Choice D rationale
Analysis is the phase of the nursing process where the nurse interprets the assessment data to identify the client’s health problems and needs. It involves critical thinking and clinical judgment to determine the underlying causes of the client’s condition. In this scenario, the nurse is not analyzing data but rather evaluating the outcome of an intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Ensuring that the patient has been adequately monitored is important, but it is not the first step when considering the use of restraints. The nurse should first explore alternative interventions.
Choice B rationale
Proceeding with the application of restraints without considering alternatives can lead to unnecessary use of restraints, which can cause physical and psychological harm to the patient.
Choice C rationale
Exploring alternative interventions to address the patient’s behavior is the first step. Restraints should only be used as a last resort when other interventions have failed.
Choice D rationale
Obtaining verbal consent from the patient’s family is important, but it is not the first step. The nurse should first explore alternative interventions.
Correct Answer is D
Explanation
Choice A rationale
Following the order as prescribed without clarification can lead to errors if the order is unclear or incomplete.
Choice B rationale
Administering the medication at a later time without clarification can also lead to errors and may delay necessary treatment.
Choice C rationale
Disregarding the order and seeking approval from another physician is not appropriate. The nurse should seek clarification from the ordering physician.
Choice D rationale
Asking the physician to clarify the dosage and route ensures that the order is accurate and complete, reducing the risk of medication errors.
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