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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
“The client will be able to perform daily activities independently.”. This goal is not specific or time-bound. It does not provide a clear timeframe or measurable criteria for achieving the goal.
Choice B rationale
“The client’s pain will be managed effectively.”. This goal is not specific or measurable. It does not provide clear criteria for what constitutes effective pain management or a timeframe for achieving the goal.
Choice C rationale
“The client states he feels better.”. This goal is not specific, measurable, or time-bound. It does not provide clear criteria for what “feeling better” means or a timeframe for achieving the goal.
Choice D rationale
“The client will be able to walk one mile on post-op day 2 after knee surgery.”. This goal is a SMART goal as it is Specific, Measurable, Achievable, Relevant, and Time-bound. It provides clear criteria for what the client should achieve and a specific timeframe for achieving it.
Correct Answer is B
Explanation
Choice A rationale
Ignoring the error, even if it does not affect patient care, is incorrect. Ignoring errors can lead to a culture of complacency and potentially more significant errors in the future. It is essential to address all errors to maintain accurate records and ensure patient safety.
Choice B rationale
Drawing a single line through the error, initialing, and dating it is the correct action. This method maintains the integrity of the medical record while clearly indicating that an error was made and corrected. It ensures transparency and accountability in documentation.
Choice C rationale
Leaving the error as is and informing the nurse manager is not the best practice. While informing the nurse manager is important, the error should be corrected in the medical record to prevent any potential confusion or miscommunication.
Choice D rationale
Erasing the incorrect entry and writing the correct one is incorrect. Erasing or obliterating entries in a medical record is not allowed as it can be seen as tampering with the record. It is crucial to maintain the original entry and make corrections transparently.
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