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
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Correct Answer is C
Explanation
Choice A rationale
This statement does not provide a recommendation for the next steps in the patient’s care. The R step in SBAR stands for Recommendation, which involves suggesting what should be done to address the situation. Stating that there are no provider’s prescriptions available does not fulfill this requirement.
Choice B rationale
This statement is more appropriate for the Assessment step, where the nurse describes the patient’s current condition. The R step should focus on what actions need to be taken next, not just the patient’s current state.
Choice C rationale
This statement is correct because it provides a clear recommendation for the next steps in the patient’s care. The R step in SBAR is meant to suggest what should be done to address the situation, and reviewing the client’s orders is a specific action that can be taken.
Choice D rationale
This statement is more appropriate for the Situation or Background steps, where the nurse describes what has happened to the patient. The R step should focus on what actions need to be taken next, not just the patient’s history.
Correct Answer is D
Explanation
Choice A rationale
Planning involves setting goals and determining the appropriate interventions to achieve those goals. It is not the step being performed when changing a wound dressing.
Choice B rationale
Evaluation involves assessing the effectiveness of the interventions and determining if the goals have been met. It is not the step being performed when changing a wound dressing.
Choice C rationale
Assessment involves gathering data about the client’s condition. While assessment is an ongoing process, it is not the primary step being performed when changing a wound dressing.
Choice D rationale
Implementation involves carrying out the planned interventions. Changing a wound dressing is an example of implementing a nursing intervention.
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