After completing the planning step of the nursing process for a client who has an acid-base imbalance, which of the following steps should the nurse take next?
Evaluation
Data Collection
Re-collection of Data
Implementation
The Correct Answer is D
Choice A reason: Evaluation is the final step of the nursing process, where the nurse assesses the client's response to the nursing interventions.
Choice B reason: Data Collection is the first step of the nursing process, where the nurse gathers information about the client's health status.
Choice C reason: Re-collection of Data may be necessary if there are changes in the client's condition, but it is not the immediate next step after planning.
Choice D reason: Implementation is the correct answer because it is the step where the nurse puts the care plan into action, following the planning step.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Cerebral edema is not typically a manifestation of hyperkalemia. Hyperkalemia can cause neurological symptoms due to its effect on nerve transmission, but cerebral edema is more commonly associated with conditions like traumatic brain injury, stroke, or brain tumors.
Choice B reason: Wheezing is a respiratory symptom and is not directly related to hyperkalemia. It is more commonly associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD).
Choice C reason: Hypoactive bowel sounds may indicate a gastrointestinal issue but are not a specific sign of hyperkalemia. Hyperkalemia can affect smooth muscle contraction and could potentially lead to intestinal motility issues, but this is not a primary manifestation.
Choice D reason: Decreased deep tendon reflexes can be a manifestation of hyperkalemia. Hyperkalemia affects the neuromuscular junction and can lead to muscle weakness, which may manifest as decreased reflexes. Normal potassium levels in the blood are typically between 3.5 and 5.0 millimoles per liter (mmol/L). Hyperkalemia occurs when potassium levels rise above 5.5 mmol/L.
Correct Answer is B
Explanation
Choice A reason: Granola may contain ingredients like nuts and dried fruits that are high in potassium, which is not
suitable for a low potassium diet.
Choice B reason: Many salt substitutes contain potassium chloride instead of sodium chloride, and using them can increase potassium intake, which is not recommended for a client on a low potassium diet.
Choice C reason: Molasses is high in potassium, so replacing sugar with molasses when baking would not be
appropriate for someone on a low potassium diet.
Choice D reason: Orange juice is high in potassium compared to apple juice, making it an unsuitable choice for
someone on a low potassium diet.
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