During the planning step of the nursing process, the nurse performs which activity? Select one answer

Choice A reason: Ineffective thermoregulation is a nursing diagnosis that indicates a problem with the body’s ability to maintain a normal temperature range. It can be caused by factors such as infection, inflammation, or environmental exposure. It can result in symptoms such as fever, chills, sweating, or shivering. The client’s temperature of 102oF (38.9oC) suggests that they have ineffective thermoregulation, but it is not the highest priority nursing diagnosis, as it is not immediately life-threatening. Therefore, this choice is incorrect.

Choice B reason: Decreased cardiac output is a nursing diagnosis that indicates a problem with the amount of blood pumped by the heart per minute. It can be caused by factors such as arrhythmias, heart failure, or shock. It can result in symptoms such as hypotension, tachycardia, dyspnea, or oliguria. The client’s heart rate of 144 beats/minute and irregular suggests that they have decreased cardiac output, which is the highest priority nursing diagnosis, as it can lead to organ failure or death if not treated promptly. Therefore, this choice is correct.

Choice C reason: Ineffective breathing patern is a nursing diagnosis that indicates a problem with the rate, rhythm, depth, or quality of respirations. It can be caused by factors such as airway obstruction, lung disease, or anxiety. It can result in symptoms such as dyspnea, cyanosis, or hypoxia. The client’s respiratory rate of 22 breaths/minute is within the normal range and does not indicate an ineffective breathing patern. Therefore, this choice is incorrect.

Choice D reason: Ineffective renal tissue perfusion is a nursing diagnosis that indicates a problem with the blood flow to the kidneys. It can be caused by factors such as renal artery stenosis, dehydration, or sepsis. It can result in symptoms such as oliguria, hematuria, or azotemia. The client’s vital signs do not indicate an ineffective renal tissue perfusion, and there is no evidence of renal impairment or dysfunction. Therefore, this choice is incorrect.

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coffee. The nurse should not delay providing care for a client who may have suffered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coffee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coffee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coffee.