Prior to administration of an antihypertensive medication, the nurse notes the client's heart rate is 50. The nurse then determines the blood pressure medication should be held. Which part of the nursing process is being fulfilled?
Assessment
Analysis
Planning
Evaluation
The Correct Answer is A
A. Assessment: Assessment involves collecting data about the client's condition. Noting the heart rate before administering medication is part of the assessment.
B. Analysis: Analysis involves interpreting the collected data to make decisions about the client's care. While the nurse is analyzing the data (the heart rate), this step follows the initial assessment.
C. Planning: Planning involves setting goals and deciding on interventions based on the assessment and analysis. Holding the medication could be considered part of planning but comes after assessing the heart rate.
D. Evaluation: Evaluation involves determining the effectiveness of interventions. This is not applicable in this situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Preparing the client for discharge: Discharge preparation typically requires a comprehensive assessment to ensure all aspects of the client’s health and care needs are addressed.
B. On initial evaluation by the home health nurse: The initial evaluation requires a comprehensive assessment to establish a baseline for the client's overall condition and care plan.
C. Reassessing a client for pain after giving pain medication: A focused assessment targets a specific problem area, such as evaluating pain levels after an intervention.
D. Checking skin assessment on a patient with a medical device in place: This is an example of a focused assessment, concentrating on the skin integrity around the medical device.
Correct Answer is B
Explanation
A. Lean gently over the back of a chair with legs crossed: This posture may appear informal and disinterested.
B. Sit in front of the client at eye level and lean forward: Sitting at eye level and leaning forward shows attentiveness and engagement, enhancing the importance of the education.
C. Have their cell phone visible and diverting the eyes to check messages: Checking a cell phone is distracting and shows a lack of attention and respect for the client.
D. Cross her arms over her chest and avoid eye contact: Crossing arms and avoiding eye contact can be perceived as defensive and uninterested.
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