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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Sit patiently, quietly, and engaged. This shows the nurse is present and supportive, allowing the client to feel comfortable and respected.
B. Use open-ended questions starting with "Why."Questions starting with "Why" can be perceived as accusatory or confrontational, potentially increasing the client's discomfort.
C. Use open-ended questions starting with "Tell." Open-ended questions encourage the client to express themselves more freely, facilitating communication.
D. Allow the client time to think and reflect. Giving the client time respects their need to process thoughts and feelings before responding.
E. Use close-ended questions to establish an increase in communication. Close-ended questions can limit responses and do not encourage the client to open up or elaborate on their feelings.
Correct Answer is C
Explanation
A. Decreased vision but the client is wearing glasses: As long as the client is wearing glasses and can see adequately, decreased vision is not a barrier to learning that would require postponing teaching.
B. Hearing loss, hearing aids are functioning well: With functioning hearing aids, the client should be able to hear and understand the discharge instructions, so this is not a barrier to learning that requires postponement.
C. Language and no access to an interpreter: Without an interpreter, the client may not understand the instructions, which is a significant barrier to learning. This requires postponing the teaching until an interpreter is available.
D. The client's culture: While cultural differences can influence learning, they do not inherently create a barrier that necessitates postponing teaching unless they directly affect comprehension or communication.
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