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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Related Questions
Correct Answer is C
Explanation
A. Develop short-term goals for the client in the teaching plan: Developing goals is part of the planning phase, not the assessment phase.
B. Show the client how to draw up the insulin in a syringe: This is part of the implementation phase, where the nurse provides instructions and demonstrations.
C. Assess the client’s readiness for learning: Assessing the client’s readiness to learn is part of the assessment phase, determining if the client is prepared and willing to learn the new skill.
D. Ask the client to demonstrate self-injection: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the skill taught.
Correct Answer is B
Explanation
A. Assess the client's pain level: Assessing the client's pain level is part of the assessment step, not the evaluation step.
B. Ask the client to demonstrate use of the incentive spirometer: Asking the client to demonstrate use of the incentive spirometer is a way to evaluate whether the client has understood and can perform the skill.
C. Develop a short-term goal for the client: Developing a short-term goal is part of the planning step, not the evaluation step.
D. Provide instructions on how to use the incentive spirometer: Providing instructions is part of the implementation step, not the evaluation step.
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