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
Explanation
A. Planning: Developing goals is part of the planning phase, where the nurse sets objectives and outcomes for the patient’s care.
B. Assessment: Assessment involves collecting data about the patient’s condition.
C. Implementation: Implementation involves putting the care plan into action.
D. Evaluation: Evaluation involves determining whether the patient has met the goals and outcomes set during the planning phase.
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.
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