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 B
Explanation
A. Primary prevention: Primary prevention involves measures taken to prevent diseases or injuries before they occur, such as vaccinations or health education to prevent onset of illness. Teaching blood sugar monitoring to someone with diabetes is not primary prevention.
B. Tertiary prevention: Tertiary prevention involves managing disease post-diagnosis to slow or stop disease progression. Teaching a diabetic patient to monitor their blood sugar helps manage their existing condition and prevent complications, making it tertiary prevention.
C. Secondary prevention: Secondary prevention includes screening and early detection of disease to halt or slow its progress. Monitoring blood sugar levels in a diabetic patient is not about early detection but managing an existing condition.
D. Disease surveillance: Disease surveillance involves continuous, systematic collection, analysis, and interpretation of health data. This is not what the nurse is doing when teaching a client to monitor their blood sugar.
Correct Answer is D
Explanation
A. Proper foot care will be demonstrated to clients during the program: This is specific and measurable but lacks a timeframe and does not clearly define a goal for the clients.
B. A facility will be reserved for the program: This is a task rather than a goal related to client outcomes.
C. Handouts and teaching materials will be distributed: This is another task rather than an outcome goal for clients.
D. Clients will have a decreased incidence of foot ulcers within a month: This is a SMART goal as it is specific, measurable, achievable, relevant, and time-bound. It focuses on a specific health outcome for clients.
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