The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:
implementation
evaluation
planning
assessment
The Correct Answer is C
A. Implementation: Implementation occurs after interventions have been planned and involves carrying out those interventions.
B. Evaluation: Evaluation occurs after implementation to assess if the intervention was effective.
C. Planning: The planning phase involves choosing the best interventions based on patient assessment and nursing diagnosis.
D. Assessment: Assessment is gathering information about the patient, not deciding on interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
thoroughly. The patient may not have verbalized pain but could still be experiencing it.
B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.
C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).
D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).
Correct Answer is C
Explanation
A. Ensure subjective documentation: JCAHO (Joint Commission on Accreditation of Healthcare Organizations) promotes objective documentation to ensure accuracy and reliability in patient care records.
B. Make sure that all nurses use the same charting system: JCAHO does not mandate a uniform charting system, as institutions may use different electronic health record (EHR) systems.
C. Ensure quality patient care: JCAHO’s primary role is to establish and enforce standards to improve patient safety and healthcare quality.
D. Make sure insurance companies get paid correctly: JCAHO’s focus is on patient care quality, not financial reimbursement.
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