Twenty minutes after administering pain medication to the patient, the nurse asks if the patient's pain level has decreased. What phase of the nursing process does this demonstrate?
Assessment
Analysis/Diagnosis
Planning
Implementation
Evaluation
The Correct Answer is E
Choice A reason: Assessment is the first phase of the nursing process, where the nurse collects data about the patient's health status, needs, preferences, and goals.
Choice B reason: Analysis/Diagnosis is the second phase of the nursing process, where the nurse interprets the data and identifies the patient's problems, risks, and strengths.
Choice C reason: Planning is the third phase of the nursing process, where the nurse develops a care plan that specifies the expected outcomes, interventions, and priorities for the patient.
Choice D reason: Implementation is the fourth phase of the nursing process, where the nurse executes the care plan and performs the interventions for the patient.
Choice E reason: Evaluation is the fifth and final phase of the nursing process, where the nurse measures the effectiveness of the interventions and compares the actual outcomes with the expected outcomes. Asking the patient about their pain level after giving pain medication is an example of evaluation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: William, who exercises three times a week, does not have a modifiable risk factor for osteoporosis. Exercise is actually beneficial for bone health, as it stimulates bone formation and reduces bone loss. Exercise also improves muscle strength, balance, and coordination, which can prevent falls and fractures.
Choice B reason: Samantha, who has a family history of osteoporosis, does not have a modifiable risk factor for osteoporosis. Family history is a genetic factor that cannot be changed or controlled. Having a parent or sibling with osteoporosis increases the risk of developing the condition, especially if they have had a fracture.
Choice C reason: Juanita, who smokes two packs of cigarettes a day, has a modifiable risk factor for osteoporosis. Smoking is a lifestyle factor that can be changed or controlled. Smoking increases the risk of osteoporosis by reducing the blood supply to the bones, decreasing the absorption of calcium, and lowering the levels of estrogen, which protects the bones.
Choice D reason: Tori, who is postmenopausal at age 40, does not have a modifiable risk factor for osteoporosis. Menopause is a natural process that occurs when the ovaries stop producing estrogen, which leads to bone loss and increased risk of fractures. Menopause cannot be prevented or reversed, but its effects on bone health can be managed with hormone therapy, calcium, and vitamin D supplements.
Correct Answer is B
Explanation
Choice A reason: Fluid volume deficit is a condition in which the body loses more fluid than it gains, resulting in dehydration, hypotension, and electrolyte imbalances. It is not a complication of IV fluid therapy, but rather a reason for initiating it.
Choice B reason: Fluid volume excess is a condition in which the body retains more fluid than it needs, resulting in edema, hypertension, and heart failure. It is a potential complication of IV fluid therapy, especially in older adults who have reduced renal function and cardiac output. The nurse's assessment findings of crackles, shortness of breath, and jugular vein distention are indicative of fluid overload and pulmonary congestion.
Choice C reason: Speed shock is a systemic reaction that occurs when a substance is administered too rapidly into the bloodstream, causing adverse effects such as chest pain, dyspnea, hypotension, and cardiac arrest. It is not a complication of IV fluid therapy, but rather a risk associated with IV medication administration.
Choice D reason: Pulmonary embolism is a blockage of one or more pulmonary arteries by a blood clot, fat, or air, causing impaired gas exchange, chest pain, dyspnea, and hemoptysis. It is not a complication of IV fluid therapy, but rather a possible outcome of venous thromboembolism, which can be prevented by using anticoagulants and mechanical devices.
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