While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused by the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
Assessment
Diagnosis
Evaluation
Implementation
The Correct Answer is A
The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the effectiveness of care (evaluation).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Cheyne-Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes ². It is marked by rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea ¹.
Correct Answer is B
Explanation
The most appropriate response by the nurse would be to explain to the client that antibiotics have no effect on viruses. Upper respiratory infections, such as the common cold, are caused by viruses and therefore antibiotics would not be effective in treating the infection. It is important for the nurse to educate the client about the appropriate use of antibiotics and to address any misconceptions they may have.
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