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).
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
In this situation, the nurse demonstrated integrity. After realizing the mistake of giving a client who was NPO a morning breakfast tray, the nurse took responsibility for the mistake by notifying the physician and the client, explaining the consequences of the mistake, and documenting the situation in the client's medical record. The other options (Altruism, Human dignity, and Social justice) are not directly related to this situation.
Correct Answer is B
Explanation
The nurse would question the discharge of a client to be cared for by the family if the client and family lack knowledge of the treatment regimen. It is important for the client and family to have a good understanding of the treatment regimen in order to provide safe and effective care at home. The other options (The client will need sterile dressing changes, The client will be discharged with a feeding tube, and The client will be receiving IV medications by home health nurses) are not situations that would necessarily prevent discharge to be cared for by the family.
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