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
Related Questions
Correct Answer is C
Explanation
Turning, deep breathing, and coughing exercises are important for clients recovering from surgery as they help prevent the development of pneumonia. After surgery, clients may have difficulty taking deep breaths and coughing due to pain or discomfort. This can lead to the accumulation of mucus in the lungs, increasing the risk of pneumonia. By performing these exercises, clients can help clear their lungs and reduce their risk of developing this complication. While these exercises may also help prevent other complications such as thrombophlebitis, the primary reason for performing them is to prevent pneumonia.
Correct Answer is D
Explanation
The number "+3" in this documentation represents the pulse amplitude. Pulse amplitude refers to the strength or force of the pulse and is typically measured on a scale of 0 to 4+. A "+3" pulse is considered to be full or strong, indicating good blood flow to the area being palpated.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today