A client has a nasogastric tube and the medication tablets will need to be crushed. After verifying in the drug guide which tablets can be crushed, the nurse crushes each medication individually, mixes each in 20 mL of fluid and administers them one at a time down the nasogastric tube Which phase of the nursing process does this represent.
Planning
Diagnosis
Evaluation
Implementation
Assessment
The Correct Answer is D
A) Planning: The planning phase involves setting goals and determining the actions needed to achieve those goals. While the nurse may have planned to administer the medications through the nasogastric tube, the specific actions of crushing the tablets, mixing them with fluid, and administering them fall under a different phase. Therefore, planning is not the correct phase for the actions described.
B) Diagnosis: The diagnosis phase is when the nurse identifies and formulates nursing diagnoses based on data collected about the patient’s health status. The actions of preparing and administering medication do not fall under this phase, as diagnosis pertains to assessing health problems or needs.
C) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. The nurse would evaluate the effectiveness of the medication administration after it has been done, but the actual action of giving the medication is part of implementation, not evaluation.
D) Implementation: Implementation is the phase where the nurse carries out the planned interventions, including administering medications. In this case, the nurse is taking specific steps to prepare and administer the crushed tablets down the nasogastric tube, which is a direct action related to the care plan. This phase involves performing the tasks necessary to carry out the interventions that were decided during the
planning phase.
E) Assessment: Assessment involves collecting data about the client’s health status, such as physical examination, history, and vital signs. The actions taken to crush and administer medications are not part of the assessment phase, which focuses on gathering information, not delivering care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["20"]
Explanation
1. Determine the concentration of the guaifenesin:
The label states 100 mg/5 mL.
2. Set up a proportion to find the volume (in mL) needed:
100 mg / 5 mL = 400 mg / x mL
3. Solve for x:
Cross-multiply: 100x = 400 * 5
100x = 2000
x = 2000 / 100
x = 20 mL
Answer: The nurse will administer 20 mL to the client.
Correct Answer is ["20"]
Explanation
Identify the total units of heparin in the bag:
The IV bag contains 25,000 units of heparin in 250 mL.
Identify the desired hourly dose:
The client is ordered to receive 2,000 units of heparin per hour.
Calculate the mL containing 2,000 units:
We can set up a proportion:
(25,000 units) / (250 mL) = (2,000 units) / (x mL)
Solving for x, we get:
x = (2,000 units x 250 mL) / 25,000 units x = 20 mL
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