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 ["4"]
Explanation
Identify the desired dose: The doctor has ordered 40 mg of atorvastatin.
Identify the available tablet strength: Each tablet contains 10 mg of atorvastatin.
Set up the calculation: We need to find out how many tablets are needed to administer 40 mg of the medication.
We can use the following formula:
(Desired dose) / (Tablet strength) = Number of tablets
Plug in the values and calculate:
(40 mg) / (10 mg/tablet) = 4 tablets
Correct Answer is D
Explanation
A) This medication neutralizes gastric acid in the stomach by direct contact: Sucralfate does not neutralize gastric acid. Instead, it works by forming a protective barrier over the ulcer, which helps protect it from further damage by stomach acid and promotes healing. Sucralfate is a mucosal protectant, not an acid-neutralizing agent.
B) "You should take this medication after meals to help limit gastric acid secretion": Sucralfate should be taken on an empty stomach, typically 30 minutes to 1 hour before meals, to allow it to form an effective protective barrier over the ulcer. Taking it after meals would interfere with its action and effectiveness.
C) "This medication decreases gastric acid production by blocking histamine 2 receptors": Sucralfate does not work by blocking histamine 2 receptors. Histamine 2 receptor antagonists, such as ranitidine, work by reducing gastric acid secretion. Sucralfate works by coating and protecting the ulcer rather than by reducing acid production.
D) "You should take this medication 30 minutes to 1 hour before meals and at bedtime": Sucralfate should be taken on an empty stomach, typically 30 minutes to 1 hour before meals and at bedtime. This timing ensures that the medication can form an effective barrier over the ulcer before food intake and helps maximize its healing properties.
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