A client is to receive insulin lispro at 0730. Prior to administering the medication, the nurse reviews the medical records for past medical history and obtains the client's fingerstick blood glucose reading. What phase of the nursing process does this represent?
Evaluation
Planning
Implementation
Assessment
Diagnosis
The Correct Answer is D
A) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. It involves determining if the interventions provided were effective in achieving the desired outcomes. In this scenario, the nurse is still
gathering information before the action is taken, so evaluation is not the correct phase.
B) Planning: Planning is the phase in the nursing process where the nurse develops a care plan, which includes setting goals and determining interventions based on the client's needs. Although reviewing the medical record and blood glucose level is important for planning the administration of insulin, this is more about gathering data rather than forming a plan of care.
C) Implementation: Implementation refers to the actual delivery of the nursing interventions or actions. In this case, administering the insulin would be part of the implementation phase, but reviewing the medical history and obtaining a fingerstick blood glucose reading are steps taken before implementing the medication.
D) Assessment: The nurse is collecting pertinent information about the client’s condition, including reviewing the medical record and obtaining the blood glucose level. Assessment is the first step in the nursing process and involves gathering information to help guide clinical decisions.
E) Diagnosis: Diagnosis is the phase in which the nurse analyzes the assessment data to identify the client’s health problems or potential risks. While the nurse is collecting data, the diagnosis comes after the assessment phase, when the nurse has enough information to make a clinical judgment about the client's health status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Polyethylene Glycol: Polyethylene glycol is a medication typically used to treat constipation by promoting bowel movements. While it can be useful in managing constipation, it is not commonly prescribed after a myocardial infarction. In this situation, the focus is more on medications that promote heart health, reduce cardiac workload, and prevent complications related to the heart attack.
B) Bisacodyl: Bisacodyl is a stimulant laxative used to relieve constipation. However, this medication is not typically prescribed immediately following a myocardial infarction. Stimulant laxatives can cause dehydration and excessive fluid shifts, which can be harmful to a client recovering from a heart attack. The focus would be on safer options for bowel management in this context.
C) Senna: Senna is also a stimulant laxative, used for relieving constipation. Similar to bisacodyl, it is not ideal for clients who have recently experienced a myocardial infarction due to its potential for causing dehydration and electrolyte imbalances, which could negatively affect heart function. A gentler approach to bowel management is preferred for these clients.
D) Docusate Sodium: Docusate sodium is a stool softener commonly prescribed to prevent constipation, especially in clients who have recently had a myocardial infarction. After a heart attack, it's important to avoid straining during bowel movements, as this could increase pressure on the heart. Docusate sodium helps soften stools and promotes smoother bowel movements without stimulating the gastrointestinal system in a way that would elevate cardiac stress. It is the most appropriate choice for this client.
Correct Answer is B
Explanation
A) Planning: The planning phase of the nursing process involves identifying specific goals and outcomes for the patient based on their condition. In this scenario, the nurse has already administered the medication and is assessing the effectiveness, which is a part of evaluating the plan of care. Planning would have occurred prior to medication administration to decide on interventions, but it is not the phase the nurse is in now.
B) Evaluation: Evaluation is the phase where the nurse assesses whether the nursing interventions and treatments are effective in achieving the desired outcomes. In this scenario, the nurse is evaluating the effect of the baclofen dose by observing whether it reduced muscle spasms and pain. The nurse's focus on assessing the result of the medication and its impact on the client’s condition indicates the evaluation phase of the nursing process.
C) Diagnosis: The diagnosis phase occurs before interventions and involves identifying health problems or conditions that need attention. In this case, a nursing diagnosis such as "impaired mobility" or "pain related to muscle spasticity" might have been formulated earlier, but the focus now is on evaluating the effectiveness of the treatment, not on diagnosing the problem.
D) Implementation: Implementation is the phase where the planned interventions are carried out. Administering baclofen to the client would fall under this phase. However, since the nurse is now assessing the effect of the medication after its administration, this action takes place after the intervention and falls under the evaluation phase, not implementation.
E) Assessment: Assessment is the phase where data is gathered about the patient’s condition, including physical and mental health. In this case, the nurse would have assessed the client initially to determine the need for baclofen, but four hours later, the nurse is evaluating the outcome of the medication, not gathering initial data. Therefore, the action described is not part of the assessment phase but rather the evaluation phase.
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