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

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) The nurse formulates a goal "The client will be free from infection for the duration of the hospitalization": This action reflects the planning phase of the nursing process. The planning phase involves setting goals and determining the best interventions to achieve the desired outcomes for the client. In this case, the goal is to prevent infection, which is a specific, measurable outcome that can guide further interventions.

B) The nurse assesses the client's white blood cell count: Assessing the client's white blood cell count is an important step in data collection, which is part of the assessment phase of the nursing process. It helps the nurse gather information about the client's current health status but is not a planning activity. The nurse would use the information from the assessment phase to formulate goals and plan interventions.

C) The nurse administers the ordered oral antibiotics: Administering antibiotics is an action related to the implementation phase of the nursing process. The implementation phase involves carrying out the planned interventions. In this case, the administration of antibiotics is a direct action taken to address the risk for infection, but it is not the planning phase.

D) The nurse teaches the client the appropriate hand washing technique: Teaching hand hygiene is an important intervention, but it falls under the implementation phase of the nursing process. It involves educating the client to help prevent infection, which is an action taken based on the goals and plan developed earlier. While important, it’s not the planning phase itself.

A. The client will remain free from visible bleeding, bruising, and signs of internal bleeding (tachycardia and hypotension) during this shift. B. The client will verbalize understanding of dietary restrictions while on warfarin and provide examples of foods that contain vitamin K during this shift C. The client will state their pain level is less than 4 on a 0-10 pain scale during aspirin therapy. D. The client will remain free from any signs and symptoms of deep vein thrombosis,

Correct Answer is A

Explanation

A) The client will remain free from visible bleeding, bruising, and signs of internal bleeding (tachycardia and hypotension) during this shift: This is the most appropriate outcome for the "Risk for bleeding" nursing diagnosis. Since both aspirin and warfarin are anticoagulants, they increase the client's risk of bleeding. The priority is to monitor for and prevent any signs of visible bleeding, bruising, or more serious internal bleeding, which could manifest as tachycardia or hypotension. This outcome directly addresses the client's safety by focusing on detecting and preventing bleeding complications.

B) The client will verbalize understanding of dietary restrictions while on warfarin and provide examples of foods that contain vitamin K during this shift: While this is an important goal for clients on warfarin (because vitamin K can interfere with the effectiveness of warfarin), it is not the most immediate concern in the context of the "Risk for bleeding" diagnosis. Dietary restrictions should be discussed but are not as time-sensitive or directly related to the prevention of bleeding in the short term, especially during this shift.

C) The client will state their pain level is less than 4 on a 0-10 pain scale during aspirin therapy: While managing pain is important, this outcome does not directly address the risk for bleeding associated with both aspirin and warfarin therapy. The priority nursing concern here is preventing bleeding, not pain management during aspirin therapy.

D) The client will remain free from any signs and symptoms of deep vein thrombosis (DVT): While preventing DVT is important for patients on anticoagulant therapy, the focus of this nursing diagnosis is on the risk of bleeding, not thrombosis. Therefore, this outcome is not as relevant to the immediate concerns related to the prescribed medications (aspirin and warfarin).

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses the client and determines the client is at risk for infection. Which activity best reflects the planning phase of the nursing process?

Correct Answer is A

Explanation

The client is prescribed aspirin and warfarin. Based on side effects of both medications, the nurse identifies "Risk for bleeding" as a nursing diagnosis for this client. What outcome is appropriate for this nursing diagnosis?

Correct Answer is A

Explanation

A client is ordered .9mg ondansetron, IV, PRN q6 hours for nausea. The nurse anticipates which of the following sources to cause potential medication error?

A client with seasonal allergies takes diphenhydramine at bedtime to help their symptoms. The client develops low hemoglobin low white blood cell counts which is otherwise unexplained. What type of reaction is the client experiencing?

A client is prescribed ondansetron for nausea. When reviewing the client's medical history, which finding would concern the nurse?

The client receives 200 mg of a medication on a consistent schedule. How much drug is in the body at 4 half-lives?

The client is to receive acetaminophen 1000 mg IV Q6 hours. Today, the nurse administered acetaminophen 1000 mg PO. Which of the 9 rights was not followed in this situation?

The nurse has identified several diagnoses for a client in the hospital. Which problems should the nurse identify as having highest priority?

During a period of time when the computerized medication order system was down, the prescriber wrote admission the nurse is transcribing them. The nurse is having difficulty transcribing one order because of the prescriber's handwriting. Which is the best action for the nurse to take at this time?

A client is preparing a medication for administration and is disposing the remaining medication. Which action by the client indicates the need for additional education?