A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process?
Assessment
Planning
Diagnosis
Evaluation
The Correct Answer is A
Choice A reason: Assessment is the first and most important phase of the nursing process, as it involves collecting and analyzing data about the patient's health status, needs, and preferences. The nurse should have assessed the patient's blood pressure before administering the antihypertensive medication, as it could have been contraindicated or required a dosage adjustment. By failing to do so, the nurse put the patient at risk of hypotension and its complications.
Choice B reason: Planning is the second phase of the nursing process, in which the nurse sets goals and outcomes for the patient's care and selects appropriate interventions. The nurse did not make an error in this phase, as the administration of the antihypertensive medication was part of the plan of care for the patient with hypertension.
Choice C reason: Diagnosis is the third phase of the nursing process, in which the nurse identifies the patient's actual or potential health problems based on the assessment data. The nurse did not make an error in this phase, as the diagnosis of hypertension was accurate and supported by the patient's history and vital signs.
Choice D reason: Evaluation is the fourth and final phase of the nursing process, in which the nurse measures the patient's progress and outcomes and modifies the plan of care as needed. The nurse did not make an error in this phase, as the re-checking of the blood pressure and the recognition of the patient's symptoms were part of the evaluation process. However, the nurse should have also notified the provider and implemented interventions to treat the hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cognitive domain of learning involves the mental processes of acquiring, storing, and applying knowledge. It includes skills such as remembering, understanding, analyzing, and evaluating. An example of cognitive learning is the RN asking the client to explain the purpose and effects of his inhaler.
Choice B reason: Affective domain of learning involves the emotional aspects of learning, such as attitudes, values, beliefs, and feelings. It includes skills such as receiving, responding, valuing, and committing. An example of affective learning is the RN asking the client how he feels about using his inhaler.
Choice C reason: Psychomotor domain of learning involves the physical aspects of learning, such as movement, coordination, and manipulation. It includes skills such as imitating, practicing, adapting, and creating. An example of psychomotor learning is the RN asking the client to demonstrate proper use of his inhaler.
Choice D reason: Kinesthetic domain of learning is not a recognized domain of learning, but rather a learning style that refers to the preference of learning by doing or experiencing. Kinesthetic learners tend to learn best by engaging in physical activities, such as hands-on tasks, simulations, and experiments.
Correct Answer is A
Explanation
Choice A reason: Administering a vaccine to a well child is an example of the RN working in a health promotion role through primary prevention. Primary prevention is the level of prevention that aims to prevent disease or injury before it occurs. It involves reducing exposure to risk factors and enhancing protective factors. Vaccination is a primary prevention strategy that protects the child from contracting or spreading infectious diseases, such as measles, polio, or tetanus.
Choice B reason: Obtaining a blood glucose level on a client with hypoglycemia (low blood sugar) is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through tertiary prevention. Tertiary prevention is the level of prevention that aims to reduce the complications and disability associated with chronic or irreversible diseases or injuries. It involves providing treatment, rehabilitation, and support services. Obtaining a blood glucose level on a client with hypoglycemia is a tertiary prevention strategy that monitors the client's condition and prevents further deterioration or complications, such as coma or seizures.
Choice C reason: Educating a patient on wound care is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through secondary prevention. Secondary prevention is the level of prevention that aims to detect and treat diseases or injuries early, before they become more serious or chronic. It involves screening, diagnosis, and intervention. Educating a patient on wound care is a secondary prevention strategy that helps the patient to prevent infection, promote healing, and avoid complications, such as scarring or gangrene.
Choice D reason: Administering a nebulizer treatment to a client with asthma is not an example of the RN working in a health promotion role through primary prevention. This is an example of the RN working in a disease management role through tertiary prevention. Tertiary prevention is the level of prevention that aims to reduce the complications and disability associated with chronic or irreversible diseases or injuries. It involves providing treatment, rehabilitation, and support services. Administering a nebulizer treatment to a client with asthma is a tertiary prevention strategy that helps the client to relieve symptoms, improve lung function, and prevent exacerbations, such as asthma attacks.
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