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 A
Explanation
Choice A reason: This is the correct answer because paralytic ileus is a condition in which the intestinal motility is decreased or absent, resulting in the inability to pass gas or stool. It is a common complication of abdominal surgery, as the manipulation of the bowel can cause inflammation and nerve damage. The nurse should monitor the client for signs of bowel obstruction, such as abdominal distension, nausea, vomiting, and pain.
Choice B reason: This is not the correct answer because Clostridium difficile colitis is a condition in which the normal flora of the colon is disrupted by antibiotic therapy, allowing the overgrowth of a toxin-producing bacteria that causes inflammation and diarrhea. It is not a common complication of abdominal surgery, but rather a risk associated with prolonged hospitalization and antibiotic use.
Choice C reason: This is not the correct answer because constipation is a condition in which the stool is hard, dry, and difficult to pass. It is not a common complication of abdominal surgery, but rather a side effect of opioid analgesics, which can slow down the bowel movements. The nurse should encourage the client to increase fluid and fiber intake, and use stool softeners as prescribed.
Choice D reason: This is not the correct answer because fecal impaction is a condition in which a large mass of stool is stuck in the rectum, preventing the passage of gas or stool. It is not a common complication of abdominal surgery, but rather a result of chronic constipation, dehydration, or immobility. The nurse should assess the client for signs of impaction, such as abdominal cramping, rectal pressure, and leakage of liquid stool.
Correct Answer is E
Explanation
Choice A reason: Assessment is the first phase of the nursing process, where the nurse collects data about the patient's health status, needs, preferences, and goals.
Choice B reason: Analysis/Diagnosis is the second phase of the nursing process, where the nurse interprets the data and identifies the patient's problems, risks, and strengths.
Choice C reason: Planning is the third phase of the nursing process, where the nurse develops a care plan that specifies the expected outcomes, interventions, and priorities for the patient.
Choice D reason: Implementation is the fourth phase of the nursing process, where the nurse executes the care plan and performs the interventions for the patient.
Choice E reason: Evaluation is the fifth and final phase of the nursing process, where the nurse measures the effectiveness of the interventions and compares the actual outcomes with the expected outcomes. Asking the patient about their pain level after giving pain medication is an example of evaluation.
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