A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

Assessment

Evaluation

Diagnosis

Planning

Answer and Explanation

The Correct Answer is B

A. Assessment. This is incorrect because assessment refers to the initial data collection before interventions are performed. The nurse auscultating the lungs after administering the medication is part of evaluating the effectiveness of treatment.

B. Evaluation. This is correct because evaluation involves determining whether the intervention was successful in achieving the desired outcome. The nurse is assessing lung sounds to determine if the inhaled medication improved airway clearance and breathing.

C. Diagnosis. This is incorrect because diagnosis involves identifying the patient's health problems based on assessment data. The nurse is not formulating a diagnosis in this scenario but rather checking the response to treatment.

D. Planning. This is incorrect because planning involves setting patient goals and selecting interventions before implementation. The nurse auscultating lung sounds after treatment is an evaluation step, not a planning step.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. This is a closed-ended question that leads to a simple "yes" or "no" response, limiting the amount of information the nurse gathers.

B. While this is important information, it is not an appropriate opening question for a full nursing assessment, as it does not encourage the patient to share their primary concern.

C. This open-ended question allows the patient to provide a detailed narrative, helping the nurse gather a comprehensive history.

D. This is a closed-ended question that focuses only on pain rather than encouraging the patient to share their full reason for seeking care.

A. Risk for alteration in skin integrity B. Activity Intolerance C. Risk for Infection D. Deficient Fluid volume

Correct Answer is B

Explanation

A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.

B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.

C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.

D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.

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 nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is the most appropriate open-ended question to begin a nursing assessment?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?

A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?