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?
The nurse formulates a goal "The client will be from infection for the duration of the hospitalization."
The nurse assesses the client’s white blood cell count
The nurse administers the ordered oral antibiotics
The nurse teaches the client the appropriate hand washing technique
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
CYP 450 enzymes are responsible for the metabolism of many drugs. Smoking can induce certain CYP 450 enzymes, particularly CYP1A2, which leads to an increase in the metabolism of drugs that are substrates of this enzyme. When a person begins smoking, the induction of these enzymes can cause drugs to be metabolized more quickly, which typically results in lower drug levels in the body. However, the statement asks whether the level of medication will increase in this client, and since smoking induces enzyme activity, it would typically lead to decreased, not increased, drug levels. However, in the context of drug-drug interactions and other metabolic pathways, the metabolism rate could be altered in ways that might increase or affect the therapeutic response.
Correct Answer is A
Explanation
A) Low albumin: This factor has the most impact on the pharmacokinetic phase of distribution. Albumin is a key protein in the blood that binds to many medications. When albumin levels are low, fewer drug molecules will be bound, leading to an increased concentration of free (unbound) drug in the bloodstream. This can result in enhanced drug effects or toxicity, as the unbound drug is pharmacologically active and more readily able to cross cell membranes.
B) Renal disease: While renal disease can impact drug elimination and excretion, it does not have as direct an effect on the distribution phase of pharmacokinetics. Renal function primarily affects the clearance of drugs from the body rather than how the drug is distributed within the tissues.
C) Hepatic disease: Hepatic disease can affect the metabolism of drugs and their clearance, but it does not directly affect the distribution phase. While the liver is involved in metabolizing drugs, it is the ability to clear or process the drug that is most influenced, rather than its distribution to tissues.
D) An elevated gastric pH: Elevated gastric pH (which can occur with antacid use or in certain conditions) can affect the absorption of some medications but has minimal direct impact on the distribution phase of pharmacokinetics. Distribution is primarily concerned with how a drug moves from the bloodstream into tissues, and this is more influenced by factors like blood flow, protein binding, and the drug's lipophilicity, rather than the pH of the stomach.
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