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 C
Explanation
A) Use perfumes and air fresheners: Using perfumes and air fresheners may actually worsen nausea for some clients, as strong scents can trigger or exacerbate feelings of nausea, particularly in individuals undergoing chemotherapy. It is generally advisable to avoid strong odors in the environment to prevent triggering nausea.
B) Eat foods that are high in fibre: While a balanced diet is important, high-fibre foods may not be helpful in managing nausea and vomiting associated with chemotherapy. In fact, high-fibre foods can sometimes contribute to gastrointestinal discomfort, bloating, or constipation, which may worsen nausea in certain individuals. Therefore, fibre-rich foods are not the best option for reducing nausea and vomiting in this scenario.
C) Drink clear and carbonated beverages: Drinking clear liquids, such as water, ginger ale, or clear broths, can help reduce nausea by keeping the client hydrated and soothing the stomach. Carbonated beverages, such as ginger ale, are often recommended because the bubbles can help alleviate nausea and provide some relief. This is a well-established strategy for managing chemotherapy-related nausea and vomiting.
D) Walk frequently throughout the day: While physical activity is generally beneficial for overall health, walking frequently may not directly address nausea and vomiting caused by chemotherapy. In some cases, walking might even worsen nausea if the client is feeling weak or dizzy. Resting and staying hydrated may be more beneficial in the management of nausea associated with chemotherapy.
Correct Answer is ["20"]
Explanation
Identify the total units of heparin in the bag:
The IV bag contains 25,000 units of heparin in 250 mL.
Identify the desired hourly dose:
The client is ordered to receive 2,000 units of heparin per hour.
Calculate the mL containing 2,000 units:
We can set up a proportion:
(25,000 units) / (250 mL) = (2,000 units) / (x mL)
Solving for x, we get:
x = (2,000 units x 250 mL) / 25,000 units x = 20 mL
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.