A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

Re-collection of data

Implementation

Evaluation

Data Collection

Answer and Explanation

The Correct Answer is B

Explanation:

A. Re-collection of data:

This step involves gathering additional information or data about the client's condition. It may be necessary if there are new developments, changes in the client's status, or if the initial data collected was insufficient or inaccurate. Re-collection of data helps ensure that the nurse has comprehensive and accurate information to base the care plan on.

B. Implementation:

Implementation is the phase where the nurse puts the planned interventions into action. This step involves performing nursing actions, administering treatments or medications, providing education and support to the client and their family, and collaborating with other healthcare team members. The nurse follows the care plan developed during the planning phase to address the client's needs and achieve desired outcomes.

C. Evaluation:

Evaluation is the final step of the nursing process where the nurse assesses the client's response to interventions and the effectiveness of the care provided. The nurse compares the client's actual outcomes with the expected outcomes identified during the planning phase. If the outcomes are met, the plan may continue as is or be modified for ongoing care. If the outcomes are not met, the nurse revises the plan as necessary to improve client outcomes.

D. Data Collection:

Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, emotional, social, and environmental factors. This step involves conducting assessments, gathering medical history, reviewing laboratory and diagnostic tests, and obtaining information from the client and their family. Data collection forms the basis for identifying nursing diagnoses, developing care plans, and implementing appropriate interventions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Explanation:

A. Material safety data sheets:

Material safety data sheets (MSDS) are documents that provide information about the properties of chemicals and substances, including hazards, handling, storage, and emergency procedures. While MSDS are crucial for ensuring safe handling of materials, they primarily focus on chemical safety and may not provide detailed guidance on specimen collection protocols. Therefore, while MSDS are essential references for safety, they are not the primary source for revising specimen collection protocols.

B. Evidence-based practice:

Evidence-based practice (EBP) involves integrating the best available evidence from research studies, clinical expertise, and patient values and preferences to make informed decisions about patient care. For revising protocols, nurses should rely heavily on evidence-based guidelines and research literature related to specimen collection techniques, safety measures, accuracy, and quality assurance. EBP ensures that protocols are based on the latest scientific evidence, leading to improved patient outcomes and quality of care.

C. Client medical records:

Client medical records contain detailed information about individual patients, including their medical history, diagnoses, treatments, and laboratory results. While medical records are valuable for understanding specific patient needs and conditions, they are not typically used as primary sources for developing or revising unit-wide protocols. However, reviewing medical records may provide insights into specific challenges or issues related to specimen collection for certain patients.

D. Facility policy and procedures:

Facility policy and procedures manuals outline the organization's guidelines, protocols, and standards of practice for various aspects of patient care, including specimen collection. Nurses should refer to facility policies and procedures to understand existing protocols, safety measures, documentation requirements, and quality control processes related to specimen collection. While facility policies are important references, they may need to be updated based on current evidence and best practices, which is where evidence-based practice comes into play.

A. "The client has developed drooping facial features." B. "The client may benefit from a neurology consult." C. "The client is disoriented and pupils are slow to respond to light." D. "The client has a history of hypertension."

Correct Answer is D

Explanation

Explanation:

A. "The client has developed drooping facial features."

This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.

B. "The client may benefit from a neurology consult."

While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.

C. "The client is disoriented and pupils are slow to respond to light."

Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.

D. "The client has a history of hypertension."

This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.

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 has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting research to revise the protocol for specimen collection on their unit. From which of the following sources should the nurse retrieve the information?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

Correct Answer is D

Explanation

A newly hired nurse asks a charge nurse what safety measures are in place to prevent diversion of controlled substances on the unit. Which of the following statements should the charge nurse make?(Select All that Apply.)

A nurse is preparing to administer amoxicillin 500 mg PO. Available is amoxicillin 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?

A nurse is caring for a child who reports being physically abused by a family member. Which of the following statements should the nurse make?

A nurse is reinforcing teaching with a newly licensed nurse regarding sources of medication information. Which of the following resources should the nurse include as reliable references for the nurse to use to evaluate medication information? (Select all that apply.)(Select All that Apply.)

A nurse is preparing to administer amoxicillin 300 mg PO. The amount available is amoxicillin oral solution 250 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is researching data about best practice for reducing medication errors on a surgical unit. Which of the following steps of evidence based practice (EBP) is the nurse taking?