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.

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Correct Answer is B

Explanation

Explanation:

A. It is not permissible because the provider should disclose laboratory results or findings to a client.

This statement is not accurate in this context. While it is true that healthcare providers are responsible for disclosing test results to clients, this responsibility is typically limited to the provider-patient relationship, not to family members of healthcare workers.

B. It is not permissible because there is no nurse-client relationship between the sibling and nurse.

This is the correct choice. In healthcare ethics and legal standards, privacy and confidentiality are essential. The nurse has a duty to maintain the confidentiality of patient information, and this duty extends to family members of patients. Since there is no official nurse-client relationship between the nurse and her sibling, accessing the sibling's diagnostic test results would violate the privacy and confidentiality rights of the sibling.

C. It is permissible because the sibling has paid for the service.

Payment for services does not override the principles of confidentiality and privacy in healthcare. Even if the sibling has paid for the service, it does not grant the nurse permission to access the sibling's medical information without proper authorization.

D. It is permissible because the client's sibling made the request.

The fact that the sibling made the request does not automatically make it permissible for the nurse to access the diagnostic test results. Confidentiality and privacy considerations are paramount in healthcare, and access to patient information is typically restricted to authorized individuals involved in the patient's care.

A. Glasgow coma scale result B. History of the injury C. Medication during the next shift D. Intracranial pressure readings

Correct Answer is B

Explanation

Explanation:

A. Glasgow coma scale result - This would be included in the assessment segment of SBAR, as it provides a clinical evaluation of the client's current neurological status.

B. History of the injury - The situation segment is used to briefly explain the current situation or the reason for the report. Including the history of the injury provides context about why the client is receiving care.

C. Medication during the next shift - This information is part of the Recommendation segment of SBAR. The nurse should include any upcoming medication administration, changes in medication orders, or specific medications that need to be administered during the next shift.

D. Intracranial pressure readings - This information should be included in the Assessment segment of SBAR. It provides important data about the client's intracranial status, helps monitor for changes or trends, and guides ongoing management and interventions.

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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's sibling had a diagnostic test at the nurse's facility. The sibling asks the nurse to look up the result in the computer. The nurse should identify which of the following as the reason for her decision about her sibling's request?

Correct Answer is B

Explanation

A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Correct Answer is B

Explanation

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