A nurse in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?

Assessment

Planning

Implementation

Evaluation

Answer and Explanation

The Correct Answer is A

A.   During the Assessment phase, the nurse gathers information about the client's health status, including any potential allergies. This information is crucial for planning safe and effective care.
B.   The Planning phase involves developing a care plan based on the assessment data.
While allergies are an important consideration in planning care, they are first identified during the assessment phase.
C.   The Implementation phase involves carrying out the care plan. While it is important to be aware of allergies during this phase to ensure the safe administration of treatments, the initial identification of allergies occurs in the assessment phase.
D.   The Evaluation phase involves assessing the client's response to interventions and determining if goals have been met. While allergies are relevant in evaluating the client's response to certain treatments, they are initially identified during the assessment phase.

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Correct Answer is A

Explanation

A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.

A. Assist a client to ambulate using a gait belt. B. Review a low-sodium diet for a client who has hypertension. C. Feed a client who had a stroke 3 months ago. D. Bathe a client who had an amputation 2 days ago. E. Expllain oral hygiene to a client receiving chemotherapy.

Correct Answer is ["A","C","D"]

Explanation

Rationale A: Assisting a client to ambulate using a gait belt is a task within the scope of practice for assistive personnel. It involves physical support and monitoring, which do not require the advanced training of a registered nurse. This task ensures the client's safety while promoting mobility.

Rationale B: Reviewing a low-sodium diet is not within the scope of practice for assistive personnel as it requires nutritional knowledge and the ability to teach, which are responsibilities of a registered nurse or a dietitian.

Rationale C: Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel. This task does not require the clinical judgment of a nurse and can be performed following a predefined plan of care.

Rationale D: Bathing a client who had an amputation 2 days ago can be delegated to assistive personnel. They are trained to assist with activities of daily living, including bathing, while ensuring the client's safety and comfort.

Rationale E: Explaining oral hygiene to a client receiving chemotherapy involves patient education and understanding of the specific needs related to the client's condition, which are beyond the role of assistive personnel. This task requires the expertise of a nurse or other healthcare professional.

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A nurse in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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