A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?
Establishing the priorities of client care
Reinforcing teaching about the client's diagnosis
Asking the client about the presence of pain
Comparing the client's current laboratory values to previous results
The Correct Answer is B
A) Establishing the priorities of client care:
Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.
B) Reinforcing teaching about the client's diagnosis:
Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.
C) Asking the client about the presence of pain:
Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.
D) Comparing the client's current laboratory values to previous results:
Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.
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Related Questions
Correct Answer is B
Explanation
B) Log the previous user out of the system:
The immediate action the nurse should take is to protect the client's confidentiality by logging out the previous user from the computer system. This ensures that unauthorized individuals do not have access to the client's health information. By taking this step promptly, the nurse mitigates the risk of unauthorized viewing of sensitive information.
A) Complete an incident report:
While completing an incident report is important for documenting the occurrence, it is not the first action the nurse should take. The priority is to address the immediate breach of confidentiality by securing the computer system to prevent further unauthorized access.
C) Report the incident to the charge nurse:
Reporting the incident to the charge nurse is essential, but it should follow the immediate action of logging out the previous user from the system. The charge nurse can then coordinate any necessary follow-up actions and ensure that appropriate measures are taken to prevent similar incidents in the future.
D) Offer to conduct a unit in-service on client confidentiality:
While staff education on client confidentiality is valuable for preventing future breaches, it is not the first action needed in response to the immediate situation. Addressing the current breach takes precedence to protect the client's privacy. Staff education can be considered as a proactive measure after addressing the immediate concern.
Correct Answer is B
Explanation
A) Ask ambulatory clients to help to move clients in wheelchairs:
While enlisting the help of ambulatory clients to assist those in wheelchairs may seem logical, it is not typically recommended as it could pose safety risks to both parties during an evacuation. Assistive personnel should be trained to prioritize their own safety and the safety of others during evacuation procedures, following established protocols for assisting clients with mobility impairments.
B) Place dry towels around the bases of doors:
Placing dry towels around the bases of doors is a recommended fire evacuation procedure to prevent smoke from entering the room. This action helps create a barrier to smoke inhalation and can buy time for evacuation or rescue efforts. It is important to use dry towels or clothing to avoid fueling the fire and to minimize the passage of smoke.
C) Carry bedridden clients to safety by lifting them onto your back:
Carrying bedridden clients on one's back during a fire evacuation is not a safe or feasible method, especially for assistive personnel who may not have the physical strength or training to perform such tasks. Evacuating bedridden clients should be done using appropriate evacuation equipment such as evacuation sleds or sheets, following facility protocols and guidelines.
D) Aim the extinguisher at the top of the fire:
While using a fire extinguisher is an important aspect of fire safety training, aiming the extinguisher at the top of the fire is not always the correct approach. The appropriate technique for using a fire extinguisher depends on the type of fire and the specific instructions provided with the extinguisher. It is essential for assistive personnel to receive proper training on fire extinguisher use and to follow established procedures during emergencies.
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