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

Answer and Explanation

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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Correct Answer is A

Explanation

A) "I will contact the provider to let her know":

This response acknowledges the client's uncertainty about the procedure and indicates the nurse's commitment to address the client's concerns promptly by involving the healthcare provider. Contacting the provider allows for further discussion of the client's decision and consideration of any alternatives or additional information needed to support the client's choice.

B) "You should discuss your concerns with your family":

While involving family members in decision-making can be beneficial, especially for emotional support, the client's decision about the procedure is ultimately theirs to make. Encouraging discussion with family members without addressing the client's immediate concerns may not effectively address the situation.

C) "This procedure is perfectly safe":

Asserting the safety of the procedure without addressing the client's uncertainties or reasons for hesitation may not adequately address the client's concerns. It's essential to acknowledge and explore the client's apprehensions rather than dismissing them outright.

D) "Why are you changing your mind about the procedure?":

This response may come across as confrontational and may put the client on the defensive. It's important to approach the situation with empathy and support, allowing the client to express their concerns openly without feeling judged or pressured.

A. sublingual medication is crushed and administered through a client's gastrostomy tube. B. Finger nail marks appear on a client's wrist after a radial pulse was taken. C. Pain medication is administered 1 hr before a client has a dressing change. D. The same indwelling urinary catheter is reinserted after a failed attempt. E. Medications scheduled four times a day are administered 2 hr after the scheduled time.

Correct Answer is ["A","B","D","E"]

Explanation

A) Sublingual medication is crushed and administered through a client's gastrostomy tube: This scenario represents a violation of the client's right to refuse treatment or medication. Administering medication through a route other than the one prescribed without the client's consent is inappropriate and can result in harm or adverse effects.

B) Finger nail marks appear on a client's wrist after a radial pulse was taken: This scenario indicates a violation of the client's right to be free from abuse. Evidence of physical harm, such as finger nail marks, suggests that the client may have been handled roughly or experienced unnecessary force during the procedure, which is unacceptable.

C) Pain medication is administered 1 hr before a client has a dressing change: While administering pain medication slightly ahead of a painful procedure may be appropriate to provide optimal pain relief, it does not inherently violate the client's rights if it aligns with the client's pain management plan and preferences. Therefore, this scenario does not represent a clear violation of client rights.

D) The same indwelling urinary catheter is reinserted after a failed attempt: Reinserting the same urinary catheter after a failed attempt could represent a violation of the client's right to safe care and freedom from unnecessary discomfort. Repeated attempts at catheter insertion without clinical justification increase the risk of infection and discomfort for the client.

E) Medications scheduled four times a day are administered 2 hr after the scheduled time: Administering medications significantly late violates the client's right to receive care in a timely manner. Delayed medication administration can affect treatment efficacy and compromise the client's well-being, especially for medications with strict dosing schedules.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a group of newly licensed nurses about client rights. Which of the following scenarios should the nurse include as an example of a client rights violation for which a nurse should intervene? (Select all that apply).

Correct Answer is ["A","B","D","E"]

Explanation

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