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?

Comparing the client's current laboratory values to previous results.

Establishing the priorities of client care.

Asking the client about the presence of pain.

Reinforcing teaching about the client's diagnosis.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Comparing current laboratory values to previous results is an activity in the evaluation phase, focusing on outcome analysis and progress tracking. It is not part of the implementation phase, which involves putting planned actions into effect.

Choice B rationale

Establishing priorities occurs in the planning phase, where the nurse determines the order and urgency of interventions. It does not fall under implementation, which includes executing the established care plan.

Choice C rationale

Asking the client about pain pertains to the assessment phase, which involves gathering subjective and objective data to inform care decisions. Implementation focuses on carrying out interventions rather than data collection.

Choice D rationale

Reinforcing teaching about the client’s diagnosis is a clear action within the implementation phase, which is centered on executing the care plan. Teaching supports client understanding and self-management, directly aligning with this phase’s goals.

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Correct Answer is C

Explanation

Choice A rationale

Reporting pain as 8 on a scale of 0 to 10 indicates significant discomfort and may require analgesic adjustments. However, pain alone, without accompanying complications, does not constitute the highest priority in postoperative care.

Choice B rationale

Urinary output of 30 mL over 1 hour is below the normal adult range of 30–50 mL/hour, potentially indicating hypovolemia or renal issues. However, it does not outweigh circulatory concerns like leg mottling as the most immediate threat.

Choice C rationale

Mottling in the affected leg suggests compromised circulation, possibly due to a blood clot or arterial occlusion, which can lead to tissue ischemia. Immediate intervention is necessary to prevent irreversible damage or complications like necrosis.

Choice D rationale

Postoperative emesis can lead to dehydration and electrolyte imbalances if persistent. However, it does not pose the same urgent threat as vascular compromise seen in mottling of the affected leg.

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it. B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill. C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster. D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture.

Correct Answer is C

Explanation

Choice A rationale

Refrigerating a midstream urine sample aligns with proper storage protocols, as it prevents degradation and ensures accurate results. This action adheres to infection control standards, minimizing contamination risks during specimen processing.

Choice B rationale

Cleaning with chlorhexidine following a blood spill adheres to effective infection control practices. Chlorhexidine is a potent antiseptic that eliminates pathogens and reduces infection risks, particularly after exposure to bloodborne microorganisms.

Choice C rationale

Alcohol-based antiseptic is ineffective against varicella zoster, which requires soap and water or antimicrobial agents to ensure decontamination. Misuse of antiseptics in this scenario poses an infection hazard as the nurse may inadvertently facilitate pathogen transmission.

Choice D rationale

Using sterile 0.9% sodium chloride irrigation solution is a standard wound-cleaning procedure, promoting sterility and minimizing infection risks. This practice aligns with aseptic techniques critical in specimen collection and wound care management. .

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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?

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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?