A nurse is caring for a client who is dyspneic and slightly cyanotic, with a respiratory rate of 28/min. The nurse determines that the client has impaired gas exchange during which of the following phases of the nursing process?
Assessment.
Diagnosis.
Planning.
Evaluation.
The Correct Answer is B
The correct answer is choice B: Diagnosis.
Choice A rationale:
Assessment is the first phase of the nursing process where the nurse collects comprehensive data pertinent to the patient’s health or the situation. In the scenario, the nurse has already gathered data about the client’s respiratory status, indicating that the assessment phase has been completed.
Choice B rationale:
Diagnosis is the phase where the nurse analyzes the assessment data to determine the issues, which in this case is ‘impaired gas exchange.’ This is the phase where the nurse identifies that the client’s symptoms (dyspnea and cyanosis) and elevated respiratory rate are indicative of impaired gas exchange.
Choice C rationale:
Planning is the phase where the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. It follows the diagnosis and involves setting priorities, but in the given scenario, the nurse is still at the stage of identifying the problem rather than planning interventions.
Choice D rationale:
Evaluation is the final phase of the nursing process where the nurse assesses the client’s response to the nursing actions and plan’s effectiveness towards achieving the health care goals. Since the nurse is determining the issue, not evaluating the client’s response to interventions, this phase is not the correct answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Keep the reservoir bag fully inflated at all times.
Choice A rationale:
In a partial rebreather mask, the reservoir bag should be kept fully inflated at all times to ensure the delivery of the highest possible oxygen concentration during inspiration. The bag collects oxygen during expiration, and the one-way valve prevents the exhaled gases from entering the bag. This way, the patient can inhale a mixture of oxygen from the reservoir and fresh oxygen flow.
Choice B rationale:
Breathing through the mouth and exhaling through the nose is not a necessary instruction for a patient using a partial rebreather mask. It doesn't directly impact the effectiveness of oxygen delivery.
Choice C rationale:
Adjusting the elastic strap to fit snugly around the face is not specific to ensuring effective oxygen delivery. It is a general guideline for mask fitting but doesn't directly affect oxygen administration.
Choice D rationale:
Removing the mask every 15 minutes to check the skin is not necessary and can disrupt the delivery of oxygen therapy. It's essential to maintain a consistent oxygen supply to the patient's lungs, and removing the mask frequently can compromise that. Checking the skin can be done periodically without removing the mask completely.
Correct Answer is B
Explanation
Choice A rationale:
Although a tracheostomy collar provides oxygen directly to the trachea, the advantage specified in the question is related to the ability to breathe room air when disconnected from the oxygen source.
Choice B rationale:
This is the correct answer because a tracheostomy collar has an opening that allows the patient to breathe room air when the oxygen source is disconnected. This feature enables the patient to participate in activities without continuous oxygen delivery, promoting mobility and reducing the feeling of being tethered to an oxygen supply.
Choice C rationale:
A tracheostomy collar does not provide the highest fraction of inspired oxygen (FiO2) among low-flow systems. High-flow systems, such as non-rebreather masks or venturi masks, typically provide the highest FiO2.
Choice D rationale:
A tracheostomy collar does not deliver a fixed amount of oxygen independent of the patient's breathing pattern. Instead, it provides supplemental oxygen in response to the patient's inspiratory effort, which is a characteristic of low-flow oxygen delivery systems.
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