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 B
Explanation
Choice A rationale:
The patient's PaO2 is 65 mmHg and SaO2 is 88%. PaO2 values below 80 mmHg and SaO2 below 90% are considered below normal ranges. Therefore, the patient's oxygen levels are not within the normal range for the condition.
Choice B rationale:
This is the correct choice. The patient's PaO2 and SaO2 levels indicate that they are not receiving enough oxygen, and additional oxygen therapy is needed.
Choice C rationale:
The patient's oxygen levels are low, not high. Providing less oxygen would worsen the situation.
Choice D rationale:
The patient's oxygen levels are affected by oxygen therapy, as they indicate that the current therapy is insufficient. Additional interventions are needed to improve oxygenation.
Correct Answer is C
Explanation
Choice A rationale:
Switching to a simple face mask is not the appropriate intervention for nasal dryness and irritation. A simple face mask covers the nose and mouth, and it may not provide enough relief for nasal dryness as the oxygen flow is still directed towards the nose.
Choice B rationale:
Increasing the flow rate of oxygen will not directly improve humidity. Nasal dryness and irritation are often caused by the lack of moisture in the delivered oxygen. Increasing the flow rate may worsen the issue.
Choice C rationale:
Assessing the patient's nares for patency and skin integrity is the appropriate intervention. Nasal dryness and irritation can be caused by inadequate humidification of the oxygen. Checking the patency of the nares and the condition of the skin can help identify any issues that may be contributing to the discomfort.
Choice D rationale:
Reassuring the patient that nasal dryness is a normal side effect is not sufficient. While nasal dryness can be a common side effect of using a nasal cannula, it is essential to address the issue and provide appropriate interventions to alleviate the discomfort and prevent complications.
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