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 D
Explanation
Choice A rationale:
Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.
Choice B rationale:
Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.
Choice C rationale:
Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.
Choice D rationale:
This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.
Correct Answer is ["A","B","E"]
Explanation
The correct answer is choice a, b, and e.
Choice A rationale:
A non-rebreather mask is designed to deliver a high concentration of oxygen, often deemed the highest among low-flow systems. It achieves this through a reservoir bag that is filled with pure oxygen, which the patient breathes in without the dilution of room air.
Choice B rationale:
This mask has one-way valves that prevent the patient from rebreathing exhaled carbon dioxide. The exhaled air exits through side ports, ensuring that only oxygen from the reservoir is inhaled.
Choice C rationale:
While a non-rebreather mask delivers a high concentration of oxygen, it does not provide a consistent and precise oxygen delivery compared to devices like a Venturi mask, which are designed to deliver a specific and constant oxygen concentration.
Choice D rationale:
The design of a non-rebreather mask does not allow room air to enter through the exhalation ports. The one-way valves are there to ensure that exhaled air does not enter the reservoir bag and that room air does not mix with the oxygen being inhaled.
Choice E rationale:
By delivering a high concentration of oxygen and preventing the rebreathing of exhaled gases, a non-rebreather mask minimizes the risk of carbon dioxide retention, which can be a concern with other oxygen delivery systems that allow for the rebreathing of a portion of exhaled air.
In summary, the non-rebreather mask is advantageous for its ability to deliver a high concentration of oxygen and prevent the rebreathing of exhaled air, which also minimizes the risk of carbon dioxide retention. It is not designed for precise oxygen delivery, nor does it allow the mixing of room air during inhalation.
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