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
Choice A rationale:
At a flow rate of 4 L/min, oxygen therapy through a nasal cannula can increase the risk of oxygen toxicity, especially if used for prolonged periods. Oxygen toxicity can cause damage to the lungs and other organs.
Choice B rationale:
Carbon dioxide retention is not a common complication at this flow rate. It may occur in patients with severe chronic obstructive pulmonary disease (COPD) at higher oxygen flow rates.
Choice C rationale:
Nasal dryness is a common but relatively minor complication of oxygen therapy via nasal cannula. It can cause discomfort but is not a severe concern.
Choice D rationale:
Fire hazard is not directly related to the use of a nasal cannula but rather to the use of oxygen in the presence of flammable materials or near open flames. It is a concern for all oxygen delivery devices, not specific to nasal cannulas.
Correct Answer is D
Explanation
Choice A rationale:
Nasal cannula delivers low to moderate concentrations of oxygen and may not be effective for a client with thick secretions, dry mucous membranes, or upper airway edema. Additionally, the nasal cannula may not provide sufficient humidification to alleviate these conditions.
Choice B rationale:
The simple face mask is not ideal for a client with thick secretions, dry mucous membranes, or upper airway edema as it may not provide enough humidification and could be uncomfortable for the patient.
Choice C rationale:
A partial rebreather mask also may not be the most appropriate choice for this client as it has a reservoir bag that may not adequately humidify the oxygen, leading to discomfort and potential worsening of dry mucous membranes.
Choice D rationale:
The aerosol mask is the most appropriate choice because it delivers humidified oxygen in the form of small aerosol particles, which can help alleviate thick secretions, moisturize dry mucous membranes, and reduce upper airway edema. This mask is beneficial for patients who require higher humidity levels to maintain airway patency and comfort.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.