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:
Refilling the oxygen tank based on the client's perception of it feeling light and empty is not a reliable method, as it may lead to running out of oxygen unexpectedly.
Choice B rationale:
The nurse should instruct the client to refill the oxygen tank when the pressure gauge reads below 500 psi. This is a standardized method to ensure the client does not run out of oxygen, as the pressure gauge provides an accurate measure of the remaining oxygen in the tank.
Choice C rationale:
Refilling the tank when a hissing sound is heard from the valve is not a valid method for determining the need for a refill and may result in running out of oxygen.
Choice D rationale:
Waiting for an alarm sound from the regulator to refill the tank is not recommended, as the tank could run out of oxygen before the alarm activates.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
The nurse should instruct the patient to avoid smoking or being near open flames while using oxygen. Oxygen supports combustion, and smoking or exposure to flames can lead to a fire hazard.
Choice C rationale:
Checking the position of the oxygen delivery device frequently is important to ensure proper oxygen delivery and avoid any displacement or obstruction that may compromise the therapy's effectiveness.
Choice D rationale:
Instructing the patient to report any signs of hypoxia (low oxygen levels) or hypercarbia (high carbon dioxide levels) to the provider is crucial for early detection of potential complications and appropriate management.
Choice E rationale:
Instructing the patient to adjust the flow rate of oxygen as needed allows them to respond to varying oxygen requirements, especially during activities or changes in their respiratory condition.
Choice B rationale:
Using cotton or wool clothing and bedding is not a recommended instruction for oxygen therapy. Synthetic materials are preferred as they are less likely to catch fire compared to cotton or wool.
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