A nurse is caring for a client who is receiving treatment for an acute asthma attack. Following treatment, the nurse auscultates the client's lungs and asks the client how they feel. Which step of the nursing process does this reflect?
Assessment
Intervention
Diagnosis
Evaluation
The Correct Answer is D
Choice A reason:
Assessment involves collecting baseline data about a client’s condition before interventions are implemented. Although auscultation and questioning are assessment techniques, in this scenario they are performed after treatment to determine the effectiveness of care, not to establish initial data.
Choice B reason:
Intervention refers to actions taken to address a nursing diagnosis, such as administering medications or providing treatments. The nurse is not implementing a treatment in this situation but is instead determining the response to a previously performed intervention.
Choice C reason:
Diagnosis involves analyzing assessment data to identify nursing problems. This step occurs before planning and intervention. The nurse’s actions here are not aimed at identifying a problem but at determining whether treatment goals have been met.
Choice D reason:
Evaluation is the step of the nursing process in which the nurse determines the effectiveness of interventions by reassessing the client and comparing outcomes to expected goals. Auscultating lung sounds and asking the client how they feel after asthma treatment directly reflects evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Lactated Ringers is classified as an isotonic intravenous solution. It has an osmolality similar to plasma and is commonly used for fluid resuscitation and replacement of intravascular volume. Because it does not promote movement of water into cells, it is not appropriate when a hypotonic solution is prescribed.
Choice B reason:
Dextrose 5% with Lactated Ringers is a hypertonic solution due to the added dextrose. Hypertonic fluids draw water out of cells and into the intravascular space, which is the opposite of the intended effect when hypotonic fluids are ordered for dehydration at the cellular level.
Choice C reason:
0.9% sodium chloride, also known as normal saline, is an isotonic solution. It expands extracellular and intravascular volume without causing fluid shifts into or out of cells. This does not meet the criteria for a hypotonic solution.
Choice D reason:
0.45% sodium chloride is a hypotonic solution. It has a lower osmolality than plasma and allows water to move from the extracellular space into the intracellular space, helping to hydrate cells. This makes it the appropriate solution to administer when hypotonic IV fluids are prescribed.
Correct Answer is B
Explanation
Choice A reason:
Considering time constraints is irrelevant in an acute, potentially life-threatening situation. Prioritizing efficiency over client safety is unsafe.
Choice B reason:
The client’s symptoms indicate severe hypoglycemia, which is an emergency. The nurse must immediately address acute symptoms (e.g., administer glucose or glucagon) and obtain assistance if needed to stabilize the client. Rapid intervention prevents complications such as seizures, loss of consciousness, or death.
Choice C reason:
Continued assessment without intervention is inappropriate because the client is already showing signs of acute hypoglycemia. Immediate action takes precedence over ongoing observation.
Choice D reason:
Teaching about a diabetic diet is important for long-term management but is not the priority in an acute hypoglycemic episode. Immediate stabilization takes precedence over education.
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.