A nurse is changing a wound dressing for a post-op client. Which of the following steps is the nurse performing?

Choice A rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data and identified nursing diagnoses. It involves setting goals and determining the appropriate interventions to achieve those goals. In this scenario, the nurse is not developing a plan but rather observing the effects of an intervention that has already been implemented.
Choice B rationale
Assessment is the initial phase of the nursing process where the nurse collects and analyzes data about the client’s health status. This includes gathering information through observation, interviews, physical examinations, and diagnostic tests. In this scenario, the nurse is not collecting new data but rather observing the outcome of a previously administered medication.
Choice C rationale
Evaluation is the phase of the nursing process where the nurse assesses the client’s response to the interventions and determines whether the goals of care have been met. In this scenario, the nurse is evaluating the effectiveness of the antihypertensive medication by noting the decrease in the client’s blood pressure. This assessment helps determine if the medication is achieving the desired therapeutic effect.
Choice D rationale
Analysis is the phase of the nursing process where the nurse interprets the assessment data to identify the client’s health problems and needs. It involves critical thinking and clinical judgment to determine the underlying causes of the client’s condition. In this scenario, the nurse is not analyzing data but rather evaluating the outcome of an intervention.

Choice A rationale
Following the order as prescribed without clarification can lead to errors if the order is unclear or incomplete.
Choice B rationale
Administering the medication at a later time without clarification can also lead to errors and may delay necessary treatment.
Choice C rationale
Disregarding the order and seeking approval from another physician is not appropriate. The nurse should seek clarification from the ordering physician.
Choice D rationale
Asking the physician to clarify the dosage and route ensures that the order is accurate and complete, reducing the risk of medication errors.