A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Collect and organize client data.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Set client-centered, measurable and realistic goals.
The Correct Answer is A
A. Collect and organize client data: The first step in the nursing process involves gathering and organizing data about the clients, which is essential for making informed decisions and planning care.
B. Critically analyze client data to determine priorities: Analysis of data and setting priorities come after the initial collection and organization of client data.
C. Determine effectiveness of interventions: Evaluating the effectiveness of interventions occurs after implementing the care plan and is not the first step in the process.
D. Set client-centered, measurable and realistic goals: Goal-setting follows the collection and analysis of data and is part of the planning phase in the nursing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Shake the inhaler for 3 to 5 seconds: While shaking the inhaler is necessary, the recommendation is typically to shake it for 5 seconds before use, not 3.
B. Wait 2 minutes between inhalations: Waiting 2 minutes between inhalations allows time for the medication to work and reduces the risk of side effects. This is a correct practice for using an MDI.
C. Press down twice on the MDI canister: Generally, pressing down once per dose is the correct action. Pressing down twice might not be necessary unless directed by specific instructions.
D. Rinse the mouth with mouthwash after inhaling the medication: It is recommended to rinse the mouth with water, not mouthwash, to prevent oral thrush, especially after using inhaled corticosteroids.
Correct Answer is C
Explanation
A. The client has not been taking the medication properly: Increased dosage is usually due to the body's adaptation to the medication, not improper use.
B. The client has become addicted to the medication: Addiction is characterized by compulsive use, not necessarily by increased dosage for pain relief.
C. The client developed a tolerance to the medication: Tolerance occurs when the body becomes used to a drug, necessitating higher doses to achieve the same effect, which explains the need for a dosage increase.
D. The client is experiencing episodes of confusion: Confusion is not a typical explanation for needing an increased dose of morphine; it may indicate another issue requiring separate assessment.
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