A patient who is hospitalized for chronic obstructive pulmonary disease wants to go home. The nurse and the patient discuss the patient’s situation and decide that the patient may go home when able to perform self-care without dyspnea and hypoxia. This is an example of which phase of the nursing process?
Assessment
Evaluation
Implementation
Planning
The Correct Answer is D
A. Assessment involves gathering data about the patient’s condition, but in this case, the nurse and patient are making a decision about discharge criteria, which falls under planning.
B. Evaluation occurs after interventions have been implemented to determine whether goals have been met. Since the patient has not yet attempted self-care, this phase has not been reached.
C. Implementation refers to carrying out nursing interventions, such as administering medications or assisting with breathing exercises. The discussion about discharge criteria is a planning activity rather than an intervention.
D. Planning involves setting goals and determining the criteria for discharge, which is what the nurse and patient are doing by establishing that the patient may go home when self-care can be performed without dyspnea or hypoxia.
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Related Questions
Correct Answer is D
Explanation
a) While knowing if the patient takes generic medications is useful, it is not the priority. Generic and brand-name drugs generally have the same active ingredients and effects.
b) Orphan drugs are used to treat rare diseases, but this is not a primary concern for most patients and does not directly impact medication safety in routine assessments.
c) Asking about medication safety during pregnancy is important if the patient is pregnant or could become pregnant, but it is not the primary concern for all patients.
d) Over-the-counter (OTC) medications can interact with prescribed medications, potentially leading to adverse effects or reduced efficacy. It is crucial to assess OTC use to ensure there are no dangerous drug interactions.
Correct Answer is B
Explanation
A. Washing hands before handling medications is essential for infection control but is not the priority action in this scenario. Ensuring drug compatibility is crucial to prevent adverse interactions.
B. When administering two drugs simultaneously, the nurse’s priority is to determine if they are compatible, particularly for IV medications. Some medications can precipitate or cause harmful interactions when mixed, leading to reduced efficacy or adverse effects. Consulting a drug guide ensures safe administration.
C. Checking for drug allergies is important before giving any medication, but it is not the priority in this specific situation. Compatibility must be assessed first to ensure the drugs can be given together safely.
D. Identifying the patient is always necessary for safe medication administration, but in this case, ensuring drug compatibility is the first step before proceeding with administration. If the drugs are incompatible, the nurse must take alternative actions before giving them to the patient.
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