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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. When administering subcutaneous heparin, aspiration should be avoided because it can cause tissue damage and increase the risk of hematoma formation. This statement correctly reflects safe administration technique.
B. Firm pressure on the injection site is not recommended after heparin administration because it can increase the risk of bruising and bleeding. Instead, gentle pressure should be applied if necessary.
C. Subcutaneous injections should be given at a 45- to 90-degree angle, depending on the patient’s body mass. A 10-degree angle is too shallow and may result in improper medication delivery.
D. The subcutaneous route does not provide faster absorption than other routes such as intravenous or intramuscular. Instead, it allows for slow, steady absorption, which is desirable for anticoagulants like heparin.
Correct Answer is D
Explanation
a) "Signature" and "hospital" are not part of the six rights of medication administration. The correct rights ensure patient safety by verifying essential aspects of drug administration.
b) "Solution," "doctor," and "shift" are not part of the six rights. The focus should be on ensuring the correct patient receives the right medication in the right manner.
c) "Order" and "signature" are important for verifying prescriptions, but they are not included in the six rights of administration.
d) The six rights of medication administration are right medication, right dosage, right route, right time, right client (patient), and right documentation. These ensure medication safety and prevent errors.
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