After administration of an antihypertensive medication, the nurse notes the client’s blood pressure decreases by 10 points. Which part of the nursing process is being fulfilled?
Planning.
Assessment.
Evaluation.
Analysis.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Documenting the application of the medication is important for maintaining accurate medical records, but it is not the priority action when a patient is receiving a new medication.
Choice B rationale
Informing the patient about potential side effects is the correct answer. This action ensures that the patient is aware of what to expect and can report any adverse reactions promptly, which is crucial for their safety.
Choice C rationale
Checking the patient’s vital signs frequently is important, but it is not the priority action when a patient is receiving a new medication. The priority is to inform the patient about potential side effects.
Choice D rationale
Leaving the patient alone to rest is not appropriate when a patient is receiving a new medication. The nurse should monitor the patient and inform them about potential side effects.
Correct Answer is A
Explanation
Choice A rationale
Report the incident to the organization. According to HIPAA, the first step a healthcare provider should take after an accidental disclosure of patient information is to report the incident to the organization. This allows the organization to assess the breach, determine the extent of the disclosure, and take appropriate actions to mitigate any potential harm.
Choice B rationale
Inform the patient about the breach. While informing the patient is important, it is not the first step. The organization must first assess the breach and determine the appropriate course of action before notifying the patient.
Choice C rationale
Ask the unauthorized personnel to delete the information. This step may be part of the mitigation process, but it is not the first step. The incident must first be reported to the organization for proper assessment and documentation.
Choice D rationale
Ignore the incident unless someone reports it. This response is inappropriate and violates HIPAA regulations. All breaches must be reported and addressed promptly to ensure compliance with HIPAA and protect patient privacy.
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