Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using?

Assessing

Planning

Implementing

Evaluating

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing involves collecting data, like vital signs or skin condition, to identify patient needs. Turning a client every 2 hours follows an established plan to prevent pressure ulcers, not data collection. Assessment informs care plans, but turning is an action, not an evaluation of physiological status, making this incorrect.

Choice B reason: Planning involves setting goals and interventions, like scheduling turns to prevent pressure ulcers. Turning a client every 2 hours is executing that plan, not creating it. Planning addresses skin integrity and tissue perfusion needs, but the act of turning is the implementation phase, making this an incorrect choice.

Choice C reason: Implementing is the execution of the care plan, such as turning a client every 2 hours to prevent pressure ulcers. This action maintains skin integrity by reducing pressure on tissues, promoting blood flow and oxygenation. It follows the plan’s directives, aligning with the nursing process’s action phase, making this the correct choice.

Choice D reason: Evaluating assesses the effectiveness of interventions, like checking skin integrity after turning. Turning a client every 2 hours is the intervention itself, not its evaluation. Evaluation measures outcomes, like reduced pressure ulcer risk, but the act of turning is implementation, addressing tissue perfusion, making this incorrect.

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Correct Answer is D

Explanation

Choice A reason: Hemoglobin of 11.3 g/dL is low but not specific to malnutrition, as it may indicate anemia from various causes, like iron deficiency or chronic disease. Malnutrition affects protein levels more directly. This value requires further investigation but does not confirm malnutrition, as it reflects red blood cell status, per hematological assessment.

Choice B reason: Creatinine of 1.9 mg/dL suggests renal impairment, as it exceeds normal ranges (0.6-1.2 mg/dL), reflecting reduced kidney filtration. Malnutrition typically lowers creatinine due to muscle wasting, not elevates it. This value indicates kidney dysfunction, not nutritional status, making it irrelevant to malnutrition assessment, per renal physiology.

Choice C reason: Hematocrit of 56% indicates hemoconcentration, often from dehydration, not malnutrition. Malnutrition may cause anemia, lowering hematocrit. Elevated hematocrit reflects increased red blood cell proportion, unrelated to protein-energy deficits. This finding does not align with malnutrition’s impact on nutritional biomarkers, per laboratory diagnostic standards.

Choice D reason: Serum albumin of 2.8 g/dL (normal 3.5-5.0 g/dL) indicates malnutrition, as low levels reflect reduced protein synthesis due to inadequate dietary intake. Albumin is a sensitive marker of chronic nutritional status, decreasing in protein-energy malnutrition. This finding directly correlates with malnutrition’s physiological impact, per nutritional assessment guidelines.

A. Having chest pain B. Pulse rate of 108 C. History of angina D. Oxygen is needed.

Correct Answer is C

Explanation

Choice A reason: In SBAR (Situation, Background, Assessment, Recommendation), chest pain is part of the Situation (S), describing the current issue. Background (B) includes relevant medical history, like angina, which causes chest pain due to myocardial ischemia from reduced coronary blood flow. Chest pain is the presenting symptom, not historical context, making it incorrect for B.

Choice B reason: Pulse rate of 108 is part of the Assessment (A) in SBAR, reflecting current vital signs. Background (B) provides historical context, such as the patient’s angina diagnosis, which predisposes to myocardial ischemia. Tachycardia may result from pain or hypoxia but is a current finding, not historical data, making it incorrect for B.

Choice C reason: History of angina is the Background (B) in SBAR, providing relevant medical history. Angina, caused by coronary artery narrowing, reduces myocardial oxygen supply, leading to chest pain. This context informs the current episode of pain and tachycardia, guiding assessment and treatment, making it the correct data for the Background component.

Choice D reason: Oxygen is needed is part of the Recommendation (R) in SBAR, suggesting an intervention. Background (B) includes past medical history, like angina, which explains the patient’s predisposition to chest pain. Recommending oxygen addresses current hypoxia but is not historical data, making it inappropriate for the Background section of SBAR.

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Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which laboratory result indicates the presence of malnutrition?

Correct Answer is D

Explanation

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B?

Correct Answer is C

Explanation

The nurse is assessing a client with dark skin for the presence of a Stage I pressure ulcer. Which is the best approach to making this assessment?

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