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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Administering eye drops to the lower conjunctival sac ensures optimal drug absorption and minimizes corneal irritation. The conjunctival sac, a mucous membrane, allows medication to spread across the eye surface, treating conjunctivitis by targeting bacterial or inflammatory processes. This method avoids systemic absorption via the nasolacrimal duct, enhancing local efficacy and safety.

Choice B reason: Dropping medication onto the cornea risks irritation or injury, as the cornea is a sensitive, avascular tissue responsible for light refraction. Conjunctivitis treatment requires medication to contact the conjunctiva, not the cornea directly. This method could cause discomfort and reduce drug efficacy, as it does not target the inflamed conjunctival tissue.

Choice C reason: The sclera by the outer canthus is not ideal for eye drop administration. The sclera, a tough connective tissue, has poor drug absorption compared to the conjunctival sac. Drops placed here may run off, reducing contact with the inflamed conjunctiva in conjunctivitis, leading to ineffective treatment and potential waste of medication.

Choice D reason: The sclera by the inner canthus is near the nasolacrimal duct, increasing the risk of systemic drug absorption rather than local treatment of conjunctivitis. Drops should target the lower conjunctival sac to ensure contact with the inflamed tissue, maximizing therapeutic effect while minimizing systemic side effects like tachycardia from certain medications.

A. Onion powder B. Saturated fats C. Pepper D. Polyunsaturated fats

Correct Answer is B

Explanation

Choice A reason: Onion powder is a spice, not a fat, and contains negligible lipids or calories. It does not influence cholesterol metabolism, blood pressure, or insulin sensitivity, which are critical in managing hyperlipidemia, hypertension, and Type I diabetes. These conditions increase atherosclerosis risk via elevated LDL cholesterol, but onion powder has no role in lipid metabolism or cardiovascular health, making it irrelevant.

Choice B reason: Saturated fats, found in animal products and some plant oils, increase LDL cholesterol by enhancing hepatic production of very-low-density lipoprotein (VLDL). In patients with hypertension and Type I diabetes, this exacerbates atherosclerosis, raising cardiovascular risk. Limiting saturated fats reduces LDL levels, improves endothelial function, and supports glycemic control, aligning with dietary guidelines for these chronic conditions.

Choice C reason: Pepper is a spice with no significant fat content or impact on lipid metabolism. It does not contribute to cholesterol levels, blood pressure, or insulin resistance, which are concerns in hyperlipidemia, hypertension, and Type I diabetes. These conditions require limiting fats that elevate LDL, but pepper has no effect on lipid profiles or cardiovascular risk factors.

Choice D reason: Polyunsaturated fats, like omega-3 and omega-6 fatty acids, lower LDL cholesterol and reduce inflammation, benefiting cardiovascular health. In patients with hypertension and diabetes, these fats improve lipid profiles and endothelial function, reducing atherosclerosis risk. The dietician would encourage, not limit, polyunsaturated fats to support heart health and insulin sensitivity in managing these conditions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is to administer eye drops four times per day to a patient diagnosed with conjunctivitis. The nurse should administer the medication by gently dropping the medication onto which of the following areas?

Correct Answer is A

Explanation

A nurse is caring for a patient with increased cholesterol, hypertension, and Type I Diabetes Mellitus. The dietician comes in with the nurse to discuss an appropriate diet with the patient. Which fats will the dietician most likely encourage the patient to limit?

Correct Answer is B

Explanation

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which statement is characteristic of the bargaining stage?

A registered nurse assigns the task of tracheostomy suctioning of a client to the Licensed Practical Nurse (LPN). The LPN informs the nurse that the LPN has never performed this procedure on a client. Which of the following is the most appropriate response from the registered nurse?

The patient complains of abdominal pain. Before palpating the abdomen, which action should the nurse perform?

The nurse is providing preoperative teaching to a patient to have an operation on their colon for cancer. The nurse should take which of the following actions regarding informed consent?

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate?

The nurse is teaching a COPD patient how to perform pursed lip breathing. Which statement below is correct about pursed lip breathing?

A nurse is teaching a client at risk for melanoma about what to look out for when checking the skin. The nurse determines that the teaching was successful based on which client statement(s)? (Select all that apply)