Prior to administration of an antihypertensive medication, the nurse notes the client's heart rate is 50. The nurse then determines the blood pressure medication should be held. Which part of the nursing process is being fulfilled?

Assessment

Analysis

Planning

Evaluation

Answer and Explanation

The Correct Answer is A

A. Assessment: Assessment involves collecting data about the client's condition. Noting the heart rate before administering medication is part of the assessment.
B. Analysis: Analysis involves interpreting the collected data to make decisions about the client's care. While the nurse is analyzing the data (the heart rate), this step follows the initial assessment.
C. Planning: Planning involves setting goals and deciding on interventions based on the assessment and analysis. Holding the medication could be considered part of planning but comes after assessing the heart rate.
D. Evaluation: Evaluation involves determining the effectiveness of interventions. This is not applicable in this situation.

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Correct Answer is B

Explanation

A. Assess the client's pain level: Assessing the client's pain level is part of the assessment step, not the evaluation step.
B. Ask the client to demonstrate use of the incentive spirometer: Asking the client to demonstrate use of the incentive spirometer is a way to evaluate whether the client has understood and can perform the skill.
C. Develop a short-term goal for the client: Developing a short-term goal is part of the planning step, not the evaluation step.
D. Provide instructions on how to use the incentive spirometer: Providing instructions is part of the implementation step, not the evaluation step.

A. Disease prevention B. Tertiary C. Primary D. Secondary

Correct Answer is C

Explanation

A. Disease prevention: This is a general term and not specific to levels of prevention.
B. Tertiary: Tertiary prevention involves managing and reducing complications of established diseases.
C. Primary: Primary prevention involves actions taken to prevent the onset of disease, such as vaccinations.
D. Secondary: Secondary prevention involves early detection and treatment of diseases.

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Prior to administration of an antihypertensive medication, the nurse notes the client's heart rate is 50. The nurse then determines the blood pressure medication should be held. Which part of the nursing process is being fulfilled?

Nursing Test Bank

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