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. The client states that she will be staying with her daughter after discharge: Staying with her daughter could potentially be a support system, not a barrier to learning.
B. Client states she is having pain: Pain can significantly impair a client's ability to focus and understand new information, making it a potential barrier to learning.
C. The client states she uses a pill container to divide her daily medication: Using a pill container indicates that the client has a system in place for managing medications and is not a barrier to learning.
D. The client states her pharmacy also provides information on the medication: Having access to additional information from the pharmacy is an aid to learning, not a barrier.

A. Give the client his blood pressure medication B. Measure the vital signs C. Report any unusual lung sounds. D. Teach the patient about a heart healthy diet.

Correct Answer is B

Explanation

A. Give the client his blood pressure medication: Administering medications is outside the scope of practice for UAPs and should be done by licensed nursing staff.
B. Measure the vital signs: Measuring vital signs is within the scope of practice for UAPs and can be safely assigned to them.
C. Report any unusual lung sounds: Assessing and interpreting lung sounds require the skills and training of a licensed nurse.
D. Teach the patient about a heart-healthy diet: Teaching requires assessment and evaluation, which are within the RN’s scope of practice, not the UAP’s.

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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?

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