The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

Assessment

Diagnosis

Implementation

Planning

Answer and Explanation

The Correct Answer is D

A. Assessment has already been completed as the initial step, involving data collection.
B. Diagnosis is also completed, involving analysis and identification of the patient’s health problems.
C. Implementation occurs after planning, when nursing interventions are executed.
D. Planning is the appropriate next step, involving the creation of specific, measurable goals and interventions based on the identified nursing diagnoses.

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Correct Answer is C

Explanation

A. Continuing with the injection after seeing blood return increases the risk of injecting into a blood vessel, which is not safe for IM injections.
B. Administering at a slower rate does not address the issue of possible intravascular injection.
C. If blood is aspirated, the correct procedure is to withdraw the needle, dispose of the medication, and prepare a new dose to prevent intravascular administration, as IM injections are meant to be given into muscle tissue, not into a vein.
D. Pulling the needle back slightly is not recommended because it does not ensure that the needle is completely out of the blood vessel.

A. Vision B. Heart tones C. Bowel sounds D. Hearing

Correct Answer is D

Explanation

A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.

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The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is giving an intramuscular (IM) injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do?

Correct Answer is C

Explanation

A patient is receiving vancomycin. Which physiological function is the priority for the nurse to assess?

Correct Answer is D

Explanation

In caring for the patient's spiritual needs, the nurse asks 20 questions to assess the patient's relationship with God and a sense of life purpose and satisfaction. Which method is the nurse using?

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