The nurse is assigned to care for a newly admitted patient. Place the steps for using the nursing process in the correct order, starting with the first step.
Collect patient information.
Identify any clinical problems.
Decide a plan of action.
Carry out the plan.
Determine whether the plan was effective.
Correct Answer : A,B,C,D,E
Choice A: Collect patient information
The first step in the nursing process is to collect patient information, also known as the assessment phase. During this phase, the nurse gathers comprehensive data about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s needs and planning appropriate care.
Choice B: Identify any clinical problems
After collecting patient information, the next step is to identify any clinical problems, also known as the diagnosis phase. In this phase, the nurse analyzes the assessment data to determine the patient’s health issues or potential risks. This step involves critical thinking and clinical judgment to prioritize the patient’s problems and develop a nursing diagnosis.
Choice C: Decide a plan of action
The third step is to decide a plan of action, also known as the planning phase. During this phase, the nurse sets measurable and achievable goals for the patient’s care based on the identified clinical problems. The nurse also develops specific interventions to address these problems and achieve the desired outcomes. This plan serves as a guide for the subsequent implementation phase.
Choice D: Carry out the plan
The fourth step is to carry out the plan, also known as the implementation phase. In this phase, the nurse executes the planned interventions to address the patient’s clinical problems. This may involve administering medications, providing treatments, educating the patient and family, and coordinating care with other healthcare professionals. The nurse continuously monitors the patient’s response to the interventions and makes adjustments as needed.
Choice E: Determine whether the plan was effective
The final step is to determine whether the plan was effective, also known as the evaluation phase. During this phase, the nurse assesses the patient’s progress toward the established goals and evaluates the effectiveness of the interventions. If the desired outcomes are not achieved, the nurse may need to revise the plan and implement new strategies. This ongoing evaluation ensures that the patient’s care is continuously improved and optimized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A: RN’s workload
While the RN’s workload can influence the decision to delegate tasks, it is not the primary factor. The RN must ensure that the tasks delegated are within the LPN/VN’s scope of practice and that patient safety is not compromised. The workload of the RN is a consideration but not a determining factor.
Choice B: Skill and experience of the LPN/VN
This is a correct answer. The skill and experience of the LPN/VN are crucial in determining what tasks can be safely delegated. An LPN/VN with more experience and higher skill levels can handle more complex tasks. The RN must assess the competency of the LPN/VN to ensure that they can perform the delegated tasks safely and effectively.
Choice C: Agency policies
Agency policies are important as they provide guidelines on what tasks can be delegated and to whom. However, they are not the sole factor in the decision-making process. The RN must also consider the specific circumstances of the patient and the competencies of the LPN/VN.
Choice D: Stability of the patients
This is another correct answer. The stability of the patients is a critical factor in delegation decisions. Stable patients with predictable outcomes are more suitable for care by an LPN/VN. Unstable patients or those with complex needs require the higher level of assessment and intervention that an RN provides.
Choice E: LPN/VN teaching abilities
While teaching abilities are important, they are not the primary consideration for delegation. The focus is on the LPN/VN’s ability to perform the delegated tasks safely and effectively. Teaching abilities may come into play in specific situations but are not a determining factor in most delegation decisions.
Correct Answer is A
Explanation
Choice A: Infuse the KCl at a maximum rate of 10 mEq/hr
This is the correct answer. The recommended infusion rate for potassium chloride is generally not to exceed 10 mEq per hour to avoid complications such as hyperkalemia and cardiac arrhythmias. This rate ensures that the potassium is administered safely and effectively, allowing for proper monitoring and adjustment if necessary.
Choice B: Discontinue cardiac monitoring during the infusion
This choice is incorrect. Cardiac monitoring is essential during the infusion of potassium chloride, especially in patients with severe hypokalemia, due to the risk of arrhythmias and other cardiac complications. Continuous monitoring allows for the early detection of any adverse effects and timely intervention.
Choice C: Administer the KCl as a rapid IV bolus
Administering potassium chloride as a rapid IV bolus is dangerous and contraindicated. Rapid infusion can lead to severe hyperkalemia, which can cause fatal cardiac arrhythmias. Potassium chloride should always be administered slowly and diluted in an appropriate volume of fluid.
Choice D: Refuse to give the KCl through a peripheral venous line
While central lines are preferred for higher concentrations of potassium chloride due to the risk of irritation and phlebitis, peripheral lines can be used for lower concentrations and slower infusion rates. Refusing to administer potassium chloride through a peripheral line is not necessary if the infusion is properly managed and monitored.
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