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 True
Explanation
Choice A: True
The statement that a patient with alkalosis can develop hyperkalemia is generally incorrect. Alkalosis, which is a condition characterized by a higher-than-normal pH in the blood, typically leads to hypokalemia rather than hyperkalemia. This occurs because alkalosis causes potassium to shift from the extracellular fluid into the cells, reducing the plasma potassium concentration. Therefore, it is uncommon for alkalosis to result in hyperkalemia.
Choice B: False
The correct answer is that a patient with alkalosis is unlikely to develop hyperkalemia. Alkalosis usually causes a decrease in plasma potassium levels, leading to hypokalemia. This is due to the movement of potassium ions into the cells in exchange for hydrogen ions, which are moved out of the cells to help buffer the increased pH. Consequently, the plasma potassium concentration drops, making hyperkalemia an unlikely outcome in the presence of alkalosis.
Correct Answer is ["A","C","E"]
Explanation
Choice A: Monitor for signs and symptoms of infection
Monitoring for signs and symptoms of infection is a fundamental strategy in infection prevention. Early detection of infections allows for timely intervention, which can prevent the spread of pathogens and reduce the severity of the infection. Common signs and symptoms include fever, redness, swelling, pain, and discharge. Regular monitoring helps healthcare providers identify infections early and take appropriate actions, such as isolating the patient or starting treatment.
Choice B: Provide all patients with bottled water
Providing all patients with bottled water is not a standard infection prevention strategy. While ensuring access to clean drinking water is important, it is not specifically aimed at preventing infections. In healthcare settings, tap water is usually safe to drink if it meets regulatory standards. Bottled water may be provided in certain situations, such as during an outbreak of waterborne pathogens, but it is not a routine infection prevention measure.
Choice C: Provide education on infection prevention
Providing education on infection prevention is crucial for both healthcare providers and patients. Education helps individuals understand how infections spread and what measures they can take to prevent them. This includes proper hand hygiene, respiratory etiquette, and the importance of vaccinations. Educating patients and staff can significantly reduce the incidence of healthcare-associated infections by promoting adherence to infection control practices.
Choice D: Request an antibiotic order for a febrile patient
Requesting an antibiotic order for a febrile patient is not an infection prevention strategy but rather a treatment approach. Antibiotics are used to treat bacterial infections, not to prevent them. Overuse of antibiotics can lead to antibiotic resistance, making it crucial to use them judiciously and only when necessary. Infection prevention focuses on measures to prevent the occurrence of infections rather than treating them once they occur.
Choice E: Create a clean, safe environment
Creating a clean, safe environment is essential for infection prevention in healthcare settings. This involves regular cleaning and disinfection of surfaces, proper waste disposal, and maintaining hygiene standards. A clean environment reduces the risk of healthcare-associated infections by minimizing the presence of pathogens. Effective cleaning protocols and environmental controls are critical components of infection prevention strategies.
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