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 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.
Correct Answer is C
Explanation
Choice A: 3% Saline
3% Saline is a hypertonic solution, meaning it has a higher concentration of solutes compared to the blood plasma. It is typically used in critical care settings for specific conditions such as severe hyponatremia or cerebral edema. Administering 3% Saline to a patient with a fluid deficit who requires isotonic fluid replacement would not be appropriate because it could lead to cellular dehydration and other complications due to its high osmolarity.
Choice B: Saline 0.45%
Saline 0.45%, also known as half-normal saline, is a hypotonic solution. It has a lower concentration of solutes compared to blood plasma and is used to treat patients with hypernatremia or those who need to be rehydrated without adding too much sodium. However, it is not suitable for isotonic fluid replacement because it can cause cells to swell and potentially burst due to the influx of water into the cells.
Choice C: Saline 0.9%
Saline 0.9%, also known as normal saline, is an isotonic solution. It has the same concentration of solutes as blood plasma, making it ideal for fluid replacement in patients with a fluid deficit. Normal saline is commonly used to expand the extracellular fluid volume without causing significant shifts in fluid between compartments. This makes it the appropriate choice for isotonic fluid replacement.
Choice D: Dextrose 10%
Dextrose 10% is a hypertonic solution used primarily for providing calories in patients who need parenteral nutrition or for treating severe hypoglycemia. It is not suitable for isotonic fluid replacement because its high glucose content can lead to osmotic diuresis and fluid shifts that are not desirable in patients needing isotonic fluids.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today