The nurse is monitoring the patient's progress on a new medication regimen.
Which phase of the nursing process does this demonstrate?
Evaluation.
Planning.
Assessment.
Implementation.
The Correct Answer is A
This question tests the application of the nursing process phases. It requires identifying the specific stage where the nurse compares the patient's current status and clinical outcomes against the established goals to determine the success of the implemented interventions and the need for plan modifications.
Choice A rationale
The evaluation phase involves comparing the patient’s health status with the goals and outcomes defined in the care plan. Monitoring progress after a new medication regimen is a classic example of evaluating the effectiveness of a planned clinical intervention.
Choice B rationale
The planning phase involves setting measurable goals, outcomes, and nursing interventions based on the assessment data. While the nurse plans for the future, the action of monitoring ongoing progress is an evaluative step, not the creation of the initial care plan.
Choice C rationale
The assessment phase is the collection of patient data, including health history, physical examination, and diagnostic results. Monitoring progress happens after interventions have been initiated, whereas assessment occurs before and during the continuous data collection process to identify patient needs.
Choice D rationale
The implementation phase is the actual execution of nursing interventions and actions. While the nurse performs the monitoring, the cognitive process of determining how well the medication is working by comparing patient status to outcomes is defined as the evaluation phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This question tests understanding of the therapeutic use of lactulose in cirrhosis. It requires applying the scientific principle of ammonia clearance, as the diseased liver cannot convert toxic ammonia into urea, necessitating the use of an osmotic laxative to remove ammonia from the gut.
Choice A rationale
In cirrhosis, the liver fails to convert ammonia to urea, causing high serum levels. Lactulose acidifies the gut lumen, converting ammonia to ammonium, which is trapped and excreted in the stool, effectively lowering systemic ammonia levels and preventing hepatic encephalopathy.
Choice B rationale
Lactulose does not affect potassium levels. Potassium, with a normal range of 3.5 to 5.0 mEq/L, is typically monitored in cirrhotic patients due to diuretic use, but lactulose has no direct pharmacological mechanism that would either increase or decrease serum potassium.
Choice C rationale
Lactulose is a synthetic disaccharide and does not cause significant shifts in blood glucose. While it contains sugar, it is not absorbed into the bloodstream, meaning it does not have a systemic effect on glucose levels in patients with cirrhosis.
Choice D rationale
Bicarbonate, with a normal range of 22 to 28 mEq/L, is a base that maintains systemic pH. Lactulose does not interact with the renal or respiratory systems to regulate bicarbonate or modify the blood buffering capacity in the body of the patient.
Correct Answer is D
Explanation
This question requires knowledge of the pharmacokinetic onset of rapid-acting insulin analogs. Understanding this timeframe is essential for timing the administration of the insulin with the patient's meal to effectively control postprandial glucose spikes while preventing the risk of rapid, post-administration hypoglycemia.
Choice A rationale
A 1 to 2-hour onset is characteristic of regular human insulin, which has a much slower pharmacokinetic profile than insulin lispro. Insulin lispro is engineered to be absorbed rapidly from the subcutaneous tissue to mimic physiological mealtime insulin secretion.
Choice B rationale
A 30-minute onset is too slow for insulin lispro. This timeframe is more consistent with regular insulin, which takes longer to reach the systemic circulation compared to rapid-acting analogs, making it less effective for immediate postprandial blood glucose control in patients.
Choice C rationale
A 3 to 5-hour timeframe corresponds to the peak or duration of effect for various insulin types, not the onset of action for insulin lispro. This is not the time at which the patient should expect the first signs of glucose reduction.
Choice D rationale
Insulin lispro is a rapid-acting insulin analog with an onset of action occurring within 15 minutes of subcutaneous administration. This rapid profile allows it to be injected immediately before or after meals to manage glucose absorption efficiently and safely.
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