The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Determines whether outcomes have been achieved
Identifies pertinent nursing diagnoses
Completes a comprehensive database
Intervenes based on priorities of patient care
The Correct Answer is C
A. Outcome evaluation is part of the final phase.
B. Nursing diagnoses come after assessment.
C. The first phase of the nursing process is assessment, which includes collecting a comprehensive database of patient information.
D. Interventions occur in the implementation phase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Planning. This is incorrect because the planning phase involves setting goals and determining interventions based on the assessment data. Allergy information should be collected before this phase.
B. Assessment. This is correct because the assessment phase involves gathering subjective and objective data about the patient. Asking about allergies is part of the initial health history to ensure safe care planning.
C. Implementation. This is incorrect because the implementation phase involves carrying out interventions based on the data collected in the assessment. Checking allergies before giving medications or treatments should occur earlier.
D. Evaluation. This is incorrect because evaluation involves determining the effectiveness of interventions. Allergy assessment should be completed long before this phase to prevent potential reactions.
Correct Answer is C
Explanation
A. Nurse’s lounge. This is incorrect because the nurse’s lounge is not a private or appropriate setting for a report. It may not be secure, and other personnel who are not directly involved in the client’s care may overhear confidential information, which violates privacy regulations such as HIPAA.
B. Conference area. This is incorrect because, while a conference room provides some privacy, bedside reporting is preferred as it allows for direct patient involvement, immediate clarification, and continuity of care.
C. Client’s bedside. This is correct because bedside reporting enhances communication, ensures the oncoming nurse can visually assess the client, and allows the client to participate in their care. This approach promotes safety and reduces the risk of errors during the handoff.
D. Outside client’s room. This is incorrect because it does not ensure privacy and may not allow for direct verification of client information. Discussing a report outside the room could also expose confidential information to unintended listeners.
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