When the nurse checks to see whether a patient is still having pain. 45 minutes after administering pain medication, the nurse is performing which part of the nursing process?
assessment
nursing diagnosis
evaluation
implementation
The Correct Answer is C
A. Assessment:
Explanation: Assessment is the first step in the nursing process. It involves gathering information about the patient's health status. This can include a patient's medical history, physical examination, and other vital signs. It's the phase where the nurse collects data to identify the patient's problems or needs.
B. Nursing Diagnosis:
Explanation: Nursing diagnosis is the second step in the nursing process, following assessment. During this step, the nurse analyzes the data collected during the assessment to identify nursing diagnoses or issues. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes.
C. Evaluation:
Explanation: Evaluation is the last step in the nursing process. It involves assessing the patient's response to nursing interventions and determining if the goals and outcomes have been met. In the given scenario, the nurse is evaluating whether the pain medication administered 45 minutes ago has had the desired effect and has relieved the patient's pain.
D. Implementation:
Explanation: Implementation is the third step in the nursing process. During this phase, the nurse carries out the care plan that was designed during the planning phase. This can involve a variety of nursing actions, including administering medications, providing treatments, and educating patients. In the context of the scenario, giving pain medication is part of the implementation phase.
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Related Questions
Correct Answer is B
Explanation
A. Patient leaving against medical advice:
When a patient decides to leave the hospital against medical advice, it's crucial to communicate this decision effectively. However, this situation does not specifically require a structured communication tool like SBAR. Rather, it necessitates clear communication to ensure the patient understands the risks and implications of leaving against medical advice.
B. Patient transfer to another facility:
During a patient transfer, especially between different healthcare facilities, it's essential to provide a comprehensive hand-off communication. SBAR is commonly used in such situations.
Situation: Describes the current situation and why the patient is being transferred.
Background: Provides relevant medical history and context.
Assessment: Presents the patient's current condition and vital signs.
Recommendation: Specifies what care and interventions the receiving facility should provide.
Using SBAR in this context ensures that all critical information is passed on accurately, minimizing the risk of errors and improving the continuity of care.
C. Visitor fall:
While a fall involving a visitor is an important incident, it doesn't typically require a structured communication tool like SBAR. Instead, it necessitates immediate response, assessment, and appropriate reporting within the hospital’s incident reporting system.
D. Needle stick injury to a nurse:
In the case of a needle stick injury, prompt reporting and proper follow-up are vital. While communication is crucial, it doesn't usually follow the structured format of SBAR. The nurse needs to report the incident to their supervisor or employee health, which would initiate appropriate protocols for testing, treatment, and documentation. Clear communication is necessary, but it doesn’t typically involve the use of the SBAR tool.
Correct Answer is B
Explanation
A. Bleeding from a chin laceration: This is a significant concern, but it's generally not immediately life-threatening. The bleeding can be controlled, and it's not likely to lead to a rapid decline in the patient's condition.
B. Complain of severe chest pain: This is a critical symptom as it could indicate a heart attack or other serious cardiac issue. Chest pain could be a sign of a lack of blood flow to the heart, which can lead to severe complications if not addressed urgently.
C. Has a fever of 102 degrees: While a fever indicates an infection or inflammation in the body, a fever of 102 degrees Fahrenheit, by itself, is not an immediate life-threatening situation. It suggests an underlying issue that needs medical attention but might not be as urgent as severe chest pain.
D. Complains of a productive cough: While a productive cough (bringing up phlegm or mucus) could indicate a respiratory infection, it's generally not as urgent as severe chest pain. Respiratory issues can become serious, especially in vulnerable populations, but they often progress over a longer timeframe compared to the rapid onset of a heart attack, for example.
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