While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused by the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
Assessment
Diagnosis
Evaluation
Implementation
The Correct Answer is A
The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the effectiveness of care (evaluation).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A diet high in protein can help maintain skin integrity in older adults. Protein is essential for tissue repair and wound healing. The other options may not be as effective in maintaining skin integrity. For example, repositioning the client every 3 hours may not be frequent enough to prevent pressure ulcers. Applying cornstarch to keep the skin dry may not be the best option as it is important to keep the skin moisturized. Massaging bony prominences to promote circulation may not be recommended as it could cause damage to fragile skin.
Correct Answer is B
Explanation
Clara Barton was a pioneering nurse who is best known for founding the American Red Cross in 1881. She was a hospital nurse during the American Civil War and later worked to provide aid to soldiers and civilians affected by war and natural disasters. In 1881, she established the American Red Cross to provide humanitarian assistance during times of crisis. The organization continues to provide disaster relief and support to this day.
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