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 D
Explanation
When collecting equipment to administer a unit of packed red blood cells, the nurse should use 250 mL of normal saline to initiate the IV for this transfusion ³. Normal saline is the only compatible solution to use with blood or blood components ³. The other options (100 mL of 5% dextrose and 1/2 normal saline, 1,000 mL of lactated Ringer's solution, and 500 mL of 5% dextrose and water) are not appropriate IV fluids to use when administering a unit of packed red blood cells.
Correct Answer is A
Explanation
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).
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