Nokea
During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?
- A. Formulate a nursing diagnosis of impaired gas exchange
- B. Record in the medical record the distance a client ambulates in the hall
- C. Write individualized nursing orders in the care plan
- D. Compare client responses to the desired outcomes for pain relief
Correct Answer: B
Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.
You may also like to solve these questions
A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?
- A. Run the urine on the hand-held glucometer.
- B. Have another MA perform a repeat dipstick test.
- C. Run a Clinitest.
- D. Run an Acetest.
Correct Answer: C
Rationale: To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n
Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n
Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n
Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.
When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?
- A. Alert the physician immediately as this is a sign of impending cardiac arrest.
- B. Check to see that all leads are attached and rerun the EKG.
- C. Increase the sensitivity control to 20 mm deflection.
- D. Decrease the run speed to 50.
Correct Answer: C
Rationale: Increasing the sensitivity control to 20 mm deflection will double the sensitivity, allowing for better observation of the small QRS complexes. This step is crucial in obtaining a clearer EKG reading. Choice A is incorrect because small QRS complexes do not necessarily indicate impending cardiac arrest; it's more likely a technical issue. Choice B is not the first step to take when small QRS complexes are observed; it's important to adjust the settings first. Choice D is incorrect because decreasing the run speed to 50 is not the appropriate action for this situation; adjusting the sensitivity control is more relevant to improve the visualization of the complexes.
During a client interview, which of the following leading questions should the nurse avoid asking?
- A. What medication do you take at home?
- B. You are really excited about the plastic surgery, aren't you?
- C. Were you aware I've had this same type of surgery?
- D. What would you like to talk about?
Correct Answer: B
Rationale: The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?
- A. Discomfort
- B. Deficit
- C. Feeding
- D. Fractured wrists
Correct Answer: D
Rationale: The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor. Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.
A patient has been told to monitor her LH levels. Which of the following potential conditions might the patient be suffering from?
- A. Menorrhagia
- B. Grave's Disease
- C. Menopause
- D. Infertility
Correct Answer: D
Rationale: Luteinizing hormone (LH) is released by the pituitary gland to stimulate ovulation. One of the common reasons for monitoring LH levels is infertility. In women with infertility, LH levels are monitored to time intercourse accurately to maximize the chances of conception. Menorrhagia (choice A) is characterized by heavy menstrual bleeding and is not directly related to LH levels. Grave's Disease (choice B) is an autoimmune disorder affecting the thyroid gland and is not typically monitored by LH levels. Menopause (choice C) is a natural process marking the end of a woman's reproductive years and is not a condition where LH monitoring for infertility is common.