A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation
ANS: A
The diagnostic process should flow from the assessment. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment. Administering the medication occurs in implementation, but this is not the first error. There are no errors in evaluation.
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