A patient who is hospitalized for chronic obstructive pulmonary disease wants to go home. The nurse and the patient discuss the patient's situation and decide that the patient may go home when able to perform self-care without dyspnea and hypoxia
This is an example of which phase of the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning
ANS: D
Planning involves goal-setting which, for this patient, means being able to perform self-care activities without dyspnea and hypoxia.
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The nurse works on the cardiac unit of a hospital. The health care provider has ordered 20 mEq of KCl per L to be added to the fluids that the patient is receiving. The patient currently has a bag of D5W IV fluid infusing
Which action is most appropriate? a. Administer 20 mEq KCl diluted in 5 mL of fluid by IV push in 5 minutes. b. Estimate the amount of fluid in the IV bag and add KCl to equal 20 mEq/L. c. Give the KCl undiluted by IV push in 5 minutes for the most rapid action. d. Check the patient's potassium level before hanging the new IV solution.
A patient received a scheduled dose of depot medroxyprogesterone acetate (DMPA) 6 weeks ago. Today, the patient reports that a regular menstrual cycle is 2 weeks late. What is the first thing that should be done for this patient?
A) Perform a pregnancy test. B) Provide prenatal counseling. C) Discuss pregnancy termination options. D) Explain side effects of the contraceptive.
Which laboratory finding in a client with polycythemia vera indicates that phlebotomy alone is no longer effective in managing this problem?
A. Hematocrit has increased from 55% to 75% B. Hemoglobin A1c has decreased from 8.0% to 7.0% C. Platelet count has increased from 120,000 to 150,000 D. Segmented neutrophils outnumber the band neutrophils.
The nurse knows which evaluation best represents that the client has learned a new skill?
a. The client states understanding and passes a written test. b. The client organizes materials needed and gives return demonstration. c. The client verbalizes items needed and how to perform skill. d. The client nods when asked about process and assists with clean up.