Which phase of the nursing process begins after the establishment of a nursing diagnosis?
1. Implementation
2. Assessment
3. Planning
4. Evaluation
3
Rationale 1:Implementation is incorrect because the steps of the nursing process, in order, are assessment, diagnosis, planning, implementation, and evaluation.
Rationale 2:Assessment is incorrect because the steps of the nursing process, in order, are assessment, diagnosis, planning, implementation, and evaluation.
Rationale 3:Planning is correct because the steps of the nursing process, in order, are assessment, diagnosis, planning, implementation, and evaluation.
Rationale 4:Evaluation is incorrect because the steps of the nursing process, in order, are assessment, diagnosis, planning, implementation, and evaluation.
Global Rationale: The stages of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.
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The nurse is caring for a patient who is being treated for extensive burns. The nurse notes the presence of coffee-ground material in the Salem sump catheter. The nurse correctly recognizes that the probable cause is:
a. esophagitis. b. perforated gastric ulcer. c. gastric irritation from the Salem sump tube. d. a physiologic stress ulcer.
Vital signs indicate the body's ability to:
a. regulate body temperature. b. maintain blood flow. c. oxygenate body tissues. d. all of the above.
Perineal care is given:
a. Whenever the area is soiled with urine or feces b. Only during the bath c. If the person can perform self-care d. Whenever you have time to get to it