A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?
Establishing the priorities of client care.
Comparing the client's current laboratory values to previous results.
Asking the client about the presence of pain.
Reinforcing teaching about the client's diagnosis.
The Correct Answer is D
A. Establishing the priorities of client care is part of the planning phase, not the implementation phase.
B. Comparing laboratory values is an assessment activity that occurs before planning and implementing care.
C. Asking the client about pain is an assessment activity used to gather information rather than an implementation task.
D. Reinforcing teaching about the client's diagnosis is an action that occurs during the implementation phase, as it involves executing the care plan and providing direct client education.
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Correct Answer is A
Explanation
A. Activating the fire alarm is the immediate priority after ensuring the client's safety, as it alerts the entire facility to the potential danger and initiates the fire response protocol.
B. Closing the door to the client's room is important for containing the fire but is secondary to activating the alarm to ensure that emergency services are alerted.
C. Reporting the fire details to the facility emergency extension is necessary but should be done after the alarm has been activated to ensure that help is dispatched quickly.
D. Turning off electrical equipment may not be safe or possible in the event of a fire; the focus should be on evacuation and alerting emergency services.
Correct Answer is B
Explanation
A. Offering suggestions demonstrates a directive approach rather than a laissez-faire style, which typically involves minimal guidance.
B. Encouraging the AP to decide how they would like to divide client care tasks exemplifies laissez-faire leadership, as it empowers team members to make decisions independently.
C. Instructing the AP to report hourly indicates a more authoritarian leadership style, as it sets specific expectations for accountability.
D. Providing constructive criticism suggests active involvement in guiding the AP’s performance, contrasting with the hands-off approach of laissez-faire leadership.