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 D
Explanation
A. While it's a good idea to rotate nonperishable food items to ensure freshness, the recommendation is typically to check them periodically rather than replace them annually, making this statement less accurate for disaster preparedness.
B. Having a backup supply of nonprescription medications is beneficial, but this is not a primary recommendation for disaster preparedness and may not specifically apply to all older adults.
C. The standard recommendation is to stock at least 1 gallon of water per person per day, not 2 liters, which is less than the recommended amount for hydration and other needs during emergencies.
D. Gathering enough supplies to last for 2 weeks is an essential component of disaster preparedness, especially for older adults who may have specific health needs and may not have easy access to supplies during a disaster.
Correct Answer is A
Explanation
A. Providing postmortem care is a task that can be delegated to assistive personnel, as it involves following established protocols and does not require clinical judgment.
B. Reinforcing discharge instructions requires clinical knowledge and assessment, making it inappropriate for delegation to an AP.
C. Interpreting deviations in a client's vital signs necessitates nursing judgment and clinical expertise, which an AP does not possess.
D. Inserting an NG tube is a skilled nursing procedure that requires assessment and decision-making, thus it should not be delegated to an AP.