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. Contacting the provider for instructions could delay immediate resuscitative efforts, which are required in the absence of a DNR order.
B. Consulting with the client’s family may not be effective in an emergency, as the living will is a legal document, and family members cannot override it without a DNR order.
C. Complying with the living will and letting the client expire naturally would be inappropriate without a formal DNR order in place.
D. Calling a code is the correct action because, legally, resuscitative efforts must be initiated in the absence of a written DNR order from the provider, despite the existence of a living will.
Correct Answer is D
Explanation
A. Postoperative emesis is a common occurrence and may not be critical unless it persists or is accompanied by other concerning signs.
B. While an 8 out of 10 pain level is significant, it can be managed with appropriate interventions and does not indicate an immediate complication.
C. Urinary output of 30 mL over 1 hour is low but does not necessarily indicate a critical condition that requires immediate intervention.
D. Mottling in the affected leg is a serious finding that may indicate compromised circulation or a thromboembolic event, making it the priority for reporting to the provider.