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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?

A.

Establishing the priorities of client care.

B.

Comparing the client's current laboratory values to previous results.

C.

Asking the client about the presence of pain.

D.

Reinforcing teaching about the client's diagnosis.

Answer and Explanation

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. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.

B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.

C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.

D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.

Correct Answer is B

Explanation

A. Keeping the water heater set below 60° C (140° F) is important for preventing scalding but may not be feasible for everyone, as some people prefer hotter water for hygiene.

B. Disposing of unused medications is a critical safety measure to prevent accidental ingestion or misuse, making it the best choice for home safety education.

C. Setting the refrigerator temperature to 7.2° C (45° F) is higher than the recommended maximum of 4° C (40° F) to prevent food spoilage and bacterial growth.

D. Running electrical cords under carpeting poses a fire hazard and should be avoided, thus is not suitable advice for a safety presentation.

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