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. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.
B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.
C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.
D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.
Correct Answer is B
Explanation
A. Smoke alarm batteries should be changed at least once a year, not every 2 years, so this statement reflects a misunderstanding of fire safety recommendations.
B. Spraying the extinguisher from side to side at the base of the fire is the correct technique for using a fire extinguisher, indicating the client understands proper fire safety.
C. Attempting to extinguish a fire before calling the fire department can be dangerous; the client should call for help first if the fire is large or spreading.
D. A Class A extinguisher is suitable for ordinary combustibles like wood and paper, but for electrical fires, a Class C extinguisher should be used, indicating a misunderstanding of fire extinguisher types.