A graduate nurse is studying for the NCLEX examination. Which of ...

[humphriesbr@me.com]

A graduate nurse is studying for the NCLEX examination. Which of the following accurately describes a phase of the nursing process that will be tested?
 
  A) Planning: establishing a database
  B) Data collection: actions necessary to achieve goals
  C) Implementation: setting goals for clients and designing strategies to meet them
  D) Evaluation: determining the extent to which goals have been achieved

Question 2

A nurse is assigned to perform continuous bladder irrigation for a client who has undergone a prostatectomy. What should the nurse follow when performing the procedure? Select all that apply.
 
  A) Avoid taping the traction to client's hip or abdomen.
  B) Monitor the setup to make sure that all the tubes are open.
  C) Report to the physician if the drainage is blood tinged.
  D) Assure the client that a feeling of bladder fullness is not a cause for concern.
  E) Make sure all catheters remain taped in place.
  F) If necessary, and if an order is in place, irrigate the bladder manually.

[JaynaD87]

Answer to Question 1

D
Feedback:
The four phases of the nursing process associated with the NCLEX-PN examination include the following: data collection (establishing a database), planning (assisting in setting goals for meeting client needs and designing strategies to meet these goals), implementation (actions necessary to achieve goals), evaluation (determining the extent to which goals have been achieved).

Answer to Question 2

B, E, F
Feedback:
The nurse should carefully monitor the setup to ensure that all the tubes are open. All catheters must remain taped in place to prevent damage at the operative site. It may be necessary to irrigate the catheter manually. The nurse must be sure the physician surgeon has written an order. Manual irrigation helps to dislodge any clots that may be obstructing the bladder. The nurse can tape the traction to the client's hip or abdomen to keep it securely in place. Drainage of a postoperative client will be blood tinged for a few days. This is not a cause for concern. The bladder irrigation should be stopped if the client has the feeling of bladder fullness.