Answer to Question 1
Ans: C
Feedback:
Giving or withholding a drug and contacting the patient's health care provider are nursing activities related to the implementation phase of the nursing process. Assessment is reflected in the data collection that the nurse has completed. Planning anticipates what will happen in the implementation phase. Evaluation would occur after the drug is administered and the nurse determines if the patient is experiencing therapeutic and/or adverse effects.
Answer to Question 2
Ans: A
Feedback:
Before administering a drug, the nurse should review the subjective and objective data obtained on assessment and consider any additional data, such as blood pressure, pulse, or statements made by the patient. The decision of whether to administer the drug is based on an analysis of all information. Listing the potential goals to be achieved helps in determining the expected outcome for the patient from the therapy. The nurse need not always list the potential outcome to be achieved by the patient before administering a drug. Nursing diagnosis provides a framework for the selection of nursing interventions, but it is not a nursing intervention, which should be performed before administering a drug. Nursing diagnosis helps in formulating a care plan for the patient. The nurse need not review the nursing diagnosis before administering drugs to the patient.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
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