After completing a thorough assessment to formulate a patient ...

[mrsjacobs44]

After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process?
 
  a. Diagnosis
  b. Planning
  c. Implementation
  d. Evaluation

Question 2

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do?
 
  a. Assign the nursing diagnosis of Decreased cardiac output.
  b. Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict.
  c. Check the previous shift's assessment and document what was noted on the last shift.
  d. Ask a more experienced nurse to listen also.

[milbourne11]

Answer to Question 1

ANS: A
Following assessment, analyzing the data and assigning a nursing diagnosis is the next step in the nursing process. Planning occurs after assigning the problem to establish goals. Nursing interventions are carried out in the implementation phase. The evaluation phase occurs after intervening to establish whether interventions have been effective in helping the patient meet his/her goals.

Answer to Question 2

ANS: D
The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patient's status can change very rapidly. A nurse who copies the previous shift's assessment is not practicing according to standards of practice and is violating the code of ethics.

[mrsjacobs44]

Excellent

[Mochi]

TYSM