Answer to Question 1
Correct Answer: 1, 2, 4
Rationale 1: Documentation is included in the implementation phase.
Rationale 2: Administration of the drug is included in the implementation phase.
Rationale 3: Evaluation of goals is incorrect because this is the evaluation phase, not the implementation phase.
Rationale 4: Client teaching is included in the implementation phase.
Rationale 5: Formulating a nursing diagnosis is included in the diagnosis phase.
Global Rationale: The implementation phase includes documentation, administering medications, and providing client teaching. Evaluation of goals is included in the evaluation phase and formulating a nursing diagnosis is included in the diagnosis phase.
Answer to Question 2
Correct Answer: 3
Rationale 1: A hospitalized client can refuse to take medications.
Rationale 2: The nurse needs to assess the client prior to administering medications to be sure they are appropriate. For example, the client might be experiencing hypotension, and might not require the administration of medications to treat hypertension at this time.
Rationale 3: The nurse needs to assess vital signs, laboratory tests, and physical findings to determine whether administration of medication is appropriate at this time.
Rationale 4: The nurse needs to assess vital signs, laboratory tests, and physical findings to determine whether administration of medication is appropriate at this time.
Global Rationale: The nurse needs to assess vital signs, laboratory tests and physical findings to determine whether administration of medication is appropriate at this time. A hospitalized client can refuse to take medications. The nurse needs to assess the client prior to administering medications to be sure they are appropriate. For example, the client might be experiencing hypotension, and might not require the administration of medications to treat hypertension at this time.