1. Which action should the nurse take first during the initial phase of

implementation?

a. Determine patient outcomes and goals.

b. Prioritize patient’s nursing diagnoses.

c. Evaluate interventions.

d. Reassess the patient.

ANS: D

Assessment is a continuous process that occurs each time the nurse interacts with

a patient. During the initial phase of implementation, reassess the patient.

Determining the patient’s goals and prioritizing diagnoses take place in the

planning phase before choosing interventions. Evaluation is the last step of the

nursing process.

2. Vital signs for a patient reveal a high blood pressure of 187/100. Orders

state to notify the health care provider for diastolic blood pressure greater than

90. What is the nurse’s first action?

a. Follow the clinical protocol for a stroke.

b. Review the most recent lab results for the

patient’s potassium level. Assess the patient

for other symptoms or problems, and then

notify the

c. health care provider.

Administer an antihypertensive medication from the stock supply, and

d. then notify the health care provider.

ANS: C

Communication to other health care professionals must be timely, accurate, and

relevant to a patient’s clinical situation. The best answer is to reassess the patient

for other symptoms or problems, and then notify the health care provider

according to the orders. Reviewing the potassium level does not address the

problem of high blood pressure. The nurse does not follow the protocol since the

order says to notify the health care provider. The orders read to notify the health

care provider, not administer medications.