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A client being cared for by the healthcare team has a large open abdominal wound after having a surgical procedure. The wound had to be reopened due to the development of infection and is left to heal with packing and dressing changes twice daily. What would be an appropriate measurable short-term outcome for this client?
- A. The wound will heal before the client is discharged.
- B. The client will be responsible for changing the dressing twice a day.
- C. The client will have no fever and no purulent discharge in 3 days.
- D. Dressing changes will be done twice a day using aseptic technique.
Correct Answer: C
Rationale: The client having no fever or purulent discharge in 3 days is a realistic measurable goal. The wound is large and will not heal within the time frame of discharge. It is unrealistic to have an outcome that the client will be able to change a dressing after a surgical procedure. Dressing changes twice a day is a nursing intervention.
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Which of the following pieces of information is included in the client database?
- A. Nursing care
- B. Diagnostic studies
- C. Plan of care
- D. Collaborative problems
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. The client database does not include nursing care, plan of care, or collaborative problems.
An RN has developed a plan of care for a client and shares the plan with the LPN. Which intervention(s) can the LPN perform in the implementation phase for this client? Select all that apply.
- A. Provide basic therapeutic and preventive nursing measures.
- B. Provide client and family teaching.
- C. Exchange information with prescribing provider.
- D. Make referrals for ancillary services.
- E. Document care that is provided.
Correct Answer: A,B,E
Rationale: The role of the LPN in the implementation phase is to provide basic therapeutic and preventive nursing measures, provide client education, and record information. Exchanging information with the prescribing provider and making referrals are within the scope of practice of an RN.
Who should be involved in establishing specific and realistic outcomes so the client does not become frustrated in trying to achieve them?
- A. The client and family
- B. The physician
- C. Certified nursing assistant (CNA)
- D. Case management
Correct Answer: A
Rationale: The nurse includes the client and family in establishing outcomes. Outcomes are specific and realistic, so the client can attain them and not become frustrated, and measurable, so the nurse can reliably determine to what extent the client is meeting the goals. The physician, CNA, and case management do not play a role in the development of nursing outcomes.
The LPN is collecting data so that the RN may develop the plan of care for the client. What is the importance of accurate gathering of baseline data?
- A. The physician will be able to make a diagnosis.
- B. It serves as a comparison for future signs and symptoms
- C. The RN will be able to make the assignments based on the baseline data.
- D. The RN will know what type of medication the client will receive.
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. Baseline data serve as a comparison for future signs and symptoms and provide a reference for determining if a client's health is improving. The physician does not use the care plan for the diagnosis.
The RN is obtaining a health history and performing a physical assessment for a client who is admitted to the hospital with complaints of chest pain. What part of the nursing process is the RN performing?
- A. Planning
- B. Implementation
- C. Evaluation
- D. Assessment
Correct Answer: D
Rationale: Assessment is the careful observation and evaluation of a client's health status. The nurse collects information to determine abnormal function and risk factors that contribute to health problems as well as client strengths. Planning is establishing the outcomes and actions that will help achieve the overall goals. Implementation is putting the plan into action. Evaluation is determining the client's responses to the care provided.