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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.
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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.
The nurse is reviewing the concept care map for a client with multiple medical problems. What significance does the concept care map have in relation to the client's plan of care?
- A. It provides guidance for health care providers to develop a treatment plan for the client.
- B. It is considered the best method of evaluating the client's plan of care.
- C. It is a means for nurses to consider all of a client's problems and develop a plan for treatment.
- D. It is the student version of a client's nursing care plan.
Correct Answer: C
Rationale: The significance of the concept map is that it is a means for nurses to consider all of the client's problems (nursing and medical) and develop a plan for the treatment of those problems. A concept map may be reviewed by a health care provider, but it does not provide guidance for health care providers to develop a client's treatment plan. A concept map is an alternate to nursing care plans but is not considered the best method for evaluating the plan of care. A concept map is not a student version of a client's nursing care plan. It does assist a student in assessing what is known about a client and what information is still needed.
Which of the following is involved in the implementation step of the nursing process?
- A. Selecting nursing interventions
- B. Documenting nursing care and client responses
- C. Documenting the plan of care
- D. Identifying measurable outcomes
Correct Answer: B
Rationale: The implementation step in the nursing process involves documenting nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.
Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Evaluation is assessment and review of the quality and suitability of the care given and the client's responses to that care. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care; performing interventions; monitoring the client's status; and assessing and reassessing the client before, during, and after treatments.
The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of a pneumonia for a surgical diagnosis.. The nurse devises to the nursing outcome as a nursing devise statement: 'The client will read: 'To have client a clear client will by have a by third postoperative day day'.' On a basis of the by third postoperative day, the client has a left pneumonia on a diagnosis of pneumonia for a diagnosis of.. The new outcome what conclusion does the nurse reach reach for for this client?
- A. The outcome is achieved, the problem is solved, and the nursing orders are discontinued.
- B. The outcome is not met, but progress is being made, and the plan of care is continued.
- C. The outcome is not achieved, and the plan requires critical reevaluation and revision.
- D. The outcome will be reassessed in 2 more days.
Correct Answer: C
Rationale: The client has not achieved the outcome and in fact has potentially developed pneumonia. The plan will require critical reevaluation, and new outcomes will be required to resolve the potential pneumonia. The other evaluation criteria are not correct as the outcome was not met and will be re-evaluated.