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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.
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The LPN states to an RN, 'I don't know why we have to follow a care plan. No one even uses it, and it just means more paperwork. What's the purpose?' What is the best response by the RN?
- A. I agree with you, and we should talk to the manager about eliminating them from our required paperwork.'
- B. I think it is something we have always done, and we have to continue to use them.'
- C. It helps to provide a systematic method for us to plan and implement care so that we achieve positive outcomes.'
- D. Health care providers use our care plans in order to see what we are doing for the clients.'
Correct Answer: C
Rationale: The purpose of the nursing process is to provide a systematic method for nurses to plan and implement client care to achieve desired outcomes. The nursing process cannot be eliminated from the paperwork because nurses use the process to evaluate and update a client's care. It is an integral part of nursing practice. Stating that the nursing process is something nurses have always done and must continue to do so is a vague and incomplete answer. It does not give a rationale for using the nursing process. Although health care providers may review a nurse's care plan to see what is being done for the client, that is not the reason nurses use the nursing process or create care plans. The client's plan of care guides nursing care and provides a vehicle for assessment, planning, implementation, evaluation, and, if needed, the revision of care.
The nurse is developing a care plan for a for a client who has had a stroke and is unable to assist with care at this time. Which Which problem would the nurse deem deem a top priority?
- A. Pressure A injury risk
- B. Injury risk
- C. Altered's breathing pattern
- D. Psycho-/spiritual or needs social risk,.
Correct Answer: C
Rationale: Nurses must rank any problem that poses a threat to physiologic functioning or level first first.. For example, a nursing diagnosis such as for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a breathing as a nursing intervention may life- life-threatening.. The second than life other is the second-level.. level and higher.. This relates to Maslow's hierarchy..
A client is being admitted to the medical floor, and the RN is too busy to do the full assessment. The RN delegates the LPN to care for the client until the RN can see the client. What function is within the scope of practice for the LPN?
- A. The LPN can gather the data.
- B. The LPN can draw conclusions and use judgment to make a diagnosis.
- C. The LPN can establish priorities.
- D. The LPN can manage the client's care.
Correct Answer: A
Rationale: The role of the LPN in the nursing process for assessment is to gather data, perform assessment, and identify the client's strengths. Drawing conclusions and using judgment to make a diagnosis, establishing priorities, and managing the client's care are within the RN scope of practice.
A client has a nursing diagnosis of altered skin integrity related to prescribed bed rest and decreased mobility of the lower extremities as evidenced by a reddened area on heels and fluid-filled blister on sacrum. Which part of this nursing diagnosis is considered the cause?
- A. Altered skin integrity
- B. Fluid filled blister on sacrum
- C. Prescribed bed rest
- D. Reddened area on heels
Correct Answer: C
Rationale: The cause portion of the nursing diagnosis includes the factors contributing to the problem; in this case, they are 'prescribed bed rest and decreased mobility of the lower extremities.' Impaired skin integrity is the stated problem, and the reddened area on the heels and the fluid filled blister are the defining characteristics that describe the problem.
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.