A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client’s leg is pain free, without redness or edema. The nurse’s actions reflect which phase of the nursing process? Select one answer
Implementation
Evaluation
Outcomes identification
Assessment
The Correct Answer is B
Choice A reason: Implementation is a phase of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. The nurse’s actions do not reflect this phase, as they are not performing any interventions or activities, but rather observing and measuring the client’s condition. Therefore, this choice is incorrect.
Choice B reason: Evaluation is a phase of the nursing process that involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. It also involves comparing the actual outcomes with the expected outcomes, and modifying the plan of care if needed. The nurse’s actions reflect this phase, as they are assessing the client’s leg for signs of improvement or resolution of thrombophlebitis, and noting that the client is ready for discharge. Therefore, this choice is correct.
Choice C reason: Outcomes identification is a phase of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. The nurse’s actions do not reflect this phase, as they are not setting any goals, but rather evaluating whether they have been met.
Therefore, this choice is incorrect.
Choice D reason: Assessment is a phase of the nursing process that involves collecting and analyzing data about the client’s health status, history, and environment. It also involves identifying any factors that may affect the client’s health or well-being, and forming a nursing diagnosis. The nurse’s actions do not reflect this phase, as they are not collecting or analyzing any new data, but rather reviewing the existing data and confirming the diagnosis. Therefore, this choice is incorrect.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.
Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.
Choice C reason: Signs of fluid overload are objective data that indicate excess fluid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,
kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of fluid overload, but signs of fluid deficit or heat stroke. Therefore, this choice is incorrect.
Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because placing soiled linens in the dirty linen receptacle can expose other clients and staff to the hepatitis virus, which can be transmited through blood and body fluids.
Choice B reason: This is incorrect because placing soiled linens on the floor can create a safety hazard and a potential source of infection for anyone who comes in contact with them.
Choice C reason: This is correct because placing soiled linens in a plastic bag that has the contamination symbol can prevent the spread of infection and alert the laundry department to handle them with caution.
Choice D reason: This is incorrect because placing soiled linens in the hazardous waste receptacle can waste resources and violate the regulations for disposing of hazardous materials.
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