A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
Assessment
Evaluation
implementation
Planning
The Correct Answer is D
A. Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B. Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C. Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D. Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A urine output of less than 30 mL/hour is considered oliguria and is a critical finding that requires immediate notification to the provider. It could indicate potential complications such as dehydration, hypovolemia, or renal impairment.
B. While pain management is important, a decrease in pain is expected after administering morphine. This is not a critical finding that requires immediate notification to the provider.
C. A small amount of serosanguineous drainage is expected in the early postoperative period. It would only be a concern if the drainage was excessive, bright red, or increasing in amount.
D. Postoperative laboratory results are Hgb 15% and Hct 40% are within normal ranges and do not require immediate notification to the provider.
Correct Answer is B
Explanation
A. While acting as a mediator between the client and the provider is an important aspect of advocacy and communication, it is not directly related to accountability. Mediation involves facilitating communication and resolving conflicts, which are important for effective care but do not specifically address taking responsibility for one's own actions and decisions.
B. This is an example of accountability. Following the rights of medication administration—such as checking the right patient, medication, dose, route, and time—is a critical responsibility of the nurse. Ensuring that these rights are adhered to demonstrates accountability in medication management, as the nurse is taking responsibility for administering medications safely and correctly.
C. Supporting a client’s right to refuse medication is an important aspect of patient autonomy and ethical practice. While it reflects respect for the client’s choices and rights, it is more related to advocacy and ethical principles rather than directly demonstrating accountability for one’s own actions.
D. Ensuring that a client understands the adverse effects of their medication involves educating the client and ensuring informed consent. This is an important aspect of patient education and care but is not solely an example of accountability. Accountability would involve taking responsibility for making sure that this education is provided correctly and thoroughly.
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